Clinical Tools

Clinical Tools

Name Description



  • Malaria is a disease caused by the parasite Plasmodium (P)
  • The infection is usually transmitted by the bite of an infected female Anopheles mosquito. The only way a mosquito can transmit malaria is if it has been infected through a previous blood meal from a person infected with the parasite. The parasites from that meal mature in the mosquito and are injected into another person that the mosquito bites. The parasite matures in the red blood cells of the human before destroying them.
  • Plasmodium falciparum is the commonest specie in virtually all parts of Africa accounting for 98 % of the cases and is associated with significant morbidity and mortality. P. falciparum is responsible for most cases of severe malaria.
  • Other species, which include P. Malariae, P. Ovale, form up to 2% of the cases. P. Vivax is very rare in Africa, however in Ethiopia and Eritrea, it accounts for about 40% of the cases seen.


The level of endemicity of malaria in Africa varies from country to country and sometimes from region to region within the same country. Some of the factors responsible for the variations in endemicity include

  • Rainfall pattern   
  • Altitude
  • Temperature

High rainfall pattern is associated with high malaria transmission while places with high altitude and low temperatures tend to be associated with lower rates of transmission. These are only factors that affect the occurrence but not necessarily the severity of malaria.



  • Stable malaria/High Risk - Where malaria is transmitted all year round, but may have seasonal variation. Adults living in these areas usually acquire some protection against malaria and may be less likely to get severe malaria.
  • Unstable malaria/Low to Moderate Risk - Malaria is characterized by intermittent transmission that may be annual, bi-annual or variable epidemic due to poor immunity against malaria
  • Malaria free areas/Sporadic - Usually the population has no immunity whatsoever against malaria and therefore all ages are prone to severe malaria if exposed to the parasite


Malaria characteristically presents with fever. However, patients may complain of headache, muscle pains, joint weakness, chills and rigors. In most cases one will just feel unwell or tired with loss of appetite. Young children may present with abdominal pain, vomiting and poor feeding.



Malaria infection may present as uncomplicated malaria or severe malaria. It is important for proper patient management to always try and classify a patient with malaria. This will enable the management to be well focused, while helping the health worker to also look out for features that are associated with progression to life threatening disease. A heavy workload should not be used as an excuse not to classify your patient. You will find out that classifying the patient will ease your work and ensure that the patient is well managed.


Uncomplicated malaria:

Presence of the following clinical features with laboratory confirmation (i.e. either slide or RDT positive result).

  • Fever
  • Headache
  • Muscle pains
  • Joint weakness
  • Chills
  • Rigors
  • Loss of appetite
  • Abdominal pain
  • vomiting
  • Poor feeding in babies


Severe malaria:

This is acute malaria with signs of severity and / or evidence of vital organ dysfunction. Severe malaria is most common with P. Falciparum infection. In a patient with P. falciparum asexual parasitaemia and no other confirmed cause for their symptoms, the presence of one or more of the clinical or laboratory features below classifies the patient as suffering from severe malaria


  • Prostration (i.e. generalised weakness (inability to stand or walk) +++
  • Impaired consciousness (confusion or drowsiness or coma) +++
  • Respiratory distress (difficulty in breathing, fast deep breath) +++
  • Multiple convulsions+++
  • Circulatory collapse+
  • Pulmonary oedema (radiology)+/-
  • Abnormal bleeding (Disseminated intravascular coagulopathy) +/-
  • Jaundice (yellowness of the eyes) +
  • Haemoglobinuria (Coca-Cola coloured urine) +/-
  • Severe anaemia (Hb <5 gm/dl) +++
  • Acute renal failure+/-
  • Persistent vomiting+
  • Hypoglycaemia++
  • Hyper parasitaemia++
  • Acidosis+


  • Prostration (i.e. generalised weakness (inability to stand or walk) +++
  • Impaired consciousness (confusion or drowsiness or coma) ++
  • Respiratory distress (difficulty in breathing, fast deep breath) +
  • Multiple convulsions+
  • Circulatory collapse+
  • Pulmonary oedema (radiology)+
  • Abnormal bleeding (Disseminated intravascular coagulopathy) +
  • Jaundice (yellowness of the eyes) +++
  • Haemoglobinuria (Coca-Cola coloured urine) +
  • Severe anaemia (Hb <5 gm/dl) +
  • Acute renal failure++
  • Persistent vomiting+
  • Hypoglycaemia++
  • Hyper parasitaemia+
  • Acidosis++

It is recognized that the resources needed to confirm or ascertain many of the features listed above may sometimes not be available in many of our district level health facilities. In view of this difficulty, it has become necessary to classify severe malaria in a manner that would allow for prompt recognition of those who need treatment. Such groupings are particularly important in children, where a single yardstick may not sufficiently address their peculiar needs.



It is an illness usually characterized by a fever without any signs of severe disease but its clinical presentation may mimic other diseases, which often makes diagnosis difficult. A comprehensive presentation of clinical features has already been discussed in the previous learning unit. It is however important to note that some patients may just feel unwell with vague body pains and loss of appetite. In children, they may present with refusal to eat or feed, decreased activity and sometimes the symptoms may be non-specific.


