MALARIA

Malaria is a disease caused by parasites, viruses or bacteria. It is a disease of humans and the
parasite is spread to humans through the bites of infected mosquitoes. This disease can be life
threatening and it amounts for over one million deaths.

EPIDEMIOLOGY

Malaria has been recognised as a severe and life-threatening illness for thousands of years. It
still is one of the most common diseases affecting humans worldwide. The major impact of the
disease is almost entirely on the developing countries, with the heaviest burden in Africa.
Almost half of the total world population is exposed to the risk of contracting malaria. Certain
people are at higher risk of getting malaria and developing severe disease. These include
pregnant women, infants, children under five years of age, people with HIV/AIDS, and travelers
coming from areas where malaria is not present. Of the deaths recorded of malaria, a large
proportion was young children in sub-Saharan Africa. This is the most vulnerable group affected
with the condition. In areas with high transmission, the most vulnerable groups are young
children. These children are vulnerable because they have not developed immunity to malaria
yet. Pregnant women are also at risk because their immunity has been decreased by pregnancy.

TRANSMISSION OF MALARIA

All species of plasmodium are responsible for malaria infection: Plasmodium falciparum,
Plasmodium Malariae, Plasmodium Ovale, Plasmodium vivax and Plasmodium knowlesi. In
Nigeria, over three quarter of Malaria infection are caused by P.falciparum followed by
malariae and then Ovale.

Malaria is transmitted mainly 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. There are rare conditions where there is transfusion of blood containing the
erythrocytic phase of the parasite (Transmission Malaria) or very rarely from mother to child
through placenta (Congenital Malaria).

The major vectors of human malaria are Anopheles gambiae, Anopheles arabiensis, Anopheles
funestus and Anopheles melas.

The mosquitos become infected by ingesting human blood containing male and female
gametocytes. The life cycle take about 12 days to complete, depending on the atmospheric
temperature (optimum temperature lies between 17 and 18 degrees). The incubation period in
the mosquito i.e the interval elasping from the ingesting of infected blood by the mosquito to
the appearance of sporozoites in the saliva of the mosquito is known as the EXTRINSIC
INCUBATION PERIOD. The PRE-PATENT PERIOD (INTRINSIC INCUBATION PERIOD) is the time
which elapses between the infection of man by sporozoites and the first appearance of
erythrocytic parasites in the blood and this is usually 6-9days except in plasmodium malariae
which ranges from 13-16days. Thereafter symptoms of Malaria appear as parasitemia (i.e the
presence of erythrocytic parasites in the blood) build up.

LIFECYCLE OF PLASMODIUM.

The life cycle of Plasmodium occurs in two phases in two different organisms, partly in man and
partly in mosquito.

1. SEXUAL PHASE (SPOROGONY) ; occurs in mosquito as a DEFINITE HOST

2. ASEXUAL PHASE (SCHIZOGONY) ; occurs in man as an INTERMEDIATE HOST

SEXUAL PHASE

•The infected mosquito sucks up the gametocytes, both male and female from an infected
person along with it's blood meal. This marks the beginning of the sexual phase.

•The male and female gametocyte fuse to form an elongated mobile zygote called Ookinete.

•The Ookinete then migrates to the intestinal wall of the mosquito and develops into an
Oocyst. Oocyst is an encysted form of the zygote.

•The oocyte matures into a sporozoite which migrates to the salivary gland of the mosquito
from where it can be transferred to another host (man) through a bite.

This phase lasts about 10 -14 days.

ASEXUAL PHASE

This phase has four stages and it is also called the pathophysiology of malaria in man.

The stages include;

• Primary or pre-erythrocytic schozogony

• Erythrocytic schozogony
• Gametogony

• Secondary exo-erythrocytic or dormant schozogony

Infection is initiated when the female Anopheles mosquito introduces sporozoites into the body
during a blood meal. The sporozoites invade the liver parenchyma cells. The liver cells rupture
giving off thousands of merozoites which invade the red blood cells. In plasmodium, Ovale and
vivax, the pre erythrocytic schizonts produce in addition to the blood merozoites, other
merozoites which invade morew liver cells (secondary erythrocytic phase) to liberate more
merozoites into the blood stream. These merozoites resulting from secondary (persistent) liver
phase ( the Hypnozoites) are responsible for the relapse at later stage.

