Chapter 4. Uncomplicated Malaria PPT draft.pptx

Handout for health professional

1. Malaria Case Management Training for Health Professionals Chapter-4 Management of Uncomplicated Malaria November, 2023 Addis Ababa

2. Chapter introduction Chapter title- Management of uncomplicated malaria Duration- 255 minutes Chapter learning objectives: At the end of this chapter, participants will be able to: Define uncomplicated malaria Manage all uncomplicated malaria cases according to the national guidelines . Provide proper health counselling regarding the treatments and prevention against malaria infection. 11/03/2024 Malaria case management for Health Care Workers 2

3. Chapter introduction Contd… Chapter sessions Session 5.1 -Definition and diagnosis of uncomplicated malaria Session 5.2 Treatment of uncomplicated malaria Session 5.3 Patient counseling during uncomplicated malaria management Session 5.4 Management of treatment failure Session 5.5 The Pharmacovigillence in uncomplicated malaria treatment     11/03/2024 Malaria case management for Health Care Workers 3

4. Session 5.1-Definition and diagnosis of uncomplicated malaria Session objectives: At the end of this session participants will be able to: Define uncomplicated malaria Diagnose uncomplicated malaria u sing the diagnostic steps. Duration- 45 minutes 11/03/2024 Malaria case management for Health Care Workers 4

5. Introductory activity Case: A 34 years old male patient from a malarious area presented to a rural OPD with fever of three days duration. The axillary temperature record was 38 c. Based on your experience what important other questions do you ask, what tests will you order? 11/03/2024 Malaria case management for Health Care Workers 5

6. Definition of uncomplicated Malaria Definition : 1-Symptomatic malaria ( Fever and other associated symptoms) + 2-The presence of asexual forms of malaria parasites in blood sample + 3-No signs of severity or evidence of vital organ dysfunction. Clinical features of uncomplicated malaria are very non-specific and are shared by a number of different illnesses. Diagnosis at all times should be confirmed either by microscopy or Rapid Diagnostic Tests (RDT).   11/03/2024 Malaria case management for Health Care Workers 6

7. Diagnosis of uncomplicated malaria Clinical suspect: In malarious areas: A patient with fever or history of fever with in the past 48 hours is assumed to have clinical malaria. In non malarious areas: A patient with fever or history of fever within the past 48 hrs. and history of travel to malarious area within the last one month and other common causes of acute febrile illness should be also looked for. Treatment based on clinical diagnosis alone is unreliable, and when possible should be confirmed by laboratory tests. 11/03/2024 Malaria case management for Health Care Workers 7

8. Diagnosis of uncomplicated malaria Parasitological diagnosis: The two main methods of parasitological confirmation are light microscopy and malaria RDTs. Required for confirmation of the diagnosis of malaria. Recommended for all suspected cases in all transmission settings. Patients who test negative by malaria RDT or microscopy do not need anti-malarial medications. 11/03/2024 Malaria case management for Health Care Workers 8

9. Advantages of parasitological diagnosis: Improve care of parasite-positive patients. Identification of parasite-negative patients for whom another diagnosis must be sought; Prevent the unnecessary use of anti malarial drugs. Used to confirm treatment failure Improve malaria case detection & reporting. 11/03/2024 Malaria case management for Health Care Workers 9

10. Objective of treatment of uncomplicated malaria Three main objectives: 1-Clinical Objective : Eradication from the body of the infection that caused the illness (Cure). Prevent progression to severe disease and prevent additional morbidity associated with treatment failure. 2-Public Health Objective: Reduce transmission of the infection to others, i.e. to reduce the infectious reservoir. 11/03/2024 Malaria case management for Health Care Workers 10

11. Objective of treatment Contd…. 3-Antimalarial Drug Resistance Objective: Prevent the emergence and spread of resistance to antimalarial. Tolerability, the adverse effect profile and the speed of therapeutic response are also important considerations. 11/03/2024 Malaria case management for Health Care Workers 11

12. Practice exercise Instruction Read and analyze the case below individually and answer the given question in 10minutes Scenario- A 34 years old male patient from a malarious area presented to a rural OPD with fever, headache, chills and rigors of three days duration. No other remarkable complaints The axillary temperature record was 38 c and no other remarkable physical findings. Task What tests are important for this patient? Why? What is the diagnosis of this patient and Why? 11/03/2024 Malaria case management for Health Care Workers 12

