Malaria

The word malaria comes from 18th century Italian mala meaning "bad" and aria meaning "air".
Most likely, the term was first used by Dr. Francisco Torti, Italy, when people thought the disease
was caused by foul air in marshy areas.
It was not until 1880 that scientists discovered that malaria was a parasitic disease which is
transmitted by the anopheles mosquito, called "malaria vectors", which bite mainly between
dusk and dawn. The mosquito infects the host with a one-cell parasite called plasmodium. By the
end of the 18th century, scientists found out that Malaria is transmitted from person-to-person
through the bite of the female mosquito, which needs blood for her eggs.
Approximately 40% of the total global population is at risk of Malaria infection. During the 20th
century the disease was effectively eliminated in the majority of non-tropical countries.
According to the latest estimates, released in December 2013, there were about 207 million
cases of malaria in 2012 (with an uncertainty range of 135 million to 287 million) and an
estimated 627 000 deaths (with an uncertainty range of 473 000 to 789 000). Malaria
mortality rates have fallen by 42% globally since 2000, and by 49% in the WHO African
Region. Most deaths occur among children living in Africa where a child dies every minute
from malaria. Malaria mortality rates among children in Africa have been reduced by an
estimated 54% since 2000.
There are five types of malaria:

Plasmodium vivax (P. vivax) - milder form of the disease, generally not fatal. This
species is most commonly found in Asia, Latin America, and parts of Africa. Infections can
sometimes lead to life-threatening rupture of the spleen. Special medications are used to
eradicate P. vivax from the liver This type of malaria can hide in the liver and return later to
cause a relapse years after the first infection. It also has the widest geographic distribution
globally. About 60% of infections in India are due to P. vivax.
Plasmodium malariae (P. malariae) - It is found worldwide but is less common than the
other forms. It has milder form of the disease, generally not fatal. However, the infected
human still needs treatment because no treatment can also lead to a host of health problems.
This type of parasite has been known to stay in the blood of some people for several decades.
Plasmodium ovale (P. ovale) - This species is rarely found outside Africa or the western
Pacific islands. Symptoms are similar to those of P. vivax. Like P. vivax, P. ovale can hide in
the liver for years before bursting out again and causing symptoms
Plasmodium falciparum (P. faliparum) - the most serious form of the disease. It is most
common in Africa, especially sub-Saharan Africa. P. falciparum is resistant to many of the
older drugs used to treat or prevent malaria.
Plasmodium knowlesi (P. knowlesi) - causes malaria in macaques but can also infect
humans.occurs in certain forested areas of South-East Asia.

Kingdom

Protista

Subkingdom

Protozoa

Phylum

Apicomplexa

Class

Sporozoasida

Order

Eucoccidiorida

Family

Plasmodiidae

Genus

Plasmodium

Species

Falciparum, malariae, ovale, vivax

Taxonomic Classification

Morphological Differences of Plasmodium Species

The morphology of P. knowlesi parasites in human infections closely resembled those of P.

falciparum in the early trophozoite stage and P. malariae in the later stages of the erythrocytic
cycle. Although there were some minor morphological differences between the blood stages
of P. knowlesi and P. malariae, it would be difficult to positively identify knowlesi malaria
based on morphology alone. However, even in the absence of PCR facilities, severe
symptoms, a parasitaemia >5,000/l blood, with P. malariae parasite morphology and a recent
history of time spent in the forest fringe areas of Southeast Asia should be enough to make a
diagnosis of knowlesi malaria. In view of what is now known of the distribution and severe
manifestation of knowlesi malaria, continued misdiagnosis of this important pathogen is no
longer acceptable.