Merozoites released into the blood stream, are directed towards their second target, the red
blood cells. As they invade, they mark the beginning of the erythrocytic phase. The first stage
after invasion is a ring stage that evolves into a trophozoite. The trophozoites are not able to
digest the haem so they convert it to haemozoine and digest the globin that is used as a souve
of amino acids for their reproduction. The next cellular stage is the erythrocytic schizont
( initially immature and then mature schizont). Each mature schizont gibes birth to new
generation merozoites (erythrocytic schozogony) that, after the RBCs rupture, are released in
the blood stream in order to invade other RBCs. This is when parasitemia occurs and clinical
manifestations appear.

The liver phase occurs only once while the erythrocytic phase undergoes multiple cycles; the
merozoites released after each cycle creates the febrile waves.

The asexual phase lasts. Approximately 48hrs in plasmodium falciparum, Ovale and vivax and
72 hrs in plasmodium malariae some of the asexual forms in the red blood cells differentiates
into asexual forms called gametocytes. The gametocytes in the infected red blood cells serve as
source of infection when they're picked up by mosquitoes during blood meal.

SIGNS AND SYMPTOMS (CLINICAL MANIFESTATIONS)

1. Prodromal phase

This is the phase between end of incubation period and the point at which characteristic
symptoms of the illness appear(nonspecific symptoms). These prodromal symptoms are;
malaise, Weakness Generalized arthralgia (pain in the joints), Headache, Bitterness of mouth.

2. Feverish phase

It starts with the manifestation of fever. The fever could in some cases be only in the evenings
for about 2-3days. The major symptoms of this stage are ; fever, vomiting, anorexia, abdominal
pain etc. Sometimes malaria may be acute in children and manifest with other signs of malaria
immediately.

CONTROL OF MALARIA.

Spray insect repellants on your exposed skin. The recommended repellent contains 20-35% N
N, N-Diethyl-meta-toluamide (DEET).

Use a mosquito net over the bed if your bedroom isn’t air-conditioned or screened. For
additional safety, you can treat the mosquito net with the insecticide permethrin.

When you go out, in addition to spraying insect repellants on your exposed skin, you can also
spray on your clothing. Mosquitoes find it easy to bite through thin clothing.

Keep your home and surroundings clean without any junks or wastes.
When it comes to controlling the disease, keep an eye out for the symptoms like fever with high
temperature. As soon as you find any possible signs of malaria, consult your doctor
immediately.

Make sure you don’t keep your windows and doors open at night as mosquitoes get active
during the night and pose a higher risk. You can either use a mosquito or any net to seal your
window and then open for the whole day.

Some drugs are given in combination with other drugs. The type of parasite will determine
what type of medication you take and how long you take it.

CHEMOPROPHYLAXIS

This is the practice of introducing and antimicrobial agent for preventing and infection or for
suppressing contacted infection before the clinical manifestations.Malarial chemoprophylaxis
functions by targeting the liver schizont, blood schizont, or hypnozoite stages of the
plasmodium life cycle. All recommended primary prophylaxis regimens involve taking a
medicine before, during, and after travel to an area with malaria. Beginning the drug before
travel allows the antimalarial agent to be in the blood before the traveler is exposed to malaria
parasites. The three most commonly prescribed medications for chemoprophylaxis are
Atovaquone-proguanil, Doxycycline, and Mefloquine.

