Islamic Republic of Afghanistan Ministry of Public Health General Directorate of Preventive Medicine Communicable Diseases Control Directorate National Malaria and Leishmaniasis Control Programme

Prevention of malaria:

There are three main ways in which we try to reduce the spread of malaria:

• 
  Treat people who are sick with malaria quickly so that the microorganisms cannot be sucked up by a mosquito,
  
• 
  Reduce the numbers of mosquitoes by controlling their breeding sites, and
  
• 
  Preventing mosquito bites by using bed nets with insecticide.
  

Step 1. Register the patient. If the CHW is illiterate the family member or patient or patient’s family member will help to register the patient.

Step 2. Please follow the procedures

1. 
   ASK about : ( ask the patient or guardian in case of children)
   

• 
  The chief complaints: fever, headache, earache, throat pain, chilling, vomiting, cough, breathing difficulties, burning micturition.
  
• 
  Present illness: explanation of the above symptoms eg patient complains of fever and CHW must enquire after the fever history
  
• 
  Past history of the complaints: History of body feeling hot within 2-3 days, duration of the symptoms
  
• 
  History of past illness: history of past episode of fever, malaria etc
  

2. 
   LOOK:
   

• 
  Observe the appearance- ill looking/ unconsciousness/ drowsiness/ stable
  

3. 
   FEEL:
   

• 
  Use the back of your palm to check if the patient’s forehead feels hot
  

4. 
   Inspect the patient for : (more emphasise in case of children)
   

• 
  Ear discharge ( ask about ear pain)
  
• 
  Infection of the skin
  
• 
  Fast breathing / breathing difficulties
  
• 
  Sore throat ( ask about throat pain)
  

5. 
   TEST
   

• 
  Measure body temperature with thermometer from armpit (≥37.5°C/99.5° F or above) if the patient has fever
  
• 
  Use RDT (if needed)
  

1. 
   If the patient’s symptoms are similar to that of malaria and his/her condition is stable without any danger sign, use RDT. Treat the patient with ACT or Chloroquine if the result is positive for the malaria test. Give the first dose instantly.
   
2. 
   Refer the patient with danger signs to the nearest health facility.
   

• 
  He/she is uunable/unwilling to drink or feed (breastfeeding for children)
  
• 
  He/she vomits everything
  
• 
  History of convulsions
  
• 
  Presence of Lethargy / drowsiness / unconsciousness
  
• 
  she is severely anaemic
  

3. 
   Refer the patient of less than 5 months age with RDT positive result to the nearest health facility.
   
4. 
   Refer the pregnant women (1^st trimester) with RDT positive result to the nearest health facility.
   

RDT is a malaria diagnostic device that detects malaria specific protein (antigens) which is produced by malaria parasites.

It has

• 
  Space A for buffer
  
• 
  Space S for blood sample
  
• 
  Window C for control
  
• 
  Window test for Pf or PAN (Plasmodium another- P. vivax, or P. malaria or P. ovale) result
  

• 
  No need for laboratory facilities
  
• 
  Easy to carry
  
• 
  Simplicity and rapidity of the tests.
  
• 
  No need for electricity or laboratory equipment.
  
• 
  Minimal requirement for training (basic skills acquired in 1 day).
  
• 
  Acceptable levels of sensitivity and specificity, and
  

• 
  More expensive than microscopy.
  
• 
  Prolonged positive result after effective treatment.
  
• 
  Storage conditions of RDTs
  

1-Prepare the materials needed

• 
  RDT
  
• 
  new, unopened lancet
  
• 
  Alcohol swab
  
• 
  disposable gloves
  
• 
  timer or watch
  
• 
  Safety box
  
• 
  Pencil or marker for labeling the RDT
  
• 
  Record book and pen for results
  

2- Check

- Colour of desiccant

3- Wear disposable gloves.

Doing the test (1)

1. 
   Open the RDT packet and take out device just before use
   
2. 
   Label RDT with patient’s name or ID before doing the test
   
3. 
   Clean the patient’s finger with an alcohol swab and let it dry before doing a finger prick
   
4. 
   Discard used lancet immediately in the safety box
   
5. 
   Touch the surface of the blood with the collecting tube/device to get 5mL of blood
   

6) Slowly deliver the blood from the collecting tube onto the sample wall (S)

7) Discard the used blood collecting tube immediately in the sharp box

8) Invert the buffer bottle vertically and slowly dispense the required number of

9) Wait for the prescribed time (e.g.15-20 minutes) before reading the results

• 
  Keep RDTs in the coolest part of the room, but never freeze them. They do not need refrigeration
  
• 
  Protect RDTs from excessive heat (Keep it within 4⁰-30⁰ C)
  
• 
  Store away from direct sunlight
  
• 
  Do not store close to a wall or ceiling, as both absorb heat during the day
  
• 
  Store a minimum of 30 cm away from walls and ceiling
  
• 
  Do not store directly on the ground
  
• 
  To reduce damage from moisture, water, and pests, store on a shelving unit or shelf, if possible
  

• 
  Take alcohol swab and clean the patient’s finger
  
• 
  Let it dry before the pricking
  
• 
  Open the lancet
  
• 
  Prick the finger with lancet
  
• 
  Discard the lancet in to the sharp box
  
• 
  Swab the first drop of blood
  
• 
  Press the pricked finger for second drop of blood
  
• 
  Touch the surface of the blood with the collecting tube to get 5mL of blood
  
• 
  Slowly deliver the blood from the collecting tube on to the sample wall (S)
  
• 
  Discard the used blood collecting tube immediately in the safety box
  

• 
  Participants will follow the instruction of RDT use (mentioned above)
  
• 
  They will follow the given Pictorial procedure of RDT use
  
• 
  They will apply on patients
  
• 
  Otherwise they will form groups and do the practical on each other.
  