Transmission
Malaria is transmitted exclusively through the bites of Anopheles mosquitoes. The intensity of
transmission depends on factors related to the parasite, the vector, the human host, and the
environment.About 20 different Anopheles species are locally important around the world. All
of the important vector species bite at night. Anopheles mosquitoes breed in water and each
species has its own breeding preference; for example some prefer shallow collections of fresh
water, such as puddles, rice fields, and hoof prints. Transmission is more intense in places

where the mosquito lifespan is longer (so that the parasite has time to complete its
development inside the mosquito) and where it prefers to bite humans rather than other
animals. For example, the long lifespan and strong human-biting habit of the African vector
species is the main reason why about 90% of the world's malaria deaths are in Africa.
Transmission also depends on climatic conditions that may affect the number and survival of
mosquitoes, such as rainfall patterns, temperature and humidity. In many places, transmission
is seasonal, with the peak during and just after the rainy season. Malaria epidemics can occur
when climate and other conditions suddenly favour transmission in areas where people have
little or no immunity to malaria. They can also occur when people with low immunity move
into areas with intense malaria transmission, for instance to find work, or as refugees.
Human immunity is another important factor, especially among adults in areas of moderate or
intense transmission conditions. Partial immunity is developed over years of exposure, and
while it never provides complete protection, it does reduce the risk that malaria infection will
cause severe disease. For this reason, most malaria deaths in Africa occur in young children,
whereas in areas with less transmission and low immunity, all age groups are at risk.
Human-to-human transmission of malaria
As the parasite exists in human red blood cells, malaria can be passed on from one person to the
next through organ transplant, shared use of needles/syringes, and blood transfusion. An infected
mother may also pass malaria on to her baby during delivery (birth) - this is called 'congenital
malaria'.People cannot "catch" malaria from others just by being near them. You can sit next to
an infected person quite safely, with no risk of infection, even if they cough or sneeze.
How Malaria is spread?
The life cycle of the malaria parasite (Plasmodium)
is complicated and involves two hosts, humans
and Anopheles mosquitoes. The disease is
transmitted to humans when an infected
female Anopheles mosquito bites a person and
injects the malaria parasites (sporozoites) into the
blood. Sporozoites travel through the bloodstream to the
liver, mature, and eventually infect the human red blood cells. While in red blood cells, the
parasites again develop until a mosquito takes a blood meal from an infected human and ingests
human red blood cells containing the parasites. Then the parasites reach the Anopheles
mosquitos stomach and eventually invade the mosquito salivary glands. When
an Anopheles mosquito bites a human, these sporozoites complete and repeat the
complex Plasmodium life cycle.

What is the incubation period of malaria?

Incubation means the time between becoming infected and the appearance of symptoms. This
generally depends on the type of parasite:
P. falciparum - 9 to 14 days
P. vivax - 12 to 18 days
P. ovale - 12 to 18 days

 P. malariae - 18 to 40 days
However, incubation periods can vary from as short as 7 days, to several months for P.
vivax and P. ovale. People on chemoprophylaxis (medication to prevent infection) have longer
incubation periods.

Symptoms
Malaria is an acute febrile illness. The first symptoms fever, headache, chills and vomiting
may be mild and difficult to recognize as malaria. If not treated within 24 hours, P.
falciparum malaria can progress to severe illness often leading to death. Children with severe
malaria frequently develop one or more of the following symptoms: severe anaemia,
respiratory distress in relation to metabolic acidosis, or cerebral malaria. In adults, multiorgan involvement is also frequent. It is extremely uncommon for malaria to cause skin
lesions or rash. In malaria endemic areas, persons may develop partial immunity, allowing
asymptomatic infections to occur. For both P. vivax and P. ovale, clinical relapses may occur
weeks to months after the first infection, even if the patient has left the malarious area. These
new episodes arise from dormant liver forms known as hypnozoites (absent in P.
falciparum and P. malariae); special treatment targeted at these liver stages is required for
a complete cure.

Who is at risk?

Approximately half of the world's population is at risk of malaria. Most malaria cases and
deaths occur in sub-Saharan Africa. However, Asia, Latin America, and to a lesser extent the
Middle East and parts of Europe are also affected. In 2013, 97 countries and territories had
ongoing malaria transmission.
Specific population risk groups include:
young children in stable transmission areas who have not yet developed protective immunity
against the most severe forms of the disease;
non-immune pregnant women as malaria causes high rates of miscarriage and can lead to
maternal death;
semi-immune pregnant women in areas of high transmission. Malaria can result in
miscarriage and low birth weight, especially during first and second pregnancies;
semi-immune HIV-infected pregnant women in stable transmission areas, during all
pregnancies. Women with malaria infection of the placenta also have a higher risk of passing
HIV infection to their newborns;
people with HIV/AIDS;
international travellers from non-endemic areas because they lack immunity;
immigrants from endemic areas and their children living in non-endemic areas and returning
to their home countries to visit friends and relatives are similarly at risk because of waning or
absent immunity.