A complete history should include, in addition to the presenting symptoms, the age, place of residence and recent history of travel within or outside the country.   

Ask about the following symptoms:

  • Fever
  • Chills (feeling cold) and rigors (shaking of the body)
  • Headache
  • Joint weakness or tiredness
  • Nausea and vomiting
  • You should also ask for the common main symptoms in children, especially cough or difficulty in breathing, diarrhoea, ear pain and measles in the last three months.


  • Increased body temperature > 37.50 C
  • Enlarged spleen or liver, especially in children
  • Pallor (children/pregnant women)
  • Exclude signs of severe disease


To avoid treatment of patients without malaria as malaria, it is necessary to test all suspected cases using RDTs which are available at all levels or using microscopy where conditions permit. Where an RDT is negative and there is still high suspicion of malaria, a slide for microscopy should be taken and sent to the laboratory. Second opinion should be sought in such cases and referral if in doubt. In children below five years, the Integrated Management of Neonatal and Childhood Illness (IMNCI) guidelines provide clinical criteria for the management of fever in both low and high-risk areas (see IMNCI guidelines at your institution). There is significant overlap in the clinical presentation of acute respiratory tract infections (pneumonia) and malaria. Children with pneumonia could have malaria and the converse is also true.  Thus, in areas of high transmission all children presenting with fever, even in the presents of other symptoms, should have an RDT done.

In pregnancy, in low malaria areas, women acquire little immunity and get acute symptomatic disease more severe than non-pregnant women. Primigravidas in high malaria areas also have a high risk for placental infection and chronic anaemia.

Exclude other causes of fever:

  • Viral infections
    • Acute respiratory tract infections Measles (high fever, generalised skin rash with cough, red eyes or mouth sores).
    • Mumps (usually have swelling at the angle of the jaw)
    • Chicken pox (will have a vesicular rash).


  • Bacterial infections
    • Pneumonia (cough with fast breathing)
    • Acute ear infection in children
    • Urinary tract infection (frequency or pain on passing urine, loin pains)
    • Typhoid (persistent fever for over 7 days)
  • Opportunistic infections in HIV and AIDS patients


All suspected cases of malaria should be confirmed before treatment is commenced. Blood slides for malaria parasites are required in:

  • Areas of low endemicity
  • Cases of treatment failure

Malaria parasites found on a thick blood smear confirm a diagnosis of malaria. If a laboratory is available, it is important to:

  • Make a thick and thin blood film for malaria parasites
  • Check full blood count (FBC)

Note: Where an RDT is negative and there is still high suspicion of malaria, a slide for microscopy should be taken and sent to the laboratory. A second opinion should be sought in such cases and patients referred if in doubt.


Prompt, safe and effective treatment of uncomplicated malaria prevents progression to severe malaria.

Goal of treatment of uncomplicated malaria

  • Cure of infection (eradication from the body the infection that caused the illness requiring treatment), thus preventing progression to severe           disease
  • reduce transmission (reduce infectious reservoir)
  • prevent the emergence and spread of antimalarial drug resistance


Inquiry of malaria treatment before the current illness is important because it may indicate treatment failure and hence the need for second line malaria medicine


Who should receive Malaria Medicine?

  1. All suspected cases with parasitological confirmation


Choice of malaria medicine

First line medicine should be given by the oral route

Second line medicines should only be used:

  • When there is no improvement after 48 hours
  • If there is reappearance of signs and symptoms of malaria within 14 days after the patient initially recovered and has a positive slide
  • In cases of treatment failure
  • When a patient is allergic or intolerant to the first line medicine.
  • When the 1st line medicine is contraindicated.



First line medicine

      Artemether/Lumefantrine (Co-artemether)


Second line medicine

      Artesunate-Amodiaquine (AS/AQ)


Alternative Second line medicine

Oral Quinine + Doxycycline or Clindamycin


Treatment Failures

It is important to re-assess the patient thoroughly and perform a blood smear for malaria parasites. Also, ask the patient about adherence to and tolerance of prescribed medicine(s) dosing. 


Treatment in Pregnancy

Due to increased risk of severe disease in pregnancy, uncomplicated malaria is an emergency and requires a very effective treatment with lowest possible clinical failure. Some malaria medicines are contraindicated in pregnancy. However, the treatment is usually the same as in any other uncomplicated malaria


First trimester

Oral Quinine + Clindamycin


Second and third trimester

Co-artemether or AS/AQ



Non-falciparum malarias are susceptible to artemisinin derivatives, thus Coartmether can be used to treat these infections. However, P vivax and P ovale form hypnozoites (parasite stages in the liver) which can result in multiple relapses weeks to months later after the primary infection has been treated, hence the need for radical cure with primaquine. Caution should be taken in scenarios where Glucose-6-Phosphate Dehydrogenase Deficiency (G6PD) deficiency of the patient is not known.


Treatment of P Vivax and P Ovale

  • Give an Artemisinin combined therapy (as for Falciparum malaria above) combined with Primaquine, anti-relapse medicine, at a dose of 0.25mg base/kg body weight, taken with food once daily for 14 days in patients WITHOUT G6PD deficiency.
  • Patients with mild to moderate G6PD deficiency, Primaquine 0.75mg base/kg body weight should be given once a week for 8 weeks. Primaquine should not be used in patients with severe G6PD deficiency.

