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Infectious Diseases

Malaria (Uncomplicated)

An acute febrile illness caused by Plasmodium parasites transmitted by Anopheles mosquitoes, presenting without signs of severity or evidence of vital organ dysfunction.

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Referral and warning signs

When to refer

Refer if: Patient develops any signs/symptoms of severe malaria (see INF033). Unable to tolerate oral medication (persistent vomiting). No clinical improvement after 2-3 days of appropriate ACT treatment. Pregnancy in 1st trimester requiring quinine.

Red flags

  • Any danger sign suggesting progression to severe malaria (altered consciousness, seizures, prostration, respiratory distress, jaundice, dark urine, severe vomiting, bleeding).

Signs and symptoms

  • Fever (>37.5°C axillary) or history of fever in past 48h.
  • Headache.
  • Muscle aches (myalgia), Joint pains (arthralgia).
  • Weakness, fatigue, malaise.
  • Chills, rigors (may occur).
  • Loss of appetite, nausea, mild vomiting.
  • Mild diarrhoea (sometimes).
  • Mild anaemia (pallor).
  • Mild dehydration.
  • Minimally enlarged, soft spleen (sometimes).

Risk factors

  • Exposure to Anopheles mosquito bites in endemic area.
  • Lack of immunity (young children, visitors to endemic areas).
  • Lack of protective measures (bed nets, repellents).
  • Pregnancy (increased susceptibility).

Diagnosis

Clinical assessment

Suspicion based on fever or history of fever in endemic setting. Symptoms are non-specific.

Differential diagnosis

  • Viral URTI / Common Cold / Influenza.
  • Gastroenteritis.
  • Urinary Tract Infection (UTI).
  • Pneumonia.
  • Typhoid Fever.
  • Brucellosis.
  • Other febrile illnesses.

Investigations

  • Parasitological Confirmation is MANDATORY before treatment:
  • - Malaria Rapid Diagnostic Test (RDT): Preferred method for rapid diagnosis. Detects malaria antigens (HRP2 for P. falciparum, pLDH for all species). Reliable, easy to use.
  • - Microscopy (Thick and Thin Blood Smear): Gold standard. Allows species identification and quantification of parasitaemia. Requires trained microscopist and equipment. Preferred over RDT if recent treatment, persistent symptoms, or RDT negative with high suspicion.
  • Consider FBC (Hb level) if pallor present.

Diagnostic criteria

Symptoms suggestive of malaria + Positive RDT or Blood Smear for Plasmodium parasites.

Management

Non-pharmacological management

  • Ensure adequate hydration (oral fluids).
  • Rest.
  • Tepid sponging for high fever.

Pharmacological treatment

  • Antimalarial Treatment (Artemisinin-based Combination Therapy - ACT is first line):
  • - First Line: Artemether-Lumefantrine (AL / Coartem) PO. Dose based on weight bands (see UCG table p.170). Given twice daily for 3 days (Day 1: dose at 0h and 8h; Day 2 & 3: dose Q12H). Should be given with fatty food/drink for better absorption. (LOC: HC1+)
  • - First Line Alternative: Artesunate-Amodiaquine (AS+AQ) PO. Dose based on age bands (see UCG tables p.170-171). Given once daily for 3 days. (May have higher risk of side effects than AL).
  • - Second Line: Dihydroartemisinin-Piperaquine (DHA+PPQ / DP) PO. Dose based on weight bands (see UCG table p.171). Given once daily for 3 days. Longer post-treatment prophylactic effect.
  • - Third Line (If ACTs unavailable/contraindicated): Quinine tablets PO Q8H for 7 days. Dose based on weight (see UCG table p.172). Often used with adjunct like Doxycycline/Clindamycin (specialist). Less effective, poor adherence, more side effects.
  • Special Groups:
  • - Pregnancy 1st Trimester: Quinine (+ Clindamycin if available) for 7 days is historically recommended. ACTs now considered relatively safe by WHO if benefits outweigh risks, but national guidelines prevail (UCG 2023 still lists Quinine first line). Consult specific guidelines.
  • - Pregnancy 2nd & 3rd Trimester: Artemether-Lumefantrine (AL) is preferred ACT.
  • - Infants <4-5kg: Specific dosing/formulations needed, consult national guidelines/specialist.
  • Symptomatic Relief:
  • - Paracetamol PO for fever/headache. (LOC: HC1+)

Monitoring

Advise patient to return if symptoms worsen or do not improve within 2-3 days. Monitor adherence to full 3-day ACT course.

Complications

  • Progression to severe malaria if untreated or inadequately treated.
  • Anaemia.
  • Recrudescence (incomplete cure) or Re-infection.

Prevention

  • Use of Long-Lasting Insecticide-treated Nets (LLINs).
  • Indoor Residual Spraying (IRS) in targeted areas.
  • Larval source management.
  • Appropriate case management (prompt diagnosis and effective treatment).
  • Intermittent Preventive Treatment in Pregnancy (IPTp) with SP.
  • Seasonal Malaria Chemoprevention (SMC) in eligible regions/age groups.
  • Personal protection (repellents, clothing).

Patient education

  • Explanation of malaria diagnosis.
  • Importance of completing the FULL 3-DAY course of ACT medication, even if feeling better.
  • How to take medication correctly (e.g., AL with fatty food).
  • Symptom management (fever, hydration).
  • Signs of severe malaria requiring immediate return to health facility.
  • Importance of using bed nets consistently.
  • Seeking prompt testing/treatment for future fevers.

Uganda-specific notes

Malaria is highly endemic. P. falciparum predominates. Presumptive treatment based on fever alone is DISCOURAGED; parasitological confirmation (RDT/Microscopy) is mandatory. Artemether-Lumefantrine (AL) is the standard first-line ACT.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 2, Section 2.5.2, 2.5.2.1

  • Consolidated Guidelines for the Prevention and Treatment of Malaria in Uganda

    (Latest MOH Malaria Guidelines)

For learning and professional reference. Use current local guidance and clinical judgement.

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