Diagnosis and treatment

Early diagnosis and treatment of malaria reduces disease and prevents deaths. It also
contributes to reducing malaria transmission. Demonstration of the parasites in peripheral
blood is important to a diagnosis. Several effective methods of diagnosis have been
developed:
Fluorescent dye staining
DNA probe specific for P. falciparum
PCR diagnostics
ELISA detection of P. falciparum antigen
WHO recommends that all cases of suspected malaria be confirmed using parasite-based
diagnostic testing (either microscopy or rapid diagnostic test) before administering treatment.
Rapid tests can detect proteins called antigens that are present in Plasmodium. These tests
take less than 30 minutes to perform. However, the reliability of rapid tests varies
significantly from product to product. Thus, it is recommended that rapid tests be used in
conjunction with microscopy. A second type of test is the polymerase chain reaction (PCR),
which detects malaria DNA. Because this test is not widely available, it is important not to
delay treatment while waiting for results.
According to the CDC, the following drugs are commonly used for treating malaria:
artemether-lumefantrine (Coartem)
atovaquone-proguanil (Malarone)
chloroquine
clindamycin (used in combination with quinine)
doxycycline (used in combination with quinine)
mefloquine (Lariam)
quinidine
quinine
artesunate
The choice of drug depends on the species of Plasmodium and the risk of drug resistance in the
area where the malaria was acquired. In sub-Saharan Africa, for example, older drugs like
chloroquine are largely ineffective.
Most medications are available only as tablets or pills. Intravenous treatment with quinidine may
be needed in severe malaria or when the patient cannot take oral medications. Malaria during
pregnancy requires treatment by someone who is an expert in this area. Miscarriage and maternal
death may occur, even in the best of hands.
Patients with P. vivax or P. ovale may not be completely cured by the above medications, even
though the symptoms resolve. This is because the parasites can hide in the liver. A medication
called primaquine is used to eradicate the liver form, but this drug cannot be given to people who
are deficient in an enzyme called G6PD.
The best available treatment, particularly for P. falciparum malaria, is artemisinin-based
combination therapy (ACT).

Antimalarial drug resistance

Resistance to antimalarial medicines is a recurring problem. Resistance of P. falciparum to
previous generations of medicines, such as chloroquine and sulfadoxine-pyrimethamine (SP),

became widespread in the 1970s and 1980s, undermining malaria control efforts and
reversing gains in child survival.
In recent years, parasite resistance to artemisinins has been detected in four countries of the
Greater Mekong subregion: Cambodia, Myanmar, Thailand and Viet Nam. While there are
likely many factors that contribute to the emergence and spread of resistance, the use of oral
artemisinins alone, as monotherapy, is thought to be an important driver. When treated with
an oral artemisinin-based monotherapy, patients may discontinue treatment prematurely
following the rapid disappearance of malaria symptoms. This results in incomplete treatment,
and such patients still have persistent parasites in their blood. Without a second drug given as
part of a combination (as is provided with an ACT), these resistant parasites survive and can
be passed on to a mosquito and then another person.
If resistance to artemisinins develops and spreads to other large geographical areas, the public
health consequences could be dire, as no alternative antimalarial medicines will be available
for at least five years.WHO recommends the routine monitoring of antimalarial drug
resistance, and supports countries to strengthen their efforts in this important area of work.