13. Feedback 1-The important tests are: Blood microscopy Hemoglobin Random blood sugar Blood microscopy is positive for P.falciparum and other tests within normal limit BF is indicated because this patient has fever and malaria should be always considered and diagnosed before initiating treatment. The other tests will help to diagnose complications. 2-The diagnosis of this patient is uncomplicated P.falciparum malaria because BF is positive and has no clinical and laboratory indicators of vital organ dysfunction. 11/03/2024 Malaria case management for Health Care Workers 13

14. Reflecting questions When and how to apply those tests and diagnostic steps in your real practice settings 11/03/2024 Malaria case management for Health Care Workers 14

15. Session summary What are the criteria we used to diagnose uncomplicated malaria? What are the steps we follow to diagnose uncomplicated malaria? 11/03/2024 Malaria case management for Health Care Workers 15

16. Resources for further reading Malaria case management guidelines WHO malaria 3rd edition 11/03/2024 Malaria case management for Health Care Workers 16

17. Session 5.2-Treatment of uncomplicated malaria Session objectives: At the end of this session participants will be able to: Provide the standard treatment for all patients with uncomplicated malaria. Duration- 60 minutes 11/03/2024 Malaria case management for Health Care Workers 17

18. Introductory activity What are the first line anti-malaria drugs you are using for the treatment of uncomplicated malaria? 11/03/2024 Malaria case management for Health Care Workers 18

19. Uncomplicated malaria treatment 11/03/2024 Malaria case management for Health Care Workers 19

20. 11/03/2024 Malaria case management for Health Care Workers 20 Alternative treatment for uncomplicated malaria:

21. Uncomplicated malaria treatment in pregnancy No need to admit or label all malaria in pregnancy as severe malaria. Treat non complicated cases as non pregnant adults. Give full course AL in all trimester for P.falciparum or mixed infection. Give full course CQ for P.vivax infection in all trimester. Single dose PQ and radical cure is contraindicated in all trimester. DP is indicated as a second-line or alternative drug. 11/03/2024 Malaria case management for Health Care Workers 21

22. Uncomplicated malaria treatment in pregnancy contd… Weekly CQ prophylaxis for P.vivax infection After completing three days course of CQ, pregnant mothers will take 2tabs of CQ weekly until delivery and 6months of lactation then radical cure is indicated. IPTp with fansidar is not recommended in Ethiopia. 11/03/2024 Malaria case management for Health Care Workers 22

23. Uncomplicated malaria treatment in HIV, TB and malnutrition These patients are at higher risk for treatment failure and progression to severe malaria. Factors that reduce the anti-malaria drug bioavailability are : Drug interactions, Weak immune system, Reduced drug absorption Hypoalbuminemia However, there is insufficient evidence to change the drug and dosing, they should be monitored closely. 11/03/2024 Malaria case management for Health Care Workers 23

24. Supportive treatments in uncomplicated malaria A-Arrest fever Treat especially in children Use paracetamol 15mg/kg every 4hrs Fanning, tepid sponging Use the IMNCI algorithm B-Prevent hypoglycemia Encourage to take food and fluids. 11/03/2024 Malaria case management for Health Care Workers 24

25. Anti-malaria drugs information 1-Artemether – Lumefantrine (AL) FDC drug given two times a day for three days Has very fast parasite elimination, so reduce fever promptly Effective against mature gametocyte clearance Effective in multi-drug resistant areas Has no any evidence of organ or system specific toxicity 11/03/2024 Malaria case management for Health Care Workers 25

26. Anti-malaria drugs information contd… Indications of AL: Uncomplicated P.f malaria Uncomplicated mixed P.f and P.v malaria Uncomplicated P,v when chloroquine not available If no RDT/BF test for high risk and other causes of fever ruled out. 11/03/2024 Malaria case management for Health Care Workers 26

27. Anti-malaria drugs information contd… Contraindications of AL: Persons with a previous history of reaction after using the drug. For chemoprophylaxis combined with other drugs or alone. Persons with severe and complicated malaria should not be treated with oral medications 11/03/2024 Malaria case management for Health Care Workers 27

28. Anti-malaria drugs information contd… 11/03/2024 Malaria case management for Health Care Workers 28 Tablet containing 20 mg Artemether plus 120 mg Lumefantrine in a fixed dose.