Treatment of P Malariae and P Knowlesi

Treat as for P. Falciparum malaria

Mixed P Falciparum and other infections

A 14-day course of Primaquine should be given for mixed infections including P. Vivax and/or P. Ovale.

  • Efforts should be made to trace the origins of the non-falciparum malaria patients.


For high temperature > 38.50C

  • Avoid over clothing
  • Give Paracetamol 10 mg/kg in children or 500-1000 mg in adults 3 times daily or give Aspirin  ONLY in adults 300-600 mg 3 times daily
  • Encourage patient to take extra fluids and feeds

Follow Up

Tell the patient to return if fever persists for 2 days after commencement of treatment or immediately if condition gets worse or develops signs of severe disease. In case the patient returns, ask whether they adhered to the treatment as advised and do blood smear for malaria parasites. Do a complete assessment to exclude any other possible causes of fever.

Actions to take

1)    If a patient adhered to treatment and the blood slide is positive, give second line malaria medicine

2)    If a patient adhered to treatment and slide is negative, look for other causes of or refer for further management

3)    In case of poor adherence to treatment, repeat the treatment under observation


  • Tell the patient or the caregiver the reason for giving the medicine.
  • Demonstrate how to measure and take or give the correct dose.
  • Observe the patient taking the medicine.
  • Explain that the treatment must be completed even if the patient feels well.
  • Advise them on when to return.       

Check that the patient or caregiver has understood the instructions before leaving the health facility.


It is important to note that the presence of any life threatening condition makes malaria severe. Thus, any patient with malaria who is unable to swallow tablets has any evidence of vital organ dysfunction, or a high parasite count is at increased risk of dying. Hence in the assessment of any patient with suspected malaria, you should carefully look for signs of severe malaria.

In areas of high malaria transmission, malaria is the commonest cause of fever and death especially in young children. Patients can deteriorate rapidly within a few hours or days leading to life-threatening situations like coma, repeated convulsions, shock, severe anaemia etc.

Why does severe malaria need special attention?

This is because:

  • It is a common cause of avoidable death
  • Correct prompt treatment and good nursing care greatly improves outcome.
  • Delayed treatment may result in higher risk of neurological sequelae or deaths

Who are the people at risk for severe malaria?

  • Children < 5 years old in areas of high endemicity
  • People of all ages in areas of low endemicity
  • People returning to highly endemic areas after absence of > 6 months
  • Travellers from areas with little or no malaria
  • Pregnant women especially first pregnancy
  • Patients with sickle cell anaemia - autosplenectomy
  • Internally displaced persons
  • Patients who have had splenectomy.
  • Patients with HIV and AIDS or any other form of immunosuppression

Factors that influence severity of illness

Species of Plasmodium: Severe malaria is mainly caused by P. falciparum though P. Vivax has been implicated in recent past.

Endemicity: Adults and some older children who have lived for long in endemic malaria areas are less susceptible to severe malaria due to the immunity that are developed in these age groups.  However, the under-fives that are non-immune may develop severe malaria.

Host Factors and clinical conditions: Adults visiting endemic areas for the first time, children and pregnant women and people with HIV and AIDS are more susceptible to severe malaria.

Parasite medicine resistance: Degree of parasite medicine resistance that prevails locally also influences severity of malaria.



The effects of malaria infection range from completely asymptomatic infection to fatal severe disease and many factors influence the clinical manifestations. These factors include:

  • Cytokines produced by the individual in response to malaria infection called tumour necrosis factor (TNF). These may cause some of the symptoms and signs of severe malaria, e.g. coma, hypoglycaemia, acidosis and adult respiratory distress syndrome (ARDS).
  • Other mechanisms like sequestration of red blood cells with maturing parasites deep in the capillaries and venules may be the cause of altered level of consciousness.

Severe Malaria Complications


Anaemia is the commonest complication of malaria. It is due to the destruction of red blood cells containing parasites and even those without parasites are more rapidly destroyed during malaria illness. It is of particular importance in African children because of a high prevalence of chronic malnutrition and worm infestation, which often aggravate the anaemia. Anaemia can develop rapidly during malarial illness, especially if there is initial hyper parasitaemia. Children and pregnant women are the ones commonly affected and present with general weakness, severe palmar pallor or pallor of mucous membranes and conjunctiva. If severe it will result in acidosis and heart failure, with fast breathing, swelling of the face or feet, rapid pulse, gallop rhythm and enlarged soft painful liver.

Cerebral Malaria

Cerebral malaria is a common presentation of severe malaria and may cause residual problems.  A patient with malaria and altered level of consciousness, which is not attributable to convulsions, sedatives medicines, hypoglycaemia alone or a non-malarial cause has cerebral malaria.  A child with loss of consciousness after a febrile convulsion should not be considered to have cerebral malaria, unless coma persists for more than an hour after the convulsion. Similarly, a child with malaria and hypoglycaemia who is comatose, diagnosis of cerebral malaria cannot be sustained if consciousness is promptly restored following the administration of glucose.