Prevention
Vector control is the main way to reduce malaria transmission at the community level. It is the
only intervention that can reduce malaria transmission from very high levels to close to zero.
For individuals, personal protection against mosquito bites represents the first line of defense
for malaria prevention.
Two forms of vector control are effective in a wide range of circumstances.
1. Insecticide-treated mosquito nets (ITNs)
Long-lasting insecticidal nets (LLINs) are the preferred form of ITNs for public health
distribution programmes. WHO recommends coverage for all at-risk persons; and in most
settings. The most cost effective way to achieve this is through provision of free LLINs, so
that everyone sleeps under a LLIN every night.
2. Indoor spraying with residual insecticides
Indoor residual spraying (IRS) with insecticides is a powerful way to rapidly reduce malaria
transmission. Its full potential is realized when at least 80% of houses in targeted areas are
sprayed. Indoor spraying is effective for 36 months, depending on the insecticide used and
the type of surface on which it is sprayed. DDT can be effective for 912 months in some
cases. Longer-lasting forms of existing IRS insecticides, as well as new classes of insecticides
for use in IRS programmes, are under development.
Antimalarial medicines can also be used to prevent malaria. For travellers, malaria can be
prevented through chemoprophylaxis, which suppresses the blood stage of malaria infections,
thereby preventing malaria disease. In addition, WHO recommends intermittent preventive
treatment with sulfadoxine-pyrimethamine for pregnant women living in high transmission
areas, at each scheduled antenatal visit after the first trimester. Similarly, for infants living in
high-transmission areas of Africa, 3 doses of intermittent preventive treatment with
sulfadoxine-pyrimethamine is recommended delivered alongside routine vaccinations. In
2012, WHO recommended Seasonal Malaria Chemoprevention as an additional malaria
prevention strategy for areas of the Sahel sub-Region of Africa. The strategy involves the

administration of monthly courses of amodiaquine plus sulfadoxine-pyrimethamine to all

children under 5 years of age during the high transmission season.

Insecticide resistance
Much of the success to date in controlling malaria is due to vector control. Vector control is
highly dependent on the use of pyrethroids, which are the only class of insecticides currently
recommended for ITNs or LLINs. In recent years, mosquito resistance to pyrethroids has
emerged in many countries. In some areas, resistance to all four classes of insecticides used
for public health has been detected. Fortunately, this resistance has only rarely been
associated with decreased efficacy, and LLINs and IRS remain highly effective tools in
almost all settings.However, countries in sub-Saharan Africa and India are of significant
concern. These countries are characterized by high levels of malaria transmission and
widespread reports of insecticide resistance. The development of new, alternative insecticides
is a high priority and several promising products are in the pipeline. Development of new
insecticides for use on bed nets is a particular priority. Detection of insecticide resistance
should be an essential component of all national malaria control efforts to ensure that the most
effective vector control methods are being used. The choice of insecticide for IRS should
always be informed by recent, local data on the susceptibility target vectors.

In order to ensure a timely and coordinated global response to the threat of insecticide
resistance, WHO has worked with a wide range of stakeholders to develop the Global Plan for
Insecticide Resistance Management in malaria vectors (GPIRM), which was released in May
2012. The GPIRM puts forward a five-pillar strategy calling on the global malaria community
to:
plan and implement insecticide resistance management strategies in malaria-endemic
countries;
ensure proper and timely entomological and resistance monitoring, and effective data
management;
develop new and innovative vector control tools;
fill gaps in knowledge on mechanisms of insecticide resistance and the impact of current
insecticide resistance management approaches; and
ensure that enabling mechanisms (advocacy as well as human and financial resources) are in
place.

Vaccines against malaria

PfSPZ, an unusual experimental malaria vaccine, developed by Sanaria Inc. of Rockville,
Maryland, USA, has shown great promise in an early-stage clinical trial.
Trial researchers said the vaccine may provide 100% protection against malaria infection in
healthy adults.It is said that PfSPZ has the best result for a malaria vaccine so far.
PfSPZ is different from other vaccines. It uses weakened forms of the whole, immature
"sporozoite" phase of the parasite, and not an assortment of parasite proteins to induce an
immune response.Head researcher, Robert A. Seder, chief of the Cellular Immunology Section of

