Malaria

MALARIA CEREBRAL IN CHILDREN

Pembimbing: Dr. HERI, SpA

IDENTITAS
Tanggal 21 Januari 2013 IDENTITAS PASIEN Nama : An. Rivaldi Umur : 13 tahun Jenis Kelamin : Laki-laki

IDENTITAS ORANG TUA PASIEN

IBU Nama : Ny. Jamalia Umur : 55 tahun Pekerjaan : IRT Pendidikan : SD AYAH Nama : Tn. Barsani Umur : 60 tahun Pekerjaan : petani Pendidikan : SD

RIWAYAT KELAHIRAN
Persalinan : tidak diketahui Bayi lahir cukup bulan BBL : tidak diketahui PB : tidak diketahui Kelainan kongenital : Riw. Imunisasi : tidak diketahui

TUMBUH KEMBANG
Penyakit yang pernah diderita : Disangkal Riwayat dirawat : Disangkal Psikologi / Perkembangan Mental : Normal

Ikhtisar Kasus Kasus Ikhtisar

Seorang anak laki-laki, usia 13 tahun, BB = 65 kg, dibawa orangtuanya pada hari Senin, 21 Januari 2013 pukul 21.50 ke UGD RS AM Parikesit dengan: Keluhan Utama: pasien tidak sadarkan diri Keluhan Tambahan:demam menggigil, muntah, mimisan, seperti orang kejang, gelisah, meracau

Riwayatperjalanan Perjalanan Penyakit Riwayat penyakit:

21 Januari 2013 Pemeriksaan Fisik

Keadaan Umum:Tampak Sakit Sedang Kesadaran : E3M4V3 FrekNadi : 72 x/menit (Reg, kuat angkat, isi cukup) Frek Nafas : 22 x/menit (Reg, adekuat) TD : 100/40 mmHg Suhu : 38.50 C (axilla) K/L : CA -/-, SI -/Thoraks : Ins: Pergerakan dinding dada simetris Pal: Vocal fremitus kanan = kiri Per: Sonor kanan = kiri Aus: BND Bronkhial, Rh -/-, Wh -/BJ I & II Normal Abdomen : Ins: Perut tampak datar Pal: Nyeri tekan (+), hati teraba 1 jari bac, limpa tdk teraba besar Per: Tympani Aus: Bising Usus (+) 4x/menit Ekstremitas: Akral dingin, Capillary refill < 2 detik Kulit : Turgor cukup,

Penatalaksanaan
Dengan keadaan tersebut di atas, pasien mendapatkan penanganan di UGD sebagai berikut: - O2 2 -3 lpm

- IVFD: D5% 650 cc+ 1300 mg CAP (162 cc/jam IP) selama 4 jam selanjutnya D51/2NS 143 cc/jam selama 4 jam - IVFD: D5% 325 cc+ 650 mg CAP (162 cc/jam IP) selama 2 jam selanjutnya D51/2NS 143 cc/jam selama 6 jam - IVFD: D5% 325 cc+ 650 mg CAP (162 cc/jam IP) selama 2 jam selanjutnya D51/2NS 143 cc/jam selama 6 jam - Inj Ceftriaxone 2x 1 gr IV - PCT 3x500 mg

Pada pukul 03.15 dari Pemeriksaan Fisik didapatkan: KU: lemah FP: 46 kali/menit FN: 160 kali/menit TD: 120/70 mmHg Dokter menjelaskan kepada orangtua pasien bahwa keadaan anak kritis dan dianjurkan untuk segera dirawat di ICU Pada pukul 06.30 dari Pemeriksaan Fisik didapatkan: KU: lemah FP: 46kali/menit FN: 227kali/menit TD: 90/80 mmHg Instruksi dokter saat itu: - CIV: Widahes 325cc/jam, Asering 325 cc/jam

Penatalaksanaan
Pukul 15..00. Hasil H2TL ulang Hb/Ht/Leukosit/Trombosit: 13,0/38/9200/55.000 Instruksi dokter: - CIV: Widahes325cc/jam, Asering 325 cc/jam - Obs KU, TTV, tanda perdarahan, GDS, H2TL

Pasien dipindahkan ke ICU,terpasang selang NGT berisi cairan warna hitam kental, urin pada DC kuning pekat.