We do not as of present understand very clearly why patients with malaria develop cerebral malaria. Hence we can only offer some theories (hypothesis) about how cerebral malaria occurs. The facilitator will discuss some of these theories with you. We shall briefly consider some of the features of cerebral malaria and discuss what other conditions may be confused with them.


A patient in coma is not responsive to the surrounding, not able to talk or follow what you are doing or asking. Coma may develop either gradually or suddenly or sometimes follow convulsions and could be moderate or profound (deep coma) with no response to very painful stimuli (following application of gentle pressure over the sternum). Remember that there are many non-malaria causes of coma like meningitis, encephalitis, medicines, etc. carefully look for such causes.     


Patients have abnormal movements of the limbs (hands or legs) or the whole body, with sometimes biting of the tongue or urine incontinence. Although may be absent in a patient with cerebral malaria, they are usually multiple and focal when they occur. Convulsions may also be a result of very high temperature, especially in children or may be due to hypoglycaemia. Once there is a history of convulsion, you should find out about measures taken to abort the convulsions such as use of herbal mixtures, putting onions into the eyes, putting the legs in fire, etc.

Breathing Difficulties

Patients with severe malaria may present with fast or laboured breathing as a result of any of the following:

  • Severe anaemia resulting in acidosis and heart failure
  • Pulmonary oedema (following administration of excessive fluids). Usually there is frothing from the mouth and marked respiratory distress. This is common in malaria in pregnancy
  • ARDS (occurs as a result of malaria parasites in the lungs and could be indistinguishable from pulmonary oedema). It presents with frothing, cyanosis (blue extremities and tongue) and may be crepitations on auscultation of the chest.
  • Acidosis causes deep and rapid respiration


Low blood glucose (2.2 mmol/l) may be due to abnormal liver function or because maturing parasites consume large quantities of glucose from the blood. In children hypoglycaemia may also be a result of poor or reduced food intake. Low blood sugar is harmful to the brain. Patients may have change in behaviour, rapid pulse, convulsions or loss of consciousness or deep coma. Sometimes symptoms are vague (weakness, sweating with cold skin).

Coca-Cola coloured urine (Haemoglobinuria)

Passage of Coca-Cola coloured urine may occur in malaria as a result of excessive breakdown of red blood cells due to parasites or medicines (primaquine, quinine, sulphonamides etc.) that leads to passing haemoglobin in urine. Efforts should however be made to distinguish this from concentrated urine which may be an indication of dehydration; another potential complication of severe malaria.

Renal failure:

Renal failure develops due to low blood pressure as a result of dehydration or shock and is more common in adults with severe malaria. It is easily reversible but this may take a long time and a patient may require peritoneal dialysis to allow the kidneys recover. It is generally uncommon in children. Patients present with signs of dehydration, passing very little urine (oliguria) or no urine (anuria) and when you do renal function tests you find increased blood urea, creatinine and potassium levels. 

Spontaneous Bleeding

Some patients with malaria may have spontaneous bleeding from gums or the skin or prolonged bleeding at injections or vein puncture sites. This is a sign of severe coagulation defect and can lead to death very quickly.


In approaching the clinical assessment of a patient for severe malaria it is important that you bear in mind the following facts:

  • Severe malaria is a treatable condition, provided it is promptly recognised and early appropriate treatment given.
  • Simple laboratory tests once done may prevent adverse disease outcomes
  • Even in endemic areas, the disease can progress very rapidly.
  • Symptoms and signs of severity of the illness must be carefully looked for in the evaluation of a patient with malaria.
  • Symptoms and signs of other common diseases should always be looked for to exclude alternative severe disease


Place of residence and/or history of travel to an endemic area or of recent treatment with malaria medicines or other medicines may be important. Suspect severe malaria in any patient who presents with any of the above signs. In addition to the general history as in uncomplicated malaria you should ask about the following: -

In children ask and check for the general danger signs:

  • Has the child had more than one convulsion within the last 24 hours?
  • See if the child is lethargic or unconscious.
  • Is the child able to drink or breast feed?

A child with any general danger sign has severe disease and needs urgent attention.  Complete the assessment and commence appropriate treatment for severe disease.

In all patients ask about:-

  • Extreme weakness (Prostration) inability to eat and drink or do anything without support.  Progressive weakness should immediately alert you that the patient may be developing severe malaria.
  • Change in behaviour or coma: ask relatives to tell you any observed changes in the patients’ behaviour since the illness started or when the unresponsiveness started.
  • Convulsions: ask about the number of episodes, part of the body involved and time onset of last episode. Enquire about any previous history of seizures. Focal or multiple convulsions over a period of 24 hours is indicative of severe disease. 
  • Drowsiness or deteriorating level of consciousness
  • Time of last drink or food since the onset of the illness to rule out hypoglycaemia.
  • Fast breathing which may occur due to pulmonary oedema or acidosis.
  • Reduced urinary output (time patient last passed urine) which may be a sign of renal failure.
  • Colour of urine whether dark or Coca-Cola coloured (this may suggest excessive breakdown of red blood cells or dehydration).
  • Pregnancy (in females) which is important for treatment options.