29. Anti-malaria drugs information contd… 2-Chloroquine(CQ) Indicated for all patients with PV, PO and PM infections. It is rapidly absorbed from GI tract. Has low safety margin and is very dangerous in over dosage. Effective against the blood stage parasites. The dosage is 10mg base/kg on days 1 and 2 then 5mg base/kg on day 3 11/03/2024 Malaria case management for Health Care Workers 29

30. Anti-malaria drugs information contd… Chloroquine Treatment Schedule 11/03/2024 Malaria case management for Health Care Workers 30

31. Anti-malaria drugs information contd… 3-Primaquine Effective against all stages of gametocytes The only drug which can act in the hepatic stage of the parasites including the hypnozoites The active metabolites of its by product are very toxic which can induce hemolysis. Has low safety margins. Indicated for radical cure against P.vivax and prevention of transmission against P.falciparum 11/03/2024 Malaria case management for Health Care Workers 31

32. Anti-malaria drugs information contd… Primaquine contraindications: Pregnancy Women breast feeding infants less than six months of age Infants less than six months of age Moderate to severe G6PD enzyme deficiency Any condition that predisposes to granulocytopenia, such as Acute Rheumatoid Arthritis & SLE. 11/03/2024 Malaria case management for Health Care Workers 32

33. Anti-malaria drugs information Primaquine treatment schedule 11/03/2024 Malaria case management for Health Care Workers 33

34. Anti-malaria drugs information 3-Dihydroartemisnin-Piperaquine (DP) A fixed drug combination used to treat P.falciparum and P.vivax malaria Used in all age groups and pregnant mothers. Side effects are uncommon and no organ specific toxicity documented. Indicated during treatment failure or as an alternative treatment when the first line is not available 11/03/2024 Malaria case management for Health Care Workers 34

35. Anti-malaria drugs information DP treatment schedule 11/03/2024 Malaria case management for Health Care Workers 35 Weight 20 mg/160 mg tablet 40 mg/320 mg tablet 5 to < 8 kg 1 tab – 8 to < 11 kg 1½ tab – 11 to < 17 kg – 1 tab 17 to < 25 kg – 1½ tab 25 to < 36 kg – 2 tab 36 to < 60 kg – 3 tab 60 to < 80 kg – 4 tab ≥ 80 kg – 5 tab

36. Practice exercise Instruction Read and analyze the case below individually and answer the given question in 10minutes Scenario- A 25 years old female patient from a malarious area presented to a rural OPD with fever, headache, chills and rigors of three days duration. No other remarkable complaints. She has been ammennohric for 5 months. The axillary temperature record was 39 c, uterus is palpable and 18weeks, fetal heart beat positive and no other remarkable physical findings. The blood film revealed plasmodium vivax parasites and other findings (Hgb and RBS) are within normal range. Task What is the diagnosis of this case and why? What are the treatment options? why Which drug is contraindicated for this mother? Why? 11/03/2024 Malaria case management for Health Care Workers 36

37. Feedback 1-The diagnosis is Uncomplicated P.vivax malaria+ 2 nd trimester pregnancy BF is positive and no features of complications 2-Chloroquine for three days followed by weekly CQ prophylaxis. CQ is safe in pregnancy and CQ prophylaxis to prevent relapse. 3-Primaquine is contraindicated because of pregnancy 11/03/2024 Malaria case management for Health Care Workers 37

38. Reflecting questions When and how to apply those tests and treatment drugs in your real practice settings 11/03/2024 Malaria case management for Health Care Workers 38

39. Session summary What are the first line and alternative drugs we used to treat uncomplicated malaria? What are the other components of the uncomplicated malaria management? 11/03/2024 Malaria case management for Health Care Workers 39

40. Resources for further reading Malaria case management guidelines WHO malaria 3rd edition 11/03/2024 Malaria case management for Health Care Workers 40

41. Session 5.3 Patient counseling during uncomplicated malaria management Session objective: At the end of this session participants will provide: Comprehensive patient counselling services for patients with uncomplicated malaria. Duration- 45 minutes 11/03/2024 Malaria case management for Health Care Workers 41

42. Introductory activity A 45 years old migrant worker was diagnosed with uncomplicated mixed malaria infection and the proper anti-malaria drugs were given by the OPD nurse. What messages should be provided by the nurse and why? 11/03/2024 Malaria case management for Health Care Workers 42