Hasil Foto USG 22 Januari 2013

Hepatomegaly Splenomegaly (malaria) Cairan bebas abdomen

Follow Up 22 Januari 2013

S: gelisah + O: KU/Kesadaran : Tampak Sakit Berat Apatis FN : 128x/mnt, RR 40x/mnt, TD 100/50 mmHg, Suhu 38,9 C K/L : anemis -/-, ikterik -/Thoraks : vesikuler, rhonki -/-, wheezing -/-, BJ normal, gallop -, murmur Abdomen : BU +, supel, NT +, hati teraba 2 jari bac A: Malaria Cerebral P: - CIV: Asering 162 cc/jam dan D51/2NS 162cc/jam+CAP 2,6 cc habiskan dalam 3 jam - O2 2-3 lpm - MM/ Ceftriaxone 2x1 gr iv Paracetamol inj 3x500 mg drip Vit K 1mg dlm 500cc Asering per hari - Puasa NGT : 100 cc cairan hitam kental Urine : 500 cc pekat kehitaman

Pemeriksaan H2TL ulang pkl 21.00 Hb/Ht/Leukosit/Trombosit: 11,2/33/8.270/71.000

Follow Up 23 Januari 2013

S: gelisah -, tampang bingung, nyeri perut O: KU/Kesadaran : Tampak Sakit Berat Apatis FN : 94x/mnt, RR 28x/mnt, TD 90/60 mmHg, Suhu 37 C K/L : anemis -/-, ikterik -/Thoraks : vesikuler, rhonki -/-, wheezing -/-, BJ normal, gallop -, murmur Abdomen : BU +, supel, NT +, hati teraba 2 jari bac A: Malaria Cerebral P: - CIV: Asering 81cc/jam dan D51/2NS +CAP 2,6 cc (81cc/jam) habiskan dalam 3 jam tiap 8 jam - O2 2-3 lpm - MM/ Ceftriaxone 2x1 gr iv Tamolif 3x500 mg drip Vit K 1mg dlm 500cc Asering per hari Ranitidin 2x1 ampul - Puasa NGT : 100 cc cairan hitam kental, urin 50cc kuning pekat

Pemeriksaan H2TL ulang pkl 03.00 Hb/Ht/Leukosit/Trombosit: 10,8/33/7.700/90.000

Follow Up 24 Januari 2013

S: gelisah -, tampang bingung, nyeri perut O: KU/Kesadaran : Tampak Sakit Berat Apatis FN : 89x/mnt, RR 28x/mnt, TD 130/80 mmHg, Suhu 37 C K/L : anemis -/-, ikterik -/Thoraks : vesikuler, rhonki -/-, wheezing -/-, BJ normal, gallop -, murmur Abdomen : BU +, supel, NT +, hati teraba 2 jari bac A: Malaria Cerebral P: - CIV: D51/2NS 81cc/jam dan D51/2NS +CAP 2,6 cc (81cc/jam) habiskan dalam 3 jam tiap 8 jam, D5% 14 tpm - O2 2-3 lpm - MM/ Ceftriaxone 2x1 gr iv Tamolif 3x500 mg drip Vit K 1mg dlm 500cc dlm D5% per hari Ranitidin 2x1 ampul - Puasa NGT : 100 cc cairan hitam kental, urin 50cc kuning pekat

Pemeriksaan H2TL ulang Hb/Ht/Leukosit/Trombosit: 12/34/7.200/110.000

25 Januari 2013
S: demam -, nyeri perut O: KU/Kesadaran: Tampak Sakit Berat Apatis FN : 89x/mnt, RR 28x/mnt, TD 130/80 mmHg, Abdomen : BU +, supel, NT +, hati teraba 2 jari bac A: Malaria Cerebral P: - CIV: D51/2NS 81cc/jam dan D51/2NS +CAP 2,6 cc (81cc/jam) habiskan dalam 3 jam tiap 8 jam, D5% 14 tpm - O2 2-3 lpm - MM/ Ceftriaxone 2x1 gr iv Tamolif 3x500 mg drip Vit K 1mg dlm 500cc dlm D5% per hari Ranitidin 2x1 ampul NGT : 20 cc cairan coklat hitam kental, urin 100cc kuning jernih Diet sonde 8x30cc Lab: Hb 10,7, Ht 33%, Leukosit 7100, Trombosit 172.000