Ask history to exclude other severe diseases like: -

  • Meningitis (stiff or painful neck, similar illness and presence of a rash in a close relative may suggest meningococcal meningitis)
  • Diabetes Mellitus (Known diabetic or excessive urination and thirsty)



Medicine History:

Enquire about medicines taken for:

  • Chronic conditions
  • Current illness [including salicylates which can predispose to renal failure and bleeding tendencies, alternative medicines taken (herbal concoctions that may exacerbate complications)].
  • malaria treatment


Previous illnesses:

Ask about any history of recent febrile illness and treatment, which may suggest treatment failure or relapse (consider typhoid, and other infections).


Severe malaria physical examination:

During physical examination you should aim at:

  1. Assessing for the presence of signs of severe malaria.
  2. Identifying other possible causes of disease.

The following should be assessed: -

General examination:

You should check;

  • Vital signs: Temperature, pulse, blood pressure, respiratory rate, weight and if it is a child, do nutritional assessment using IMNCI guidelines (mid upper arm circumference, weight and height).
  • General condition of the patient e.g.
    • whether lethargic or unconscious or able to stand or walk.
    • has difficulty in breathing or fast breathing in children
  • Look for presence of severe pallor or jaundice.
  • Presence of skin rash may suggest measles/other viral diseases in children or meningococcal meningitis. Specifically look for ecchymosis (bluish red blotches on the skin), purpura and petechiae suggestive of severe thrombocytopaenia
  • Retinal bleeding
  • Signs of dehydration (slow skin pinch or sunken eyes especially in children)
  • Enlarged lymph nodes: May suggest HIV and AIDS, Tuberculosis,


Systemic Examination:

It is important to examine the patient carefully going through all systems, looking for common signs of severe malaria and to rule out any other serious illnesses. However this should not take too much time. Bear in mind that the most important problems are usually easy to identify.


Central nervous system

Assess the level of consciousness of the patient and if in coma use a coma scale. On admission endeavour to use an objective scale such as the:

  • Glasgow coma scale for adults
  • Blantyre coma scale for children or any scale with which you may be already familiar with.


In the absence of any of these you can use the AVPU scale

                A = alertness (is the patient alert)

                V = response to voice command (does the patient respond to his name)

                P = response to pain (does the patient feel pain or cry if child)

                U = unresponsive. (Patient does not respond at all)

The level of consciousness worsens as you move down the scale.


Respiratory system

  • Count respiratory rate, look for fast or deep or laboured breathing
  • Look for chest in-drawing especially in children
  • Listen to the chest for rales or any added sounds



  • Feel for the pulse, paying attention to the rate and volume (rapid pulse may suggest heart failure from severe anaemia while small and rapid pulse suggest shock )
  • Cold extremities or poor capillary refill at the tips of the fingers (delay for > 3 seconds)
  • Low blood pressure
  • Listen for heart sounds (gallop rhythm)



  • Feel for the spleen and the liver (enlarged tender liver might mean cardiac failure)
  • Loin tenderness might indicate pyelonephritis


Differential Diagnosis

  • Meningitis - patient may have a stiff neck
  • Encephalopathy - repeated convulsions or deep coma, delirium
  • Diabetes mellitus - patient may be dehydrated, acidotic or in coma
  • Septicaemia - usually very ill and toxic with warm peripheries unless the patient is in shock then the peripheries will be cold
  • Epilepsy - usually no temperature and will have history of convulsions before


Severe malaria laboratory investigations      

 The goal of laboratory investigation in a patient with suspected severe malaria should be to:

  1. Confirm diagnosis of malaria
  2. Confirm complications and assess their severity
  3. Exclude other possible causes of severe disease


The basic (minimum) investigations recommended for patients admitted in hospital for severe malaria should include:

  • Blood smear for malarial parasites
  • FBC
  • Blood sugar level
  • Lumbar puncture in unconscious patient. Where not possible give antibiotics for meningitis
  • Urinalysis for sugar (to exclude diabetes) and proteins (to exclude pregnancy-induced hypertension)
  • Blood for culture and sensitivity


In hospitals where facilities are available more comprehensive investigations can be done such as:

  • Electrolytes and urea blood culture (to exclude septicaemia)
  • Chest X-ray (pulmonary oedema)
  • Blood gases
  • Where resources are available a computerized tomography scan can be done in patients with loss of consciousness


Important points about diagnosis of severe malaria:

  • Have a high index of suspicion in patients with fever and any of the features discussed above
  • Absence of fever does not exclude a diagnosis of severe malaria
  • Microscopic diagnosis should not delay malaria treatment if there is a clinical suspicion of severe malaria, withholding treatment may be fatal
  • Patients’ progress should be monitored and management changed as deemed necessary
  • If the blood smear is negative in a patient with an initial RDT positive and signs and symptoms of severe malaria, commence malaria treatment and repeat blood slide. In high malaria transmission/endemic areas, the parasite density may not be comparable to the severity of the illness.
  • A positive blood film does not mean that malaria is the only cause of the illness in a patient
  • Each patient must be thoroughly examined to exclude other severe diseases  


Deaths from severe malaria can result either from direct effect of the disease or the complications. It is therefore important that appropriate emergency supportive measures and malaria treatment be promptly started.