Antimalarial drugs include: 1) Any Artemisinin-based Combination Therapy (ACT) 2)

SP/Fansidar 3) Chloroquine(There are parasites that are resistant to this medication) 4)
Amodiaquine 5) Quinine pills 6) Quinine injection or intravenous (IV) 7) Artesunate
rectal 8) Artesunate injection or intravenous (IV) 9) Other antimalarial: Artemisinin drugs
(artemether and artesunate). The best treatment for Plasmodium falciparum malaria, if
available, is artemisinin combination therapy. Atovaquone (Mepron®). Doxycycline (Doxy-100®,
Monodox®, Oracea®). Mefloquine. Quinine. Primaquine.
THE ROLL BACK MALARIA INITIATIVE

Malaria has plagued humankind since ancient times and is still putting nearly 40% of the world’s
population at risk. No one is certain how many people contract the disease, but estimates
suggest that it afflicts between 350 million and 500 million people every year. The World Health
Organization (WHO) estimates that 59% of the world’s clinical malaria cases occur in Africa,
38% in Asia and 3% in the Americas.

The Roll Back Malaria (RBM) initiative was launched in 1998 by WHO, the United Nations
Children’s Fund (UNICEF), the United Nations Development Programme (UNDP) and the World
Bank in response to the unacceptably huge malaria burden on health and economies. The
initiative renewed the global focus on malaria and revitalized the neglected malaria control
programme, developed after the loss of aspiration for global eradication in 1969. It has been
clearly stated that malaria eradication is not the objective of the new initiative: it is aimed at
halving malaria-associated mortality and morbidity by 2010, and it is emphasized that this can
only be achieved through strengthened local health systems .

The new approach created new opportunities for partnership between the public and private
sectors. RBM now has a very wide range of partners, including malaria-endemic countries, their
bilateral and multilateral development partners, the private sector, nongovernmental and
community-based organizations, foundations, and research and academic institutions. Voting
members of the RBM Partnership Board are: malaria endemic countries (8), donor countries (3),
UNICEF, WHO, UNDP, World Bank, research and academia (1 each), non-governmental
organizations (2), private sector (2), foundations (1). The board also includes 2 non-voting ex
officio members [6].

PURPOSE OF RBM

RBM purpose is to create an environment that helps countries develop policies and implement
relevant elements of RBM strategy. There are six elements to roll back malaria. They are: early
detection of malaria illness; rapid treatment of those who are ill; multiple means for preventing
infection; strengthening of health sector and intersectoral activities; a powerful sustained social
involvement and movement; focused research for new tools and better implementation.

CHALLENGES OF RBM

Challenges for Roll Back Malaria in the Eastern Mediterranean Region

Malaria-endemic countries are facing a number of challenges, such as:.limited coverage and
low quality of laboratory services for diagnosis, particularly in high-burden countries, where
only one-quarter of the clinical malaria cases are laboratory confirmed; weak heath information
and malaria surveillance systems, which are unable to provide reliable data on the malaria
burden; limited access to effective treatment and prevention measures; poor leadership and
management skills at national and lower levels; lack of compliance of the private sector with
national policies and guidelines; weak community involvement and lack of community
structures to deliver interventions to remote and inaccessible populations.

Countries aiming at malaria elimination are confronted with various obstacles, including:

limited expertise in malaria elimination and weak national capacity for implementing
elimination interventions; lack of an accurate and up-to-date stratification map of malaria
transmission; lack of effective strategies for coordination of cross-border activities; weak
intersectoral coordination.

Countries of the Region also face an additional constraint concerning the spread of resistance
to drugs and insecticides. The unstable political situation in certain areas due to war or civil
unrest and globalization along with rapidly changing dynamics in environment, climate and
migration pose formidable challenges.

THE WAY FORWARD

With the vision of having a malaria-free Region, RBM/WHO Regional Office for the Eastern
Mediterranean will continue to provide support to countries to provide universal coverage for
malaria control and prevention interventions, and to develop strategic plans for malaria
elimination, wherever feasible.

WHO will assist countries in their efforts to mobilize resources for the malaria programme and
to strengthen the health system, as well as in building up national capacity for malaria
elimination and in the coordination of cross-border activities. More investment will be given to
research to develop innovative strategies to address the challenges facing the programme in all
phases and settings, including complex emergency situations.

Support will be sustained to consolidate the achievements already made and to prevent the re-
emergence of malaria.