MALARIA

• Italian words “ mal “ means bad and “ aria “

means the air

12/20/2018 PREPARED BY : DR SURAJ K.C 1

PRESENTED BY : INTERN SURAJ KC
DHULIKHEL HOSPITAL
KATHMANDU UNIVERSITY
HOSPITAL

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 Introduction
• An acute and chronic illness characterized by
paroxysms of fever, chills, sweats, fatigue,
anemia, and splenomegaly
• Malaria is of overwhelming importance in the
developing world today, with an estimated
300-500million cases and more than 1 million
deaths each year.
• Most malarial deaths occur among infants
and young children.

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 Global burden
• Major worldwide problem, occurring in more
than 100 countries with a combined
population of more than 1.6 billion people
• Principal areas of transmission are Africa, Asia,
and South America.
P P VIVAX P OVALE P MALARAE
FALCIPARUM
AFRICA BANGLADESH AFRICA MOST OF
INDIA MALARIOUS
AREA
HAITI NEPAL
NEW GUIENIA PAKISTHAN
SRILANKA
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• Malaria kills about 1.4 million people
worldwide every year ,
• In the south east asia region (SEAR) all
countries except maldives have indigenous
malaria transmission
• Drug resistant P falciparum has increased
morbidity and mortality

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 MALARIA IN NEPAL
Malaria is endemic disease in Nepal.
 Most common causative agent being
plasmodium vivax and plasmodium
falciparum. Plasmodium malariae has not
been reported in the last 20 years and no
cases of plasmodium ovale.
Of the total malaria cases 17-25% cases were
plasmodium falciparum cases.

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• No deaths have been reported after 2014 in
Nepal due to malaria and its associated
complication.
• Anopheles fluviatis and Anopheles annularis
are the most common mosquito associated
with malaria in Nepal

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 EPIDEMIOLOGY IN NEPAL
13.02 million
population (47.9%) live
in malaria endemic
VDCS.

0.98 million 2.66 million 9.38

(3.62%) live in (9.8%) live in million(34.52%)
high risk VDCs, moderate risk live in low risk
VDCs, VDCs

Reference : micro stratification report

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2013
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 ANNUAL REPORT 2016/17

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 Causative agent
• Intracellular protozoa of Plasmodium species
and transmitted to humans by female
Anopheles mosquitoes.
Before 2004 After 2004
P malariae P knowlesi
P vivax P malarae
P ovale P vivax
P falciparum P ovale
P falciparum

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 Vector
female anopheles mosquito
species of anopheles mosquito:
1) Anopheline culcifacies
2) Anopheline fluvitalis
3) Anopheline stephensi
4) Anopheline anularis

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 Some facts about mosquitos
• Maximum prevalence from july to november
• Optimum temprature for development is 20-
30 c .. Cessation of development below 16
degre C
• Not found above 2000m
• Rain provides opportunities to breeding thus
to epidemics

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Exogenous phase (in mosquito)
Sexual cycle (sporogony)
Sporozoites pass through
body cavity, reach salivary
glands
Endogenous Phase (In Human)
Asexual cycle (schizogony)
Sporozoites in saliva from Exoerythrocytic
mosquito injected into human multiplication in liver cells
host

Merozoites
Oocyst grows (multiple Sporogony Schizogony
division stage: cyst bursts
to release sporozoites)
Mature schizont Enter RBC

Penetrates to outer layer of Immature schizont Ring trophozoite

stomach wall of mosquito
and encysts)
Mature
Trophozoite
Ookinete (motile zygote)

Microgamete
Zygote Gametogony
microgamete differentiation
fertilization Macrogamete
Human blood
Macrogamete enters BY
mosquito
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 Relapse
Seen with vivax and ovale :derrived from the
liver schizonts that have remain latent long
before brusting

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 Incubation period
species Incubation period
PLASMODIUM FALCIPARUM 9-14
PLASMODIUM VIVAX 12-17
PLASMODIUM OVALE 16-18
PLASMODIUM MALARIAE 18-40

Incubation period can be as long as 6-

12 mo for P. vivax

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• Some individuals living in endemic areas of malaria possess
natural/innate resistance to falciparum malaria on the basis of
inheritance of selected genes expressed in RBC:
• Haemoglobin S gene
• Thalassaemia genes
• G6PD deficiency genes
• Ovalocytosis gene
Duffy blood group Ag Fya or Fyb negative people (West
Africans)
• This is due to impaired parasite growth at low oxygen tensions
and decreased cyto-adherence.
• In ovalocytosis the rigid erythrocyte resist merozoite invasion