Goal of treatment

  • The primary objective is to prevent death due to severe malaria.
  • Secondary is preventing neurological deficits


  1. Coma or unconscious patient
  • Ensure airway is patent; gently suction the oropharynx
  • Make sure the patient is breathing
  • Nurse the patient on the lateral position
  • Insert a nasogastric tube
  • Establish an intravenous line for giving medicines and fluids
  • Correct hypoglycaemia:
  1.  Children: 2 ml/kg BWT of 50% dextrose diluted to 25% (dilute 1:1 with water for injection)
  2.  Adults: 20-50 ml of 50% dextrose.
  3.  Where intravenous access is not possible, give dextrose or any sugar solution through the nasogastric tube.
  4.  Continue to monitor blood glucose 4-6 hourly until the patient is stable. If you cannot monitor blood sugar, maintain dextrose saline infusion and pass nasogastric tube for oral feeds or dextrose water.
    • Exclude other treatable causes of coma, e.g. meningitis


  1. Convulsions
  • Ensure patent airway and that the patient is breathing.
  • Correct hypoglycaemia
  • Control temperature
  • In children give rectal diazepam 0.5 mg/kg BWT. If convulsions continue, give 10-15 mg/kg BWT of phenobarbitone I.M.
  • In adults give 10 mg diazepam I.V.

If convulsions continue with no clear cause despite above treatment, refer patients for further investigations.


  1. Severe dehydration or shock
  • In severe dehydration or hypovolaemic shock give 20-30 ml/kg BWT of normal saline and reassess the patient within 30 minutes to decide on the next fluid requirement according to the degree of dehydration. Always bear in mind the pre referral fluids given.
  • After correction of the fluid deficit it is important to reduce the maintenance fluid to two thirds of the required volume when the patient is well hydrated


  1. Severe anaemia
  • Give urgent blood transfusion to patients with severe pallor/anaemia Hb < 5g% in heart failure. It is not advisable to use any rule of thumb (e.g. a haemoglobin level). Instead assess the individual to guide management.
  • Use packed cells (10 ml/kg BWT in children) or fresh whole blood (plus a diuretic such as frusemide)
  • Where blood is not available, give pre-referral treatment and refer urgently to a health facility with blood transfusion services



As already discussed severe malaria can rapidly lead to death. It is therefore important that irrespective of the level at which a patient is seen efforts must be made to initiate appropriate malaria therapy, in order to halt or stem the progression of illness.

Give parenteral Artesunate or Quinine as an alternative where Artesunate is not available


Treatment of severe P Vivax and P Knowlesi is the same as for severe P falciparum. However, for P Vivax add primaquine for 14 days.


  1. High temperature
  • Give Paracetamol (oral) if temperature is > 38.5 o C
  • Fan the patient to lower the temperature.
  • In adults you can also use Aspirin
  1. Pulmonary oedema
  • Prop up the patient, give oxygen and frusemide 2-4 mg/kg I.V.
  • Make sure they are not in heart failure due to severe anaemia
  • Refer the patient to a centre where proper monitoring can be done
  1. Renal failure
  • Exclude pre-renal causes (hypotension and dehydration)
  • Give fluids if patient is dehydrated 20 ml/kg BWT of normal saline and challenge with frusemide 2-3 mg/kg
  • Monitor the fluid intake and output on a patient chart
  • Pass a urinary catheter to monitor urinary output
  • If the urine output is less than 0.4ml/kg BWT /hour, refer/commence for dialysis
  • There is no need to adjust the initial dosage of quinine administered to a patient in renal failure. However, where electrocardiogram facilities are not available, reduction in quinine dosage in persistent acute renal failure should be considered after the third day of therapy, unless if the patient is on dialysis.
  1. Profuse bleeding
  • Transfuse with fresh whole blood and/or fresh frozen plasma. If at a RHC give pre-referral treatment and refer urgently. Profuse bleeding in malaria may be due to thrombocytopenia.
  1. Other possible treatments
  • If meningitis is suspected and you cannot exclude it immediately by a lumbar puncture, give appropriate antibiotics
  • Other severe diseases should be treated according to the available guidelines

Treatments not recommended:

The following treatments have no role in the treatment of malaria:

  • Corticosteroids and other anti-inflammatory agents
  • Agents used for cerebral oedema, e.g. mannitol
  • Adrenaline
  • Heparin


Severe malaria is a serious condition and the clinicians and nurses should closely monitor patients. Therefore, nursing care should include all the following:

  1. Monitor vital signs
    1. Pulse
    2. Temperature
    3. Respiratory rate
    4. Blood pressure

These should be monitored at least every 4 hours but may be done more frequently at the initial stages of treatment.

  1. Monitor input and output

A strict 24-hour input and output chart should be kept in all patients with severe malaria. Examine regularly for signs of dehydration or fluid overload.