the NIAID Vaccine Research Center, said "In this trial, we showed in principle that sporozoites
can be developed into a malaria vaccine that confers high levels of protection and is made using
the good manufacturing practices that are required for vaccine licensure."For the PfSPZ vaccine
to be most effective it has to be administered intravenously (directly into the bloodstream), and
not intradermally (into the skin) or subcutaneously (under the skin).Seder said ",that these trial
results are a promising first step in generating high-level protection against malaria, and they
allow for future studies to optimize the dose, schedule and delivery route of the candidate
vaccine."Sanaria Inc. says it hopes that future human studies in the USA, Europe and Africa will
lead to licensing of "an affordable vaccine" which could be used in mass campaigns where
malaria is endemic.The company added that their aim is for PfSPZ to be used by the military,
business people, aid workers, diplomats and tourists.
On October 10th, 2013, that a large-scale Phase III African trial using the experimental malaria
vaccine RTS,S continued protecting young children up to 18 months after vaccination.The
researchers hope that the first protective shot against malaria will be available within the next 24
months.The trial showed that RTS,S reduced cases of clinical malaria in young children by 46%
after the first vaccine, compared to children of the same aged (5-17 months) who received a
control vaccine. Babies aged six to twelve weeks had a 27% lower clinical malaria incidence.

Difference between Dengue and Malaria

Dengue

Difference between Dengue and Malaria

Malaria

Dengue mosquitoes appear during daytime

Malaria mosquitoes show themselves at

nightfall

Viral in nature
Spread by Aedes Mosquito
Symptoms: fever accompanied by rash

Parasitic in nature
Spread by Anopheles Mosquito
Symptoms: cycles of sudden chills, shaking,
and fever.

Dengue reduced platelet count

Does not reduced platelet count

WHO response
The WHO Global Malaria Programme (GMP) is responsible for charting the course for
malaria control and elimination through:
setting, communicating and promoting the adoption of evidence-based norms, standards,
policies, technical strategies, and guidelines;

keeping independent score of global progress;

developing approaches for capacity building, systems strengthening, and surveillance;
identifying threats to malaria control and elimination as well as new areas for action.

GMP serves as the secretariat for the Malaria Policy Advisory Committee (MPAC), a group of
15 global malaria experts appointed following an open nomination process. The MPAC,
which meets twice yearly, provides independent advice to WHO to develop policy
recommendations for the control and elimination of malaria. The mandate of MPAC is to
provide strategic advice and technical input, and extends to all aspects of malaria control and
elimination, as part of a transparent, responsive and credible policy setting process.
WHO is also a co-founder and host of the Roll Back Malaria partnership, which is the global
framework to implement coordinated action against malaria. The partnership mobilizes for
action and resources and forges consensus among partners. It is comprised of over 500
partners, including malaria endemic countries, development partners, the private sector,
nongovernmental and community-based organizations, foundations, and research and
academic institutions.

Malaria Situation in the Philippines

Malaria is a rural disease and is one of the important mosquito-borne diseases affecting far-flung
barangays (villages) of the country. Out of the 79 provinces nationwide, 57 are malaria endemic.
This poses a huge economic, social and health burden to 11 million people who are at risk of
malaria. These areas are among the poorest in the country, belonging to the 5th - 6th class
municipalities where access to and availability of basic health services and correct health
information, remain difficult for the people at risk. This creates a huge and constant challenge to
the health deliverers and movers of the Malaria Control Program.
Malaria Status:
Figure1: Geographical Distribution of
Malaria
There are 79 provinces nationwide. The
Malaria Control Program has categorized
these 79 provinces based on the 5-year
average (see Figure 1). This helps the
program in prioritizing resources in
Categories A & B provinces. Out of the
79 provinces, 57 are malaria endemic
provinces. In 2007, 6 provinces have been
added in the list of Category D provinces.
Comparing the 2005 and 2006 malaria data, there were 35,405 cases (Morbidity Rate:
41/100,000) and 122 deaths (Mortality Rate: 0.14/100,000), a 24% reduction of malaria cases
(Morbidity Rate: 55/100,000) and 19% reduction of malaria deaths (Mortality Rate:
0.17/100,000) respectively.
The vision of the Malaria Control Program is a malaria-free Philippines by 2020. Strategies of
the MCP include the following: 1) Early diagnosis and prompt treatment; 2) Vector control
insecticide-treated mosquito net as main vector control strategy, complemented by indoor