26 Januari 2013
S: demam -, lemas O: KU/Kesadaran: Tampak Sakit Berat Apatis FN : 80x/mnt, RR 24x/mnt, TD 110/56 mmHg, Abdomen : BU +, supel, NT +, hati teraba 2 jari bac A: Malaria Cerebral P: - CIV: D51/2NS 81cc/jam dan D51/2NS +CAP 2,6 cc (81cc/jam) habiskan dalam 3 jam tiap 8 jam, D5% 14 tpm - O2 2-3 lpm - MM/ Ceftriaxone 2x1 gr iv Ranitidin 2x1 ampul PCT 500mg k/p Diet sonde 12x50cc Lab: Hb 11,3, Ht 33%, Leukosit 7400, Trombosit 237.000 Cek DL per hari dan DDR

27 Januari 2013
S: demam -, lemas O: KU/Kesadaran: Tampak Sakit Berat Apatis FN : 80x/mnt, RR 24x/mnt, TD 131/72 mmHg, Abdomen : BU +, supel, NT +, hati teraba 2 jari bac A: Malaria Cerebral P: - CIV: D51/2NS 81cc/jam dan D51/2NS +CAP 2,6 cc (81cc/jam) habiskan dalam 3 jam tiap 8 jam, D5% 14 tpm - O2 2-3 lpm - MM/ Ceftriaxone 2x1 gr iv Ranitidin 2x1 ampul PCT 500mg k/p Diet : susu 12x80cc dan bubur saring 3x1/2 porsi Lab: Hb 11,, Ht 26%, Leukosit 8200, Trombosit 301.000 Cek DL per hari dan DDR

28Januari 2013
S: demam -, lemas O: KU/Kesadaran: Tampak Sakit Berat Apatis TD 109/769 mmHg, Abdomen : BU +, supel, NT +, hati teraba 2 jari bac A: Malaria Cerebral P: - CIV: D51/2NS 81cc/jam dan D51/2NS +CAP 2,6 cc (81cc/jam) habiskan dalam 3 jam tiap 8 jam, D5% 14 tpm - O2 2-3 lpm - MM/ Ceftriaxone 2x1 gr iv Ranitidin 2x1 ampul stop PCT 500mg k/p Elkana 1x1 cth Diet : susu 12x100cc dan bubur saring 3x1 porsi

29 Januari 2013
S: demam -, lemas O: KU/Kesadaran: Tampak Sakit Berat Apatis TD 109/769 mmHg, Abdomen : BU +, supel, NT +, hati teraba 2 jari bac A: Malaria Cerebral P: - CIV: D51/2NS 81cc/jam dan D5% 14 tpm - O2 2-3 lpm - MM/ Ceftriaxone 2x1 gr iv Ranitidin 2x1 ampul stop PCT 500mg k/p Elkana 1x1 cth Diet : susu 12x120cc dan bubur saring 3x1 porsi Lab: Hb 11,, Ht 26%, Leukosit 8200, Trombosit 301.000 Cek DL per hari dan DDR

Introduction
Malaria is a tropic life threatening disease. A disease caused by members of the protozoan genus Plasmodium, a widespread group of sporozoans that pasitize the human liver and red blood cells. There are 4 species: plasmodium falciparum plasmodium vivax plasmodium ovale plasmodium malariae

Problem statement

(world)

109 countries are endemic for malaria 3.3 billion people were at risk of malaria in 2006 1.2 billion at higher risk(WHO African and SE Asia) Childhood death occurs mainly due to cerebral malaria and anemia

- Haya -

- Haya -

- Haya -

- Haya -

Classical features include cyclic symptoms

(2-6)

Cold stage:

chills and shaking

Hot stage:
Sweating stage:

fever, headache, vomiting, seizures in children .

weakness
- Haya -

- Haya -

- Haya -

- Haya -

(5-6) mild jaundice, pallor and bilateral conjunctival haemorrhages associated with P. falciparum infection.

- Haya -

(66)

Tropical splenomegaly in a patient with evidence of hypersplenism living in a P. falciparum endemic area.