  1. Monitoring unconscious patient

Unconscious or comatose patients need close monitoring of all vital signs more regularly to assess their progress. Monitor the level of consciousness at least every 6 hours using a coma scale. Patients should be turned in bed 2 hourly to avoid bedsores.

  1. Medicine chart

A clear medicine chart where all medicines given are recorded should be kept and should include dose, route, frequency, time given and all medicines given should be signed for.  

  1. Pregnant women

These should be monitored closely ensuring that they don’t become hypoglycaemic and the well-being of the foetus should also be monitored. Watch out for signs of severe anaemia and pulmonary oedema.


  1. Monitor the parasitaemia - Do blood smears every second day. If high after 2-3 days of medication, review adequacy of the medicine doses.
  1. Monitor blood glucose

Do blood glucose at least 6 hourly, and at any point immediately following deterioration of consciousness or convulsion. If it falls to < 3.4 mmol/l treat as hypoglycaemia. Where you cannot monitor blood sugar, maintain dextrose saline infusion (with dextrose made up to 10%).

Review your fluid infusion or ensure that patient gets oral feeds by nasogastric tube.

  1. Monitor FBC

If the Hb falls to critical levels or there are clinical signs of heart failure, transfuse the patient even if they had been transfused before.



The symptoms and complications of malaria in pregnancy vary according to transmission intensity and the level of acquired immunity. Pregnant women living in areas of low or unstable malaria transmission have little or no immunity to malaria, and are at higher risk of developing severe malaria than are non-pregnant adults living in the same area.

In these areas, malaria is a major cause of maternal anaemia, spontaneous abortion, stillbirth, premature delivery, low birth weight (birth weight < 2.5kg), neonatal death and maternal death. In non-immune women, severe malaria symptoms (hypoglycaemia, cerebral malaria, and pulmonary oedema being particular problems) are more common in pregnancy.


In stable transmission settings, the deleterious impact of malaria is particularly apparent in first and second pregnancies. Partial clinical immunity acquired during years of exposure to the malaria parasite prior to pregnancy does not prevent infection, but does reduce the risk of severe disease. Clinical malaria is not, therefore, a prominent feature of infection during pregnancy, and the major detrimental effects of infection are low birth weight (LBW) and maternal anaemia.

HIV infection impairs pregnant women’s ability to control P. falciparum infection. Women with HIV infection are more likely to have symptomatic malaria infections and to have an increased risk of an adverse birth outcome due to malaria. In the presence of HIV infection, placental malaria appears to be independent of the number of pregnancies, so that the risk of placental malaria is similar in HIV-infected multigravida and HIV-negative primigravidae.

Severe anaemia, exacerbated by malaria, is an important complication of pregnancy. This may be exacerbated by chronic hookworm infestations. High output anaemic cardiac failure may develop in late pregnancy as a result.

Asymptomatic hypoglycaemia may occur in pregnant women with malaria before antimalarial treatment, and pregnant women with uncomplicated or severe malaria are particularly vulnerable to quinine-induced hypoglycaemia.

There is an increased risk of pulmonary oedema precipitated by fluid overload or by the sudden increase in peripheral resistance, or auto transfusion of hyperparasitaemic blood from the placenta, which occurs just after delivery.


Since malaria in pregnancy poses significant risk to the mother, her foetus and new-born, a three-pronged approach to prevention and control of malaria among pregnant women is employed in Zimbabwe. The strategies include:

  • Use of insecticidal nets and indoor residual insecticidal spraying
  • Practicing personal protection (e.g. use of repellents, wearing clothes that cover most of the body)
  • Administration of Immune Preventative Therapy using Sulphadoxine-Pyrimethamine (SP)
  • Appropriate case management with prompt and effective treatment of malaria in pregnant women.

Prevention of malaria in pregnancy

The facilitator should discuss the use of malaria prevention in pregnancy, including the use of indoor residual spraying, use of Long-Lasting Insecticidal Nets (LLINs) and Immune Preventative Therapy

Intermittent Preventive treatment in Pregnancy

Data have shown that when pregnant women took 3 or more doses of Immune Preventative Therapy, they had less placental malaria, delivered fewer low birth weight babies and their infants had higher mean birth weights compared to those who took two doses of Immune Preventative Therapy. Given these data, WHO updated the recommendations on Immune Preventative Therapy including advocating for at least four doses of Immune Preventative Therapy at each of the scheduled focused antenatal care (ANC) visits during pregnancy in areas of moderate and high malaria transmission.

In 2014 Zimbabwe adopted the updated WHO recommendations with the hope of ensuring that more women will receive at least 3 doses of IPTp and have fewer adverse consequences of malaria in pregnancy.

