Professional Documents
Culture Documents
Malaria WACP 2008
Malaria WACP 2008
Malaria WACP 2008
Preamble
Mosquito Salivary
Zygote Gland
Hypnozoites
Exo- (for P. vivax
and P. ovale)
erythrocytic
(hepatic) cycle
Gametocytes
Erythrocytic
Cycle
Schizogony
Malaria Transmission Cycle
Exo-erythrocytic (hepatic) Cycle:
Sporozoires injected Sporozoites infect liver cells and
into human host during develop into schizonts, which release
blood meal merozoites into the blood
Parasites
mature in
mosquito
midgut and Dormant liver stages
MOSQUITO HUMAN
migrate to (hypnozoites) of P.
salivary vivax and P. ovale
glands
Erythrocytic Cycle:
Merozoites infect red
blood cells to form
Some merozoites schizonts
Parasite undergoes
sexual reproduction in differentiate into male or
the mosquito female gametocyctes
Life cycle Plasmodium
May be:
Acute uncomplicated: = acute febrile illness
Severe/complicated malaria: when there are:
Encephalopathy
Severe anaemia
Hyperpyrexia
Metabolic derangement
Acute renal or respiratory syndrome etc
Diagnosis
Both clinical and laboratory means are employed.
About 50% of clinical Δ is incorrect even by the
physicians (detection of the parasite is paramount)
Laboratory methods include:
1.Antigen detection
2. Antibody detection
3. QBC
4. PCR
5. Thick/thin blood film
Diagnosis
Antibody detection: using enzymatic immunoassay or
immunoflourescence may be used in surveys but not
useful in acute malaria (antibodies develop days or weeks after onset)
Antigen detection: e.g. parasight F, OptiMAL
The former detects histidine rich protein-2 whereas the
latter detects parasite specific lactate dehydrogenase.
-available as dipsticks and easy to use
-but antigen may remain in circulation for sometime after
the parasite has been cleared (esp HRP-2)
Diagnosis
Macro
Micro
Diagnosis
P. malariae
Ring form may have squarish appearance
Characteristics band forms
Mature schizont has daisy head appearance
Chromatin dot may be on the inner surface of
the ring
Red cell not enlarged
Diagnosis
P. ovale
Red cell enlarged
Comet form common
Rings large and coarse
Schuffner’s dots prominent
Mature schizont similar to that of P. malariae
Current status of drug
100
80 NC
NE
60
NW
40
SE
20 SS
SW
0
CQ P-S Art-Lu As=Aq
Current status of drug
Mefloquine: introduced in 1984 for acute
uncomplicated malaria and by 1990 significant
resistance has been reported in Thailand.
This drug is still very efficacious in Nigeria,
although in vitro testing of some isolates
suggested reduced sensitivity.
Was combined with P-S in the hope that
mefloquine could be protected same idea
exported to Africa.
Current status of drug
The combination with P-S did not have any advantage
over mefloquine monotherapy in Nigeria.
Mefloquine resistance mirrors that of quinine and
halofantrine but bears an inverse relationship to that of
chloroquine in any given area.
Resistance has been attributed to an ATP-dependent
P-glycoprotein pump, a product of Pfmdr gene.
Current status of drug
*A new formulation
Current status of drug
Resistance to P-S has become established in Thailand
and Indochina since the early 1970s.
East African countries were also the first to be affected
in Africa.
Pyrimethmine-sulphadoxine was used as second line
drug in Nigeria and most African countries until
recently.
Cure rate may be as low as 8% in South-south Nigeria
Current status of drug
++Theoretically, if two drugs are used and for each one a single mutational event confers complete
resistance and such events occur with a frequency of 1:10 10 nuclear divisions, the probability
of a mutation resistant to both drugs is 1:10 20
Treatment options
Combination chemotherapy may either be:
ACT or Non-ACTion
Artemisinin based Combination Therapy: especially
favoured because
artemisinin derivatives reduce parasite biomass very fast
Rapid relief of symptoms
Good safety profile
Have short half-lives*
Malaria vaccine
Vector control: avoid mosquito bite, use ITN
Chemoprophylaxis
– Traditional/conventional
– Intermittent preventive treatment
Vector control
Drugs:
Mefloquine
Chloroquine
Doxycycline
Proguanil
Atovaquone-proguanil
Malaria prophylaxis
Remember
Febrile illness ≠ malaria!
Severe or complicated malaria ≠ drug resistant
malaria!
Failure of symptom resolution does not always
mean that there is drug resistance
Your lab. may be wrong!
Failure of symptom resolution
Re-evaluate your patient including history and physical
examination
Was there an initial blood film, what was the finding?
Repeated blood film, this time both thick and film
should be done
You may have to request to look at film!
If positive, is this ETF, LTF or a NEW INFECTION?
Failure of symptom resolution