- Haya -

Clinical features and classification of malaria

uncomplicated malaria severe malaria

in special groups (young children, pregnant women, HIV /AIDS) in travellers (from non-malaria endemic regions) in epidemics and complex emergency situations

4 | Guidelines for the Treatment of Malaria

UNCOMPLICATED MALARIA (all species)

Uncomplicated malaria definition:

Fever and any of the following: Headache, Body and joint pains Feeling cold and sometimes shivering Loss of appetite and sometimes abdominal pains Diarrhoea, nausea and vomiting. Hepatospleenomegaly

Cerebral malaria

Table 1: WHO case definition of Severe Malaria Unrousable coma (GCS <Falciparum 11/15), with peripheral P.
falciparum parasitaemia after exclusion of other causes of encephalopathy Normocytic anaemia with haemoglobin <5 g dl1 (haematocrit<15%) in presence of parasitaemia >10 000 ml1 Pulmonary oedema or acute respiratory distress syndrome (ARDS) Would now also include rapid laboured acidotic breathing sometimes abnormal in rhythm Urine output of less than 400 ml in 24 h (or <12 ml kg1 in children) and a serum creatinine >265 mmol l1 (>3.0 mg dl1) Whole blood glucose <2.2 mmol l1 (40 mg dl1) Systolic blood pressure <70 mmHg or core-skin temperature difference >10C Spontaneous bleeding and/or laboratory evidence of disseminated intravascular coagulation Such patients with complicated malaria should be managed as severe malaria, i.e. with parenteral antimalarials even though they do not necessarily meet the criteria of severe disease.
Online ISSN 1471-8391 - Print ISSN 0007-1420 Copyright 2012 Oxford University Press

Severe anaemia

Respiratory distress

Renal failure

Hypoglycaemia Circulatory collapse (shock) Coagulation failure Complicated malaria: Impaired consciousness of any degree, Prostration, Jaundice, Intractable vomiting, Parasitaemia 2% in nonimmune individuals (no previous malaria)

***Levels of parasitaemia should be interpreted in the light of immunity

Diagnosis - RDT

Parasitological confirmation is done by thin-thick blood smear microscopy examination or by dipstick (Rapid Diagnostic Test [RDT]).

Differential diagnosis for severe malaria

1. Meningoencefalitis 2. Stroke 3. Tifoid ensefalopati 4. Hepatitis 5. Leptospirosis berat 6. Glomerulonefritis akut atau kronik 7. Sepsis 8. DHF atau DSS

THE PHARMACOLOGY OF ANTIMALARIALS

Class Definition Examples Blood schizonticidal drugs Class Definition Examples Class Definition Examples

Act on (erythrocytic) stage of the Quinine, artemisinins, parasite thereby terminating amodiaquine, chloroquine, clinical illness lumefantrine, tetracyclinea , atovaquone, sulphadoxine, clindamycina , proguanila Act on primary tissue forms of plasmodia which initiate the erythrocytic stage. They block further development of the infection Primaquine, pyrimethamine, proguanil, tetracycline

Tissue schizonticidal drugs

Gametocytocidal drugs

Destroy sexual forms of the parasite thereby preventing transmission of infection to mosquitoes

Primaquine, artemisinins, quinineb

a Slow b

acting, cannot be used alone to avert clinical symptoms Weakly gametocytocidal

THE PHARMACOLOGY OF ANTIMALARIALS (cont.)

Class Definition Examples Class Definition Examples Class Definition Examples Primaquine, tafenoquine

Hypnozoitocidal drugs These act on persistent liver stages of P.ovale and P.vivax which cause recurrent illness

Sporozontocidal drugs These act by affecting further development of gametocytes into oocytes within the mosquito thus abating transmission

Primaquine, proguanil, chlorguanil

1. Treatment of severe falciparum malaria

Preferred regime IV Artesunate (60mg): 2.4mg/kg on admission, followed by 2.4mg/kg at 12h & 24h, then once daily for 7 days. Once the patient can tolerate oral therapy, treatment should be switched to a complete dosage of Riamet (artemether/lumefantrine) for 3 day. Alternative regime IV Quinine loading 7mg salt /kg over 1hr followed by infusion quinine 10mg salt/kg over 4 hrs, then 10mg salt/kg Q8H or IV Quinine 20mg/kg over 4 hrs, then 10mg/kg Q8H. Plus Adult & child >8yrs old: Doxycycline (3.5mg/kg once daily) or Pregnant women & child < 8yrs old: Clindamycin (10mg/kg twice daily). Both drug can be given for 7 days. Dilute injection quinine in 250ml od D5% and infused over 4hrs. Infusion rate should not exceed 5 mg salt/kg per hour.

Reconstitute with 5% Sodium Bicarbonate & shake 2-3min until clear solution obtained. Then add 5ml of D5% or 0.9%NaCl to create total volume of 6ml. Slow IV injection with rate of 3-4ml/min or IM injection to the anterior thigh. The solution should be prepared freshly for each administration & should not be stored.