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 pathologic processes
1. Fever: occurs when erythrocytes rupture
and release merozoites into the circulation.
2. Anemia : caused by hemolysis, sequestration
of erythrocytes in the spleen and other
organs, bone marrow.
3. Immunopathologic : excessive production of
proinflammatory cytokines
4. Tissue anoxia

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 CLINICAL FEATURES
Cold stage: half an hours – 1 hour
chills , rigors , headache, nausea , malaise ,
anorexia
Pulse is rapid and weak
Hot stage : 2-6 hours
skin is dry and hot to touch , pt feels burning hot
and casts off his clothes
flushed skin, rapid respiration, marked thirst
Sweating stage : 2-4 hours
Temperature falls by crisis
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The typical periodicity of these paroxysms is approximately:

 48 hours in P. vivax i.e. fever recurs after every 48 hours (Benign tertian
fever).
In P. falciparum also its 48 hours but because of its complication its
called malignant tertian fever.
In P. falciparum and P. knowlesi fever can recur every 24 hours also
(quotidian fever)
In P. malariae fever comes every 72 hours or 4th day. (Quartan malaria)
in P. ovale because of its tertian periodicity and irregular shape of
infected RBCs its called ovale tertian.
(Note: These regular fever patterns (tertian, every 2 days; quartan, every 3 days) are seldom
seen today in patients who receive prompt and effective antimalarial treatment)

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 Severe malaria

Source : nelsons text

book of pediatrics
20 e

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 P falciparum special feature
Cytoadherence of infected erythrocytes to vascular
endothelium

obstruction of blood flow ,capillary damage,

vascular leakage of blood, protein, fluid

tissue anoxia
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 Differentials

• hepatitis tuberculosis
• sepsis pyelonephritis
• Pneumonia leptospirosis
• meningitis
• encephalitis,
• endocarditis
• gastroenteritis

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 DIAGNOSIS
1) PERIPHERAL SMEAR
2) QUANTITATIVE BUFFY COAT
3) RAPID DIAGNOSTIC TESTS
4) POLYMERASE CHAIN REACTION

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 PERIPHERAL SMEAR
THICK SMEARS :
 Have sensitivity of detecting 5-10parasites /
micro litres
 Reliable in searching the parasites, as large
volume of blood examined under each
microscopic field
 Thick film is that which will just allow printed
letters to be read and should be de
haemoglobinized before staining.

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 THIN SMEAR

 Have lower sensitivity of 200 parasites

/microlitres
 Reliable to identify the species
 Thin smears are one blood cell in thickness

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 QAUANTITIVE BUFFY COAT
• A new method
• Detects parasite in peripheral blood
• Involves the staining of centrifuged and
compressed red cell layer with acridine orange
and ecxamination of it under uv light
• Fast ,easy, and more sensitive than traditional
thick smear examination

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 Rapid diagnostic kit
• pLDH OptiMAL: This test detects P. vivax
specific lactate dehydrogenase antigen using
monoclonal antibodies.
• Rapid and simple dip-stick test (ParaSight F
test, Becton Dickinson, Europe): This test is
based on the detection of P. falciparum
histidine rich protein 2 antigen using
monoclonal antibodies.

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 Management of malaria
Uncomplicated vivax malaria:
chloroquine 25mg base /kg divided over 3 days

10mg base
/kg initial 10mg/kg on 1st
dose day
followed by OR
5mg/kg at 6 10mg/kg on 2nd
hrs ,24 hrs day
,48 hrs
5mg/kg on 3rd day

12/20/2018 PREPARED
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DAYS 36
 UNCOMPLICATED VIVAX
DAY DRUGS
DAY 1 Chloroquine (10mg/kg)
Primaquine 0.25mg/kg

DAY 2 Chloroquine (10mg/kg)

Primaquine 0.25mg/kg

DAY 3 Chloroquine (5mg/kg)

Primaquine 0.25mg/kg

Day 4 -14 Primaquine 0.25mg/kg

(2 tabs)

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• 1 tab Choloroqine = 150mg base

• 1 tab primaquine = 7.5mg

• Primaquine is contraindicated in children < 6

months and breastfeeding ladies.

• If the status of the patient about G6PD deficiency

can not be ruled out, Primaquine 0.75mg/kg once
a week for 8 weeks to be used.