43. Key patient counselling messages Counsel a patient with malaria the following key messages: He/she has got malaria Early treatment is important to prevent severe illness and death To take enough food and fluid (especially fatty meal to enhance AL absorption and to avoid risk of hypoglycemia). To return to the HC if fever persists or patient is still sick after 72 hours or any time before 72 hours if condition worsens. 11/03/2024 Malaria case management for Health Care Workers 43

44. Key patient counselling messages Malaria is transmitted by mosquitoes. Use LLIN, eliminate mosquito breeding places and protect sprayed houses from re plastering. Take all (full course), do not interrupt taking medication. Do not share drugs with others, including family members. . 11/03/2024 Malaria case management for Health Care Workers 44

45. Practice activity- Role Play Objective- Counsel a patient with uncomplicated during the treatment of uncomplicated malaria Instruction- Take 5 minutes to be familiar with the script (PM page … Two participants to play the script (one as client and the other as a health care provider) Other participants will observe the key aspect of the role play. Time- 30minutes (15 minutes for each role play with reading, discussion and feedback) 11/03/2024 Malaria case management for Health Care Workers 45

46. Role Play Contd… Scenario Patient- A 30 years old patient presented to the OPD with fever of 4days duration and headache, chills and rigors. No other complaints. Physical examinations are normal. Health worker- A nurse working in a rural HC OPD and ordered BF to the patient and the result came with P.falciparum malaria. He/she is informing the result and providing counselling for a patient with uncomplicated malaria. 11/03/2024 Malaria case management for Health Care Workers 46

47. Discussion questions Established and maintained a positive, respectful collaborative working with the patient? Demonstrated empathy? Instilled confidence? Used appropriate non-verbal communication? Elicited information clearly and effectively? Actively listen (made eye contact, let patient finish sentence, repeat /paraphrase what patient is saying? Effectively counseled the key messages ? 11/03/2024 Malaria case management for Health Care Workers 47

48. Reflecting questions When and how to apply those counselling skills in your real practice settings? 11/03/2024 Malaria case management for Health Care Workers 48

49. Session summary question What are the key health counselling messages for patients with uncomplicated malaria? 11/03/2024 Malaria case management for Health Care Workers 49

50. Session 5.4-Management of treatment failure and referral Session objectives: At the end of this session participants will be able to: Identify treatment failure and provide the proper treatment, Identify cases with referral indications and refer properly. Duration- 30minutes 11/03/2024 Malaria case management for Health Care Workers 50

51. Introductory activity What is malaria treatment failure and what is your experience in diagnosing and managing treatment failure? 11/03/2024 Malaria case management for Health Care Workers 51

52. Treatment failure It is failure of antimalarial drug to resolve parasitemia and presence of fever after the 3rd day of treatment. Common causes: Poor adherence Under dosing Vomiting Drug interaction Misdiagnosis Substandard medicines Drug resistance 11/03/2024 Malaria case management for Health Care Workers 52

53. Steps in the management of treatment failure Determine the duration (before or after 28 days) Check the causes of treatment failure ( Evaluate the patient as a new case) Confirm treatment failure with repeat blood film and do other tests. (RDT is not recommended) Check for severity symptoms and signs Decide the treatment plan 11/03/2024 Malaria case management for Health Care Workers 53

54. Management of treatment failure Within 4-28days For patients who have reported poor adherence Repeat the first line regimen based on parasite species. For patients who have reported good adherence Change to the second line drug DP for all plasmodium species. NB-Patient should complete the already started radical cure After 28days Treat all patients with the first line regimen based on parasite species. 11/03/2024 Malaria case management for Health Care Workers 54

55. Referral All patients with clinical or laboratory evidences of severity should be referred from HC to hospital. Provide first dose of pre referral treatment before referral. REMEMBER: A delay in referral could cause the unnecessary death of the patient. 11/03/2024 Malaria case management for Health Care Workers 55

56. Chemoprophylaxis No safe, effective and affordable AMD for chemoprophylaxis. LLIN, repellents, protective clothing is highly recommended. Non immune travelers visiting malarious areas mefloquine 5mg/kg weekly is recommended. Start mefloquine 2 weeks before travel and continue 4 weeks after departure. In addition to mefloquine, use preventive measures and get early treatment if becomes febrile while on mefloquine 11/03/2024 Malaria case management for Health Care Workers 56

