Public Health

Approaches to Malaria

Source: National Library of Medicine

 Malaria

Malaria is a vector borne parasitic disease caused by the

genus Plasmodium, affecting over 100 countries of the
tropical and subtropical regions of the world.
Four different Plasmodium species infect humans and cause
distinct disease patterns:
P. falciparum (malaria tropica),
P. vivax (malaria tertiana),
P. malariae (malaria tertiana) and
P. Ovale (malaria quartana)

P. falciparum and P. vivax account for 95% of malaria infections. Of these two
parasites, P. falciparum is the most deadly one, causing cerebral malaria which, if
remain untreated, leads to coma and ultimately death of the patient.

40% of the world population live in areas with the risk of malaria.
 Malaria

Around 300-500 million clinical cases of malaria are reported every year,
of which more than a million die of severe and complicated cases of
malaria.

Malaria is known to kill one child every 30 sec, 3000 children per day
under the age of 5 years.

Malaria ranks third among the major infectious diseases in causing deaths
after pneumococcal acute respiratory infections and tuberculosis, and
accounts for approximately 2.6% of the total disease burden of the world.

Although malaria has been widely eradicated in many parts of the world,
the global number of cases continues to rise. The most important reason
for this alarming situation is the rapid spread of malaria parasites that are
resistant to antimalarial drugs.
 Malaria
Malaria parasites are transmitted from one person to
another by the female anopheline mosquito.

The males do not transmit the disease as they feed only on plant
juices.

There are about 380 species of anopheline mosquito, but only 60

or so are able to transmit the parasite.
 Malaria Life Cycle

Mosquito infected with the malaria parasite bites

human, passing cells called sporozoites into the
humans bloodstream.

Sporozoites travel to the liver. Each sporozoite

undergoes asexual reproduction, in which its nucleus
splits to form two new cells, called merozoites.

Merozoites enter the bloodstream and infect red blood

cells.

In red blood cells, merozoites grow and divide to

produce more merozoites, eventually causing the red
blood cells to rupture. Some of the newly released
merozoites go on to infect other red blood cells.
 Malaria Life Cycle

Some merozoites develop into sex cells known as male

and female gametocytes.

Another mosquito bites the infected human, ingesting

the gametocytes.

In the mosquitos stomach, the gametocytes mature.

Male and female gametocytes undergo sexual
reproduction, uniting to form a zygote.

The zygote multiplies to form sporozoites, which travel

to the mosquitos salivary glands.

If this mosquito bites another human, the cycle begins

again
Life Cycle of the Malaria Parasite
 History of Malaria
Anophelines have been in Africa for
30 million years!

Symptoms first described in China in

writings from 2700 BC

The bark of the cinchona (from Cinchona bark uses in the early 17th
Bolivia) century to cure malaria (quinine)

In 1880, Alphonse Laveran discovers

plasmodia in the blood of a patient in
Algeria.

In 1897, Ronald Ross demonstrates

the mosquito transmits malaria
(India) (Nobel Prize)
Alphonse Laveran
Source: Centers for Disease Control and
Prevention.
 Malaria Basics
Geographic variability: parasite, vector,
transmission, behaviors, impact
Four species of Plasmodium in humans
Many anopheline species transmit
As yet no vaccine
Parasite resistance to drugs
Some vector resistance to insecticides
Roll Back Malaria partnership
P. falciparum Worldwide, P. vivax LAC/Asia
 Malaria Burden
Disease Burden
300-500 million
clinical cases per
year, ~1B infections?
80% of cases in
Africa
~900,000
deaths/year
>75% African
children
5th in ID deaths
 Malaria Burden (continued)
<20% of malaria cases come to
attention of the health system,
80% are private care in shops/
pharmacies (resistance)
Pregnant women at high risk of dying,
low birth weight children
Children suffer cognitive damage and
anemia
Families spend up to 25% of family
income on treatment
40 million DALYs lost annually
 Resurgence of Malaria
Ecological change
Population growth
Marginal and fragile health systems
Breakdown of health systems/control
Political upheaval
Population movement
Relaxing of control capacity and political will
after eradication effort successes
Marginal populations
 Malaria Epidemiology
Malaria is caused by
parasites of the genus
Plasmodium.
There are 4 species of
malaria parasites that can
affect humans under
natural conditions:
Plasmodium falciparum, P.
vivax, P. ovale, and P.
malariae.
The disease is spread by
the female Anopheles
mosquito
Source: National Institute of Allergy and Infectious Diseases
 Burden in Pregnancy
45 million pregnancies annually in endemic
areas of Africa 23 million (50%) in high
malaria transmission areas
3-15% of mothers suffer severe anemia and
10,000 malaria anemia deaths per year
Infants: 30% of preventable low birth weight
and 75-200,000 infant deaths per year
 Malaria in Pregnancy
Malaria
Pregnant
Women
morbidity
anemia
Fetus
fever abortions
cerebral malaria stillbirths Newborn
congenital LBW
hypoglycemia
infection prematurity
sepsis
IUGR
mortality
malaria
severe disease
General
hemorrhage
illness
mortality
 Children and Malaria
Malaria accounts for 20% of all
childhood deaths in Africa

Anemia, low birth-weight, failure to

thrive, neurological problems from
cerebral malaria

Over 500,000 African children

develop cerebral malaria

Symptoms include fever, vomiting,

and headache, convulsions, coma,
or death within 24 hours

Much of the morbidity & mortality

can be prevented with tools
currently available
Source: Roll Back Malaria. World Health Organization.
 The Malaria Challenge
Malaria is a disease of poverty & a cause of
poverty

GNP
per capita
(1995) $0-70
$0-70

$1941-2580
$1941-2580

Malaria
Index
00

33
 Economic Costs - Malaria
Economic Costs
Care & Control
Productivity, earnings
Loss of time from work
Hampers economic
development
One healthy year of
life is gained for every
$1 to $8 spent on
effectively treating
malaria cases
 Economic Impact of Malaria
>$3.6B in economic loss in 2000
1%-5% of GDP for endemic countries in
work loss
20%040% of outpatient visits and 10%-
15% of admissions
Deterrent to trade, business development,
tourism, foreign investment
 Major Issues & Challenges for
Malaria
Infrastructure and health systems
Accurate Dx and Rx, surveillance
Applying combination therapies
Drug adherence, quality
Private sector delivery and regulation
Cost and financing
Malaria Prevention and Control
 Attacking Malaria
Preventing infection (avoiding bites)
Preventing disease (using antimalarial
drugs prophylactically)
Antimalarial drugs for pregnant women
Vector control (source reduction including
larval control, indoor residual spraying)
Insecticide treated bed nets (have been
shown to reduce all-cause mortality by
20%)
Key Factors for Malaria Interventions
Prompt & Effective Treatment
Home management, availability,
resistance
Intermittent Preventive Therapy
High antenatal attendance rates in Africa
Primagravidae and HIV+ women
Insecticide Treated Nets
Availability
Targeting those most in need