residual spraying; 2) early management and disease surveillance; 4) monitoring and evaluation
drug and insecticide resistance monitoring; drug quality monitoring (pilot study to determine the
baseline profile); Quality Assurance for microscopy (GF sites) and Philippine Malaria
Information System at the provincial level.
The MCP is in the process of revising the following policies: 1) treatment policy the use of
artemisinin-based combination (artemether-lumefantrine: Coartem) as the 1st line treatment of
uncomplicated P. falciparum cases, followed by Primaquine on the 4th day of treatment. The
current treatment policy is the use of combination therapy of chloroquine and
sulfadoxine/pyrimethamine as the 1st line treatment of uncomplicated P. falciparum.
Artemisinin-based combination(Coartem) is the 2nd line treatment of uncomplicated P.
falciparum and is used if 1st line drugs are not available or if there is treatment failure from 1st
line drugs. Primaqine is given on the 4th day of treatment. Treatment of severe P. falciparum is a
combination therapy of quinine ampule/tablet plus any of the following antibiotics: Tetracycline,
Doxycycline or Clindamycin. P. vivax cases are treated with Chloroquine for 3 days and
Primaquine for 14 days ; 2) vector control use of indoor residual spraying as regular vector
control strategy based on the microstratified barangay (village) to complement ITNs, preferably
long-lasting mosquito nets. Currently, the use of IRS is used during outbreaks; 3) stratification of
endemic provinces up to the barangay (village)/sitio level.
Health services, including malaria control program has been devolved to the local government
units (Local Government Code of 1991). The Department of Health has further undergone
reorganization to address its new role and mandate under a decentralized set-up. The functions of
the DOH are policy formulation, advocacy, program development, standard setting, technical
assistance, regulation and monitoring. With regard to financial resource of MCP, Global Fund
and Roll Back Malaria Projects that assist the MCP and are major contributors of the programs
meager budget (Php 3.4M since 2001). However, in 2008, the national budget of the MCP has
increased by 2000% (Php 60M). As to human resource complement, there is only 1 staff at the
national level and is supported by 3 technical officers of WHO. At the regional level, there is a
regional malaria coordinator and a regional entomologist. However, the regional malarial
coordinator also handles 2 or more programs. To address the limited human resource,
establishment of diagnostic, clinical and vector control teams with team members coming from
the Research Institute for Tropical Medicine and Regional/Provincial Malaria Coordinators.
References:
Gardner, MJ; Hall, N; Fung, E; White, O; Berriman, M; Hyman, RW; Carlton, JM; Pain, A;
Nelson, KE (2002). "Genome sequence of the human malaria parasite Plasmodium
falciparum". Nature 419 (6906): 498
511.Bibcode:2002Natur.419..408G.doi:10.1038/nature01097.PMID 12368864.
World Heath Organization http://www.who.int/mediacentre/factsheets/fs094/en/
Taxonomical Classification http://www. Msu.edu/course/zol/316/ pspptax.htm
Spread of malaria signs and symptoms http://www.cambodiafirstclinic.com/malaria/
Malaria in the Philippines http://www.actmalaria.net/downloads/pdf/info/2008/Philippines
%20Malaria%20Country%20Profile%202008.pdf
Types of Malaria http://www.medicalnewstoday.com/articles/150670.php

 Malaria http://www.emedicinehealth.com/malaria/page2_em.htm
Morphological Classification of Plasmodium
http://www.tulane.edu/~wiser/protozoology/notes/pl_sp.html
Morphological Classification of P.
knowlesihttp://www.ncbi.nlm.nih.gov/pmc/articles/PMC2676309/
Difference between Malaria and Dengue http://ezinearticles.com/?Malaria-And-Dengue-Fever--The-Difference-Between-Them&id=5517828