Schedule for immune Preventative Therapy

  • Three (3) tablets of Sulphadoxine-Pyrimethamine (each tablet contains Sulphadoxine 500 mg and Pyrimethamine 25 mg) are given at booking (after quickening)
  • Sulphadoxine-Pyrimethamine is given to all pregnant women at each scheduled ANC visit up to time of delivery
  • The doses should be at least 4 weeks apart
  • Sulphadoxine-Pyrimethamine should ideally be given as directly observe therapy of 3 tablets of Sulphadoxine-Pyrimethamine
  • Sulphadoxine-Pyrimethamine can be given on either an empty stomach or with food
  • Sulphadoxine-Pyrimethamine should NOT be administered to women receiving Cotrimoxazole prophylaxis
    • Cotrimoxazole has antimalarial effects
    • Sulphadoxine-Pyrimethamine and cotrimoxazole both have sulphonamides and if used concurrently may lead to sulphur toxicity.
  • Pregnant woman taking Immune Preventative Therapy should also receive 5mg folic acid weekly or 0.4mg folic acid daily (high doses of folic acid reduce the efficacy of Immune Preventive Therapy


Considerations for implementation

Suspected malaria in a pregnant woman

The woman should be evaluated for malaria infection before giving Immune Preventive Therapy. If the woman is parasitological confirmed of malaria, she should be treated for malaria according to the National Treatment Policy and IPTp should be commenced or continued after completion of malaria treatment. If there is no parasitological evidence of malaria, and the woman is eligible for Immune Preventive Therapy, she should be given.



Treatment of uncomplicated malaria in pregnancy

Pregnant women with symptomatic acute malaria are a high-risk group, and require effective antimalarial medication. There is insufficient information on the safety and efficacy of most antimalarial medicines in pregnancy, particularly for exposure in the first trimester, and treatment recommendations differ from those for non-pregnant adults. Therefore, as a standard practice for the administration of any medicine pregnant women, all women of child-bearing age should be asked whether they are, or could possibly be, pregnant before an antimalarial medicine is prescribed. The following are the antimalarial medicines recommended for the treatment of uncomplicated falciparum malaria during pregnancy:

    1. In the first trimester, give a 7-day course of quinine plus clindamycin. Artemisinin Combined Therapy are not recommended as routine treatment in early pregnancy because their safety has not been fully established. An ACT is indicated only if
      • it is the only treatment immediately available
      • if treatment with 7-day quinine plus clindamycin fails
      • if there is uncertainty about the patient’s compliance with a 7-day course of treatment.
    2. In the second and third trimesters, give Coartemether or ASAQ. Alternatively, 7-day quinine plus clindamycin may be given.


Treatment of severe malaria in pregnancy

A pregnant woman with severe malaria should be given a parenteral antimalarial medicine in full doses without delay. Parenteral artesunate is more effective than parenteral quinine in reducing the risk of death from severe malaria. Although safety data on the use of artemisinins in the first trimester are limited, saving the mother’s life is the primary objective, and both artesunate (IV or IM) and quinine (IV or IM) may be considered as options.

In the second and third trimesters, parenteral artesunate is preferred over parenteral quinine, because of its antimalarial efficacy and because quinine is associated with recurrent hypoglycaemia.



This unit helps to learn about the common requirement of any patient admitted to hospital when they have recovered and are due for discharge. The records and the observations made will provide some progress of the patient's recovery e.g. falling temperature, parasite load, urine output and improving coma. It is also important to record the patient’s ability to:

  • talk
  • eat or drink
  • sit
  • stand or walk


After full recovery assess for possible residual problems of the disease or treatment. You should at least do the following: -

  1. Assess the ability of the patient to do what he/she was doing before the illness.
  2. Assess vision and hearing by asking whether they can see or hear; for children use objects or noisy rattles.
  3. Check haemoglobin/haematocrit and for malarial parasites on the 7th and 14th day after recovery.
  4. Write a summary of the events of the illness, presenting features, laboratory examination, treatment given, response to treatment and any residual problems.
  5. Organise for follow up of your patient.
  6. If patient was referred write a summary of what you did and treatment given to the referring health work.



  1. Assess the patient by asking about the fever or any other symptoms and do clinical examination looking for signs of residual disease complications and any new signs.
  2. Do laboratory examination for malaria parasites (microscopy) and Hb level on day 7 and 14 after recovery.
  3. If parasites are still present ensure that patient complies with treatment and manage as appropriate.
  4. If still anaemic, give folic acid and ferrous sulphate and review after 14 days to check on haemoglobin or haematocrit level.



The health workers should give health education to patients or guardians. This should focus on the current illness, treatment and prevention of malaria.

  • The importance of early diagnosis and prompt treatment.
  • Seeking treatment or taking available anti-malarials promptly when they have fever.
  • Counsel patients about their illness and treatment.
  • Tell the patient or the child’s mother the reason for giving the medicine.
  • Demonstrate how to measure and take or give the correct dose.
  • Explain that the medicines must be used to finish the course of treatment even if the patient feels well.
  • Advise them on when to return immediately or for follow-up.  
  • Check that patient or mother has understood before leaving the clinic.
  • Importance of antipyretics and fluid intake at home.
  • Also counsel them about feeding
  • Prevention and personal protection
  • Mosquito screening devices in the design of houses and protective dressing.
  • Use of insecticide treated materials should be encouraged.
  • Use of insecticides and mosquito repellents.
  • Environmental management especially reducing mosquito breeding sites
  • Prophylaxis (where indicated)
  • Community mobilization for malaria control
  • Use community health workers to follow up the patients
  • Work with existing community development committee and other community organizations and leaders.
  • Work with people from other sectors that are concerned with social and economic development of the community.