Guidelines for the Diagnosis and Treatment of Malaria in Somalia 2016

Introduction

The main objective of the malaria prevention and control programme in Somalia is to prevent mortality and reduce morbidity due to malaria. The groups most vulnerable to the disease, children aged under 5 years and pregnant women, are especially targeted. Effective case management - early diagnosis and treatment - is a critical component of malaria prevention and control. To achieve the main objective of reducing malaria morbidity and prevention of malaria mortality, the availability of safe, effective, affordable and accessible anti-malarial drugs is a prerequisite.

The first national diagnosis and treatment guidelines were developed in May 2005 following a consensus meeting held in Nairobi1 and updated in January 2011. Therapeutic efficacy studies conducted in 2011, 2013 and 2015 revealed high level of artesunate+sulfadoxine/pyrimethamine treatment failures (12-22%). These failure rates were above the 10% threshold level recommended by WHO (4) for changing antimalarial treatment policy. In these studies high efficacy (above 97% cure rate) of artemether+lumefantrince, second-line drug was found.

In view of the these findings, the guidelines were again updated during a consensus workshop on 22 – 23 February 2016 in Hargeisa, Somaliland. The recommendations in these updated guidelines are consistent with the National Malaria Control Strategy 2016–2020.

The updated guidelines provide adequate information to health workers on the specific details of malaria diagnosis and treatment at different levels of the health care system. The first part describes the management of uncomplicated malaria while the second part deals with management of severe malaria. The guidelines also provide recommendations for antimalarial medicines and dose regimens for intermittent preventive treatment for pregnant women.

The objectives of treatment for uncomplicated malaria are to cure (radical) the infection rapidly, prevent progression to severe disease, reduce transmission of the infection to others and prevent the emergence of anti-malarial drug resistance.

The objectives of treatment for severe malaria are to prevent death, neurological deficit and recrudescence.

Malaria epidemiology

Malaria burden in Somalia

Although there are limited national data and statistics on the burden of malaria in Somalia, it is considered a major public health problem in the country. The dominat malaria species in the country has been Plasmodium falciparum accounting more than 95%. However, increased proportion of P. vivax has been reported from North-west (Somaliland) and Northeast (Puntland) zones. A screening of patients with fever of history of attending the Bosaso regional hospital during 4 January to 14 February 2016 revealed 37.0% (258/697) 12.8% (89/697) of P. falciparum and P. vivax respectively indicating that P. vivax accounted for 25.6% of the infections. Mixed infection accounted for 0.4% (3/697). In 2015, a total of 88 139 cases, of which only 17913 were laboratory confirmed, were reported (annex 1).
However, the reported figure seems far below the real burden considering that:

• 70% of people suffering from malaria symptoms seek help outside public health facilities;
• the performance of the health information system as a whole is far from satisfactory;
• recording of malaria cases at maternal and child health centres is poor;
• reporting by health facilities to WHO is irregular, inaccurate and incomplete.

On the other hand, owing to the inadequacy, inaccessibility and non-availability of public health care facilities with reliable laboratory diagnostic facilities for the confirmation of malaria, overdiagnosis of malaria remains a serious problem. In most cases, the diagnosis of malaria is clinical and based only on fever or a history of fever. This makes it difficult to arrive at a true estimation of the malaria burden. The World malaria report 2015 estimated that there were 310 000-1 300 000 cases of uncomplicated malaria and 42-4800 malaria deaths in Somalia.

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