57. Practice exercise Instruction Form pair, read and analyze the case in your participant manual on page and answer the given questions. Scenario A 20 years old male patient from a malarious area presented to a rural OPD with fever, headache, chills and rigors of 3 days duration. No other remarkable complaints. The temperature record was 39 c, no other remarkable physical findings. The BF revealed P.falciparum parasites and other findings (Hgb and RBS) are within normal range. The clinician gave him AL and PQ single dose and send him home. On the 5 th day he came back with a complaint of fever and loss of consciousness with abnormal body movements. 11/03/2024 Malaria case management for Health Care Workers 57

58. Practice exercise contd… Questions What should the health care provider do to diagnose the patient’s problem? Why? What is the cause of the treatment failure and how do you manage this patient? Why? Time- 10minutes 11/03/2024 Malaria case management for Health Care Workers 58

59. Feedbacks Question1 -Start with the coma cares and secure ABC of life, arrest fever urgent RBS determination and correct hypoglycemia if diagnosed. Take complete history and do physical examination. Explore the cause of treatment failure Do repeat BF Question 2- The cause of the treatment failure is poor adherence. This patient has developed severe features and needs referral after giving artesunate IV/IM injection. 11/03/2024 Malaria case management for Health Care Workers 59

60. Reflecting questions When and how to apply this treatment approach in your real practice settings 11/03/2024 Malaria case management for Health Care Workers 60

61. Session summary What is anti-malaria treatment failure? What are the common causes? What will you do when treatment failure is suspected? 11/03/2024 Malaria case management for Health Care Workers 61

62. 5 - 5-Antimalaria Pharmacovigillence Session objective At the end of this session participants will be able: To identify the common adverse drug reactions of the anti-malaria drugs Record and report the ADRs Duration- 50 minutes 11/03/2024 Malaria case management for Health Care Workers 62

63. Introductory activity What is anti malaria Pharmacovigillence? 11/03/2024 Malaria case management for Health Care Workers 63

64. Definition of Pharmacovigillence Pharmacovigillence is the science and activities relating to the detection, assessment, understanding and prevention of adverse effects or any other medicine/vaccine related problem. 11/03/2024 Malaria case management for Health Care Workers 64

65. Importance of pharmacovigillence Improve patient and public health care and safety, Helps to detect medicine problems and timely communication Helps the assessment of the effectiveness and risk of medicines (prevention of harm and maximization of benefits) Encourage the safe, rational, and effective use of medicines 11/03/2024 Malaria case management for Health Care Workers 65

66. Pharmacovigillence Stages Stage 1: Detection (Collection of Individual Case Safety Reports (ICSRs), Stage 2: Assessment, Stage 3: Understanding the drug safety profile, Stage 4: Prevention of adverse effects. 11/03/2024 Malaria case management for Health Care Workers 66

67. Pharmacovigillence Methods Passive surveillance: spontaneous reporting cases Active surveillance: sentinel sites drug event monitoring registers Comparative observational studies: Cohort, case control and cross-sectional studies. Stimulated reporting and Targeted clinical investigations 11/03/2024 Malaria case management for Health Care Workers 67

68. Major factors predisposing to adverse effects Extremes of age Inter current illness: Drug Interactions: Incompatibilities between medicines and IV fluids Traditional medicines The effect of food on drug absorption and Medication errors Product quality defect 11/03/2024 Malaria case management for Health Care Workers 68

69. What to report? All suspected reactions to medicines Unknown or unexpected reactions Serious adverse drug reactions Unexpected therapeutic effects All suspected drug interactions, including interactions with other medicines, chemicals and food, Treatment failures 11/03/2024 Malaria case management for Health Care Workers 69

70. When to report? Should be reported immediately after all relevant information is compiled. Delay in reporting will make reports inaccurate and unreliable. Reporting while the patient is still in the health institution will give chance to the reporter to clear any ambiguity by re-questioning or examining the patient 11/03/2024 Malaria case management for Health Care Workers 70

71. How to report? Use the following mechanisms: The yellow prepaid report forms available at the facility 8482 (toll free line) Online reporting: ( www.efda.gov.et-serivces-e-Reporting ) Medsafety (using mobile application which can be downloaded) 11/03/2024 Malaria case management for Health Care Workers 71