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 UNCOMPLICATED FALCIPARUM MALARIA

Treatment of uncomplicated falciparum :

combination of 2 or more than 2 anti malarial
drugs with different MOA

ACT ( ATREMSININ BASED COMBINATIONS

THERAPIES ):
1) artemether + lumefantrine( 20mg + 120mg ):
Dose : 6 doses regimen over 3 days peroid

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Weigiht No of tablets
5-14 kg 1 tab
15-24 kg 2 tab
25-34 kg 3 tab
More than 34 kg 4 tab

Primaquine 0.25 mg/kg single

dose to be given on 3rd day
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 UNCOMPLICATED FALCIPARUM MALARIA

DAY DRUGS AND DOSING

DAY 1 Coartem 4 tab 2 doses 12 hours apart
(Artemether 80mg and Lumefantrine
480mg.)

DAY 2 Coartem 4 tab 2 doses 12 hours apart

(Artemether 80mg and Lumefantrine
480mg.)

DAY 3 Coartem 4 tab 2 doses 12 hours apart

(Artemether 80mg and Lumefantrine
480mg)
Primaquine 0.25mg/kg
(2 tabs) single dose

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• Coartem is a Artimesinin Combination therapy
(ACT) and consists of Artemether and
Lumefantrine in a combination of 20mg and
120mg of drugs respectively.

• 1 tab primaquine = 7.5mg

• In first trimester of pregnancy, Coartem is not
recommended and hence quinine isused.
• Tab Quinine 10mg/kg (2 tabs) q8hrly for 7 days
• 1 tab quinine = 300mg

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 Other ACT
• ARTESUNATE + AMODIAQUINE Once
a
( 4mg/kg/day) ( 10mg/kg/day ) day
for 3
days

• ARTESUNATE + MEFLOQUINE :

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 SECOND LINE TREATMENT
• ARTESUNATE + TETRACYCLINE OR
DOXYCYCLINE
artesunate 0.2mg/kg once a day
tetracycline 4mg/kg 4 times a day For 7
OR doxycycline 3.5mg/kg once a day
Or Clindamycin 10mg/kg twice a day
days

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 Severe falciparum malaria
• Main choice : artesunate 2.4mg/kg iv or im
at admission , then at 12 hours , and then 24 hours then
once a daY
OR
Quinine 20 mg salt/kg on admission (iv or im) then 10 mg
every 8 hourly

Once the patient can tolerate oral , effective oral

antimalarial is used to continue and complete
treatment ..

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For >20kg BW For <20kg

Inj Artesunate 2.4mg/kg BW IV/IM at stat
(0), 12 hours and every 24 hours then
after
Inj Artesunate 3mg/kg BW IM at stat (0),
12 hours and every 24 hours then after
OR
Inj Artemether 3.2mg IM stat and 1.6mg
IM once daily
OR
Inj Quinine 20mg/kg stat BOLUS dose
over 4 hours in D5 or DNS solution
Inj Quinine 10mg/kg q8hourly
MAINTAINENCE dose with the drug not
exceeding 5mg/kg/hour

Once the patient tolerates oral medication

start on ACT/Primaquine or Quinine therapy as
in uncomplicated falciparum malaria.
Artesunate can be given in any trimester of
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 Breaking the channel of transmission
1. Anti adult measure
a. Residual spray : spraying of indoor surfaces
of houses , cattle shed with residual
insectisides like DDT, malathion
b. Space spraying :
out door spraying of insectisides in the form
of fog or mist

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2. Anti larval measures
a. source reduction :
elimination of non essential water
bodies
b. Biological control :
mosquito can be controlled by employing
their natural enemies such as fish , fungi
bacteria
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• Fish : Gambusia affinis and lebister reticulates

• Bacteriae : bacillus sphericus and bacillus

thugringensis

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3. PERSONAL PROTECTION :
 use of bed nets : can be impregnated with
insecticides
Use of mosquito repellents
Malaria vaccine ( under trial)

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 Malaria in special cases
Pregnancy :
In 1st trimester : quinine + clindamycin ( if fails
artesunate + clindamycin )
ACT is contraindicated in 1st trimester

In 2nd trimester : ACT

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 ROLL BACK MALARIA
• Global framework to implement coordinated
action against malaria
• Launched in 1998 by WHO , UNICEF , UNDP,
and world bank

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 REFERENCES
• NELSONS TEXT BOOK OF PEDIATRICS 20TH
EDITION
• ANNUAL REPORT OF NEPAL 2016/17
• EPIDEMIOLOGY AND DISEASE CONTRO
DIVISION
• PARKS TEXT BOOK OF COMMUNITY MEDICINE
• GHAI ESSENTIAL PEDIATRICS 8TH EDITION

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