2. Treatment of uncomplicated p.falciparum

Preferred regime Artemether plus lumefantrine(Riamet) (1 tab: 20mg artemether/120mg lumefantrine) Weight Group Day 1 Day 2 Day3 Alternative regime Quinine sulphate (300mg/tab) Day 1-7: Quinine 10mg salt/kg PO Q8H Plus *Doxycycline (3.5mg/kg once a day) OR *Clindamycin (10mg/kg twice a day) *Any of these combinations should be given for 7 days. Doxycycline: Children>8yr Clindamycin: Children<8yr

5-14kg
15-24kg

1 tab stat then 8hr later

2 tab stat then 8hr later

1 tab Q12H
2 tab Q12H

1 tab Q12H
2 tab Q12H

25-34kg
>34kg

3 tab stat then 8hr later

4 tab stat then 8hr later

3 tab Q12H
4 tab Q12H

3 tab Q12H
4 tab Q12H

Take immediately after a meal or drink containing at least 1.2g fat to enhance lumefantrine absorption.

Add primaquine 0.75mg base salt/kg single dose if gametocyte is present at any time during treatment.

Children under 5 kg or below 4 months should not be given Riamet instead treat with the following regimen (see table). Dosage and administration Plasmodium falciparum for young infant
Age Group Weight group Artesunate or *Quinine Oral Quinine 10 mg/kgTDS for 4 days then 15-20 mg/kg TDS for 4 days

0-4 months

<5 kg

** IM first dose Artesunate 1.2 mg/kg or IM Arthemeter 1.6 mg/kg)

***Oral Artesunate 2mg/kg/day day 2 to day 7

Source: Malaria in Children, Department of tropical Pediatrics, Faculty of Tropical Medicine, Mahidol University.

** Preferably Artesunate/Artemether IM on day 1 if available *** When Artesunate/Artemether IM is unavailable, give oral Artesunate from day 1 to day 7 * Treat the young infant with Quinine when oral Artesunate is not available

3. Treatment of malaria caused by p.knowlesi & mixed infection (p. falciparum + p. vivax)

Treat as p. falciparum

Important notes
Riamet tablets should be taken with or after food. Patient with acute malaria re frequently averse to food, the dose may be taken with fluid and encourage patient to resume normal eating as soon as food can be tolerated. Watch all patients swallowing the first dose of Riamet and observe for 1 hour after the intake. In the event of vomiting within one hour of administration, a repeat dose should be taken. For small children Riamet can be crushed, diluted in water and then put either directly into the mouth using a syringe or given with a spoon. Riamet may cause fatigue and dizziness. Warn patient not to drive or use machines. Instruct patient to report signs/symptoms of QT interval prolongation.

Treatment in specific population & situations

Specific populations Pregnancy Preferred regime Quinine plus clindamycin to be given for 7 day Alternative regime Artesunate plus Clindamycin for 7 days is indicated if first line treatment fails

Lactating women Hepatic impairment

Should receive standard antimalarial treatment (including ACTs) except for dapsone, primaquine and tetracyclines, which should be withheld during lactation Chloroquine: 30-50% is modified by liver, appropriate dosage adjustment is needed, monitor closely. Quinine : Mild to moderate hepatic impairment-no dosage adjustment, monitor closely. Artemisinins : No dosage adjustment Chloroquine : ClCr<10ml/min-50% of normal dose. Hemodialysis, peritoneal dialysis: 50% of normal dose. Continuous Renal Replacement Therapy(CRRT) :100% of normal dose. Quinine : .ClCr 10-50ml/min : Administer Q8-12H, CLCr<10ml/min : administer Q24H,Severe chronic renal failure not on dialysis : initial dose: 600mg followed by 300mg Q12H, Hemo- or peritoneal dialysis: administer Q24H ,Continuous arteriovenous or hemodialysis: Administer Q8-12H. Artemisinin : no dosage adjustment.

Renal Impairment

Treatment of complications of malaria Severe & complicated falciparum or knowlesi malaria is a medical emergency that requires intervention and intensive care as rapidly as possible. Fluid, electolyte glucose & acid-base balance must be monitored.Intake & output should be carefully recorded.