72. Practice exercise Instruction Form pair, read and analyze the case in your participant manual on page… and answer the given questions. Scenario A 78 years old known cirrhotic patient from a malarious area presented to a rural OPD with fever, headache, chills and rigors of three days duration. No other remarkable complaints. The axillary temperature record was 39 c, no other remarkable physical findings. The blood film revealed plasmodium vivax parasites and other findings (Hgb and RBS) are within normal range. The clinician gave him CQ and PQ radical cure and sends him home. On the 4 th day he came back with dark urine color change and shortness of breath with generalized body swelling. Physical examination showed RR-40, paper white conjunctiva and Hgb-7gm/dl 11/03/2024 Malaria case management for Health Care Workers 72

73. Practice exercise contd… Questions Does this patient have any ADRs? Why? If yes which drug is most likely responsible? Does the patient have any risk factors? If yes what are they? What management steps should the health care provider do to manage the ADRs? Time- 10minutes 11/03/2024 Malaria case management for Health Care Workers 73

74. Feedbacks 1-Yes the patient has ADRs because he has symptoms and signs of ADRs. 2-Primaquine is the most likely drug causing the ADRs. 3-Yes because he is old aged and has intercurrent illness-cirrhosis. 4-Identify the cause for the ADRs Do proper assessment, stop PQ, emergency life saving interventions, refer to nearby hospital Report the ADRs using any of the methods. 11/03/2024 Malaria case management for Health Care Workers 74

75. Reflecting questions When and how to apply this treatment approach in your real practice settings? 11/03/2024 Malaria case management for Health Care Workers 75

76. Session summary What is anti-malaria pharmacovigillence? What are the common risk factors for ADRs? What will you do when ADRs is suspected? 11/03/2024 Malaria case management for Health Care Workers 76

77. Chapter summary Chapter objectives- Define uncomplicated malaria Diagnose and treat all uncomplicated malaria cases according to the national guidelines. Provide proper health counselling regarding the treatments and prevention against malaria infection. Instruction Divide participants into 4 subgroups and discuss the questions in group and assign a reporter to present your answers using a flipchart. Time- 30minutes (10minutes for group work and 5minutes for presentation) 11/03/2024 Malaria case management for Health Care Workers 77

78. Chapter summary contd… Questions Group-1- What are the basic requirements we used to define uncomplicated malaria? When do you suspect malaria and list the diagnostic tools used to confirm malaria Group-2- List parasite specific first and second line drugs we used for the treatment of uncomplicated malaria? Group-3 -What are the other supportive cares and key counselling messages for patients with uncomplicated malaria? Group-4 -What are the common causes of treatment failure and mention the management approach? 11/03/2024 Malaria case management for Health Care Workers 78

79. Feedbacks for group-1 Clinical symptoms (fever with other associated symptoms) + positive parasitological test +no evidences of vital organ dysfunction. Malaria is suspected fever of 48 hours for patients from malarious area Fever of 48 hours and travel history to malarious area within the last 4weeks for patients from non malarious area. The diagnostic tools are blood microscopy and RDT. 11/03/2024 Malaria case management for Health Care Workers 79

80. 11/03/2024 Malaria case management for Health Care Workers 80 Feedbacks for group-2 DP is the second line drug for all forms of malaria.

81. 11/03/2024 Malaria case management for Health Care Workers 81 Feedbacks for group-3 Supportive cares: A-Arrest fever Use paracetamol 15mg/kg every 4hrs Fanning, tepid sponging Use the IMNCI algorithm B-Prevent hypoglycemia Key counselling messages Inform the disease Early treatment Drug adherence Foods (fatty meal) When to return Prevention messages (LLIN, IRS, environmental

82. 11/03/2024 Malaria case management for Health Care Workers 82 Feedbacks for group-4 Common causes of failure: Poor adherence Under dosing Vomiting Drug interaction Misdiagnosis Substandard medicines Drug resistance Treatment of failure If cause is poor adherence-repeat the first line regimen. If the cause is not due to adherence- change to the second line drug DP. Patient should complete the already started radical cure Failure after 28 days use the first line regimen.

83. Resources for further reading Ethiopia MOH, Malaria case management guidelines WHO malaria 3rd edition 11/03/2024 Malaria case management for Health Care Workers 83

84. Thank you 11/03/2024 Malaria case management for Health Care Workers 84