• 
  Invalid result (the test device is invalid):
  

1. 
   No line in the control window or
   
2. 
   No line in the control & test window
   

• 
  Valid result( the test device is valid):
  

1. 
   Red line only in the control window or
   
2. 
   Red line in the control & test window
   

• 
  Negative result
  

1. 
   Red line in the control window and
   
2. 
   No line in the test window
   

• 
  Positive result
  

1. 
   Red line in the control window and
   
2. 
   Red line in the test window
   

Interpretation of positive result:

1. 
   Red line in control window & in Pf line of test window – Pf malaria case
   
2. 
   Red line in control window & in PAN line of test window – Pv malaria case
   
3. 
   Red line in control window , in Pf line & PAN line of test window – mix infection
   

After doing the test

1) Discard used gloves, swab, and desiccant in a non-sharp waste container

2) Keep used RDTs in the box. Return used RDTs for replacement with new RDTs

3) Record results in the register.
Chapter Four:

Treatment of malaria

What is ACT:

ACT - it is artemisinin combination therapy. It includes Artesunate 50/100mg + SP (sulfadoxine500 mg +Pyrimathamine 25 mg).

Treatment of P. falciparum malaria:

Artesunate(50 mg or 100 mg ) and SP( sulfadoxine500 mg +Pyrimathamine 25 mg) the recommended drugs for effective malaria treatment in Afghanistan

Important;

• 
  Day1 dose should be administrated as a Direct Observation therapy(DOT)
  
• 
  Remind the patient to complete the treatment.
  
• 
  Advice the patient to sleep under a long lasting insecticidal net to prevent Malaria attack
  

The dose chart is only applicable for:

Blister 1: adult blister

Artesunate 100 and sulfadoxin +Pyrimthamine 500mg+25mg TABLET

Blister 2 Children Blister

Artesunate 50 mg and Sulfadoxin + Pyrimethamine 500 mg + 25 mg TABLET

Chloroquine (150mg base tablet)

• 
  Registration of the patient
  
• 
  Use RDT
  

RDT positive (Pf/PAN)

Patient Stable.

Treat the patient

Patient with danger sign

Refer to health facility

Refer to health facility

Refer to health facility

Treat the patient as usual according to CHWs guideline

If Pf positive treat with ACT

Patient comes back with symptoms after treatment

Refer the patient to the nearest health facility

• 
  Register
  
• 
  Introduce each other
  
• 
  Share their expectations of the training
  
• 
  Introduce with the rules & norms of the training
  
• 
  Undertake a pre-test
  
• 
  Introduce about goal & objectives of the training
  
• 
  Know about the general information of malaria
  

At the end of the session the participants will be able to

• 
  Define malaria
  
• 
  Describe signs & symptoms of malaria
  
• 
  Identify the causative agent of malaria
  
• 
  Name the vector of malaria
  
• 
  Describe the mode of transmission of malaria
  
• 
  List the main malaria prevention methods.
  

• 
  Question and answer
  
• 
  Pictorial presentation
  
• 
  Lecture with discussion
  

General Information about malaria

• 
  What is malaria
  
• 
  Signs & Symptoms of malaria
  
• 
  Causative agent of malaria
  
• 
  Vector of malaria
  
• 
  Mode of transmission of malaria
  
• 
  Prevention of malaria
  

• 
  Note books
  
• 
  Pen, Pencil
  

• 
  Posters/ Pictures
  
• 
  Flip Chart
  

At the end of the session the participants will able to

• 
  Know what is RDT
  
• 
  Describe advantages & disadvantages of RDT
  
• 
  Use RDT to diagnose malaria
  
• 
  Store RDT at health post level
  

• 
  Demonstration of RDT
  
• 
  Question and answer
  

• 
  RDT Kits
  
• 
  Pictorial instruction about RDT use
  
• 
  Safety box
  
• 
  Register form
  

At the end of the session the participants will able to

• 
  Collect patient’s blood for RDT
  
• 
  Use RDT for diagnosis of malaria
  
• 
  Interpret the result of RDT
  

• 
  Practical group work
  
• 
  Practical use of RDT
  

• 
  Technique of blood collection from patient’s finger
  
• 
  Use of RDT for malaria diagnosis
  
• 
  Interpretation of the result of RDT
  

• 
  RDT
  
• 
  Lancet
  
• 
  Alcohol swab
  
• 
  Buffer
  
• 
  Dropper
  
• 
  Pictorial instruction about RDT use
  
• 
  Timer/ Watch
  

At the end of the session the participants will able to

• 
  Define ACT
  
• 
  Treat the falciparum malaria cases by using ACT
  

• 
  Lecture with discussion
  
• 
  Demonstration of ACT
  
• 
  Role play
  

• 
  Introduction of ACT
  
• 
  Treatment of malaria by using ACT
  

• 
  ACT (Dosage forms)
  
• 
  Pictorial demonstration of ACT, Dosage & treatment
  

Session 5: Reporting on RDT, ACT & malaria cases

At the end of the session the participants will able to

• 
  Report on used RDT, positive & negative RDT
  
• 
  Report on ACT use
  
• 
  Report on malaria cases
  

• 
  Demonstration of reporting formats
  
• 
  Small group discussion
  

• 
  Reporting system about RDT
  
• 
  Reporting system about ACT use
  
• 
  Reporting system about malaria cases
  

• 
  Different kinds of reporting formats
  

• 
  Question and answer
  
• 
  Discussion
  

• 
  Review of the previous lessons
  
• 
  Post test
  
• 
  End evaluation of course
  

• 
  Post test sheet
  
• 
  Course evaluation sheet