Immediate clinical management of severe manifestations and complications of P. falciparum malaria

Definitive clinical features Come (Cerebral malaria) Hyperpyrexia (rectal body temperature >40C) Convulsions Hypoglycaemia (glucose conc. <2.8mmol/L) Severe anaemia (hb < 7g/dl) Immediate management/treatment Monitor & record level of consciousness using Glaslow coma scale, temperature, respiratory, and depth, BP and vital signs. Treated by sponging, fanning &with an antipyretic drug. Rectal paracetamol is preferred over more nephrotoxic drugs (e.g. NSAIDs) A slow IV injection of diazepam(0.15mg/kg, maximum 20mg for adults). Correct with 50% dextrose (as infusion fluids). Check blood glucose Q4-6H in the first 48hrs. Transfuse with packed cells. Monitor carefully to avoid fluid overload. Give small IV dose of frusemide, 20mg, as necessary during blood transfusion to avoid circulatory overload.

Acute pulmonary oedema

Prop patient upright (45), give oxygen, give IV diuretic (but most patient response poorly to diuretics), stop intravenous fluids. Early mechanical ventilation should be considered.

Immediate clinical management of severe manifestations and complications of P. falciparum malaria (cont.)
Definitive clinical features Immediate management/treatment Acute renal failure (urine output <400ml in 24hrs in adults or 0.5ml/kg/hr, failing to improve after rehydration & a serum creatinine of >265mol/L) Disseminated intravascular Coagulopathy (DIVC) Exclude pre-renal causes by assessing hydration status. Rule out urinary tract obstruction by abdominal examination or ultrasound. Give intravenous normal saline If in established renal failure add haemofiltration or haemodialysis, or if unavailable, peritoneal dialysis. Transfuse with packed cell, clotting factors or platelet. Usual regime: Cryoprecipitate 10units,platelets 4-8units, fresh frozen plasma(10-15ml/kg). For prolonged PT, give vitamin K, 10mg by slow IV injection.

metabolic acidosis

Infuse sodium bicarbonate 8.4% 1mg/kg over 30min and repeat if needed. if severe, add haemodialysis.
Suspect septicaemia, take blood for cultures; give parenteral broad-spectrum antimicrobials, correct haemodynamic disturbances.

Shock (hypotension with systolic blood pressure <70mmHg)

Monitoring & follow-up

Blood smear should be repeated daily (twice daily in severe infection). Within 4872 hr after start of treatment, patients usually become afebrile and improve clinically except in complicated cases. All patients should be investigated with repeated blood film of malarial parasite one month upon recovery of malarial infection, to ensure no recrudescence.

Prevention

Avoid mosquito bites: Wearing long sleeves, trousers. Insecticide Treated Bednets Repellent creams or sprays.

Malaria vaccine
Vaccination against malaria is a burning issue today Several vaccine candidates are now being tested in africa, asia and US A vaccine developed in columbia (SPF 66) advanced to phase 3 trials in africa but failed to show efficacy in chiildren under 1 Another vaccine (RTS, S/AS02) with the potential to prevent infection and ameliorate disease is being tested by GlaxoSmithKline and the MVI at PATH in Phase I trial in Gambia

 In phase II in 2002 trials of the vaccine are being conducted among the children in Mozambique, which suffers from year-round malaria transmission offering a better opportunity to evaluate vaccine performance This vaccine has been safely tested in adult volunteeers in Belgium, Gambia, kenya and US only potential malarial vaccine

References
WHO Guidelines for the treatment of malaria -- 2nd edition.(2010) Management of severe malaria : a practical handbook. 2nd ed.(2000) MICROMEDEX 2.0 NATIONAL GUIDELINES FOR THE DIAGNOSIS, TREATMENT AND PREVENTION OF MALARIA IN KENYA.THIRD EDITION 2010. http://www.akademisains.gov.my/download/tropical/Lokman.pdf http://www.who.int/malaria/publications/countryprofiles/profile_mys_en.pdf

Malaria vaccine
Vaccination against malaria is a burning issue today Several vaccine candidates are now being tested in africa, asia and US A vaccine developed in columbia (SPF 66) advanced to phase 3 trials in africa but failed to show efficacy in chiildren under 1 Another vaccine (RTS, S/AS02) with the potential to prevent infection and ameliorate disease is being tested by GlaxoSmithKline and the MVI at PATH in Phase I trial in Gambia

 In phase II in 2002 trials of the vaccine are being conducted among the children in Mozambique, which suffers from year-round malaria transmission offering a better opportunity to evaluate vaccine performance This vaccine has been safely tested in adult volunteeers in Belgium, Gambia, kenya and US only potential malarial vaccine

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