Malaria by Dr. Aryan

Malaria, its epidemiology, types, clinical features, investigations, diagnosis and management

1. malaria PRESENTED BY: ANISH DHAKAL (Aryan)

2. Introduction A protozoal disease caused by plasmodium species. Includes: Plasmodium vivax Plasmodium falciparum Plasmodium malariae Plasmodium ovale

3. Introduction Transmitted by the bite of female anopheles mosquito. Peak of transmission between July and November. F avourable condition: temperature (20-30 degree Celsius, relative humidity (60%) area with good rainfall. Incubation period varies between 12 and 30 days.

4. World malaria report 2017 In 2016, an estimated 216 million cases of malaria occurred worldwide Most malaria cases in 2016 were in the WHO African Region (90 %) Of 91 countries reporting malaria, 14 countries in sub-Saharan region plus India carried 80% burden The incidence rate of malaria is estimated to have decreased by 18% globally Plasmodium falciparum is the most prevalent malaria parasite in sub-Saharan Africa, accounting for 99% of estimated malaria cases in 2016.

5. World malaria report 2017 In 2016, there were an estimated 445 000 deaths from malaria globally , compared to 446 000 estimated deaths in 2015 The WHO African Region accounted for 91% of all malaria deaths in 2016, followed by the WHO South East Asia Region (6 %) Fifteen countries accounted for 80% of global malaria deaths in 2016 Globally, more countries are moving towards elimination: in 2016, 44 countries reported fewer than 10 000 malaria cases , up from 37 countries in 2010 In 2016, WHO identified 21 countries with the potential to eliminate malaria by the year 2020 (E:2020 countries)

6. Classification On the basis of severity: Uncomplicated malaria (Non falciparum & Falciparum) Complicated/ severe malaria S evere anemia, Cerebral malaria

7. Clinical Features Depend on species of parasite and endemicity of disease. Sudden onset of fever- classically intermittent, Headache, Loss of appetite, Tiredness, Pain in the limbs. The illness characterized by, Cold stage: Chills and rigors with headache, nausea, malaise and anorexia (1/4- 1 hr.) Hot stage: Dry flushed skin, rapid respiration and marked thirst (2-6 hrs.) Sweating stage: Temperature falls by profuse sweating (2-4 hrs.)

8. Clinical Features P . Falciparum: Onset is often insidious, with malaise, headache and vomiting Anaemia and thrombocytopenia develops rapidly. Jaundice is common Children have no specific symptoms other than fever Cerebral malaria: confusion, seizures or coma Abortion and IUGR in pregnancy Previous splenectomy increases risk of severe malaria

9. Cont’d P. v ivax and P.ovale Several days of continued fever initially Fever starts with rigor. Temperature rises to 40 degree. Within 1 hour hot or flush phase begins The phase is followed by profuse perspiration lowering the temperature Cycle repeated 48 hours later Spleen and liver enlarge. Anemia is less rapid Relapses common in first two years of leaving the endemic area

10. P. malariae Mild symptoms and bouts of fever every third day Parasitaemia may persist for many years, occasional recrudescence of fever Chronic infection causes glomerulonephritis and nephrotic syndrome in children

11. Source:Harrison’s Principles of Internal Medicine, 19 th Edition

12. Diagnosis

13. Quantitative buffy coat smear QBC tube precoated internally with acridine orange stain and potassium oxalate Parasites concentrated below leukocyte after centrifugation Parasitic DNA is detected by acridine orange stain and appear as bright specks of light among nonflourescing RBC 16

14. Flourescent dye test Benzothiocarboxypurine intensely stain nucleic acid of parasite after penetrating RBC Does not stain nuclei of WBC Useful in field laboratory in mass screening Immunochromatographic tests OptiMal (detects the Plasmodium lactate dehydrogenase of several species) ParasightF (detects the P. falciparum histidine -rich protein 2) DNA detection (PCR) For determining whether a patient has a recrudescence of the same malaria parasite or a reinfection with a new parasite 17

15. Management

16. Non falciparum malaria First line drug remains Chloroquine Resistant cases can be treated by Artemisinin Based Combination Therapies (ACTs) Eradication of erythrocytic phases should be accompanied by eradication of hypnozoites by primaquine Tafenoquine , similar to Primaquine, remains under study P. malariae is treated with Chloroquine alone

17. Uncomplicated Malaria

18. Uncomplicated falciparum malaria Resistant to Chloroquine and Sulphadoxine-Pyrimethamine in most areas WHO recommends ACTs regimens for falciparum malaria Quinine is generally effective but needs extensive period and poorly tolerated

19. Uncomplicated Malaria

20. Severe malaria Parenteral treatment is recommended IV artesunate is proved to be superior in efficacy and better tolerability than quinine Four doses of 2.4mg/kg over 3 days, every 12 hours on Day 1 and then daily If IV artesunate is unavailable quinine or intrarectal artemether or artesunate is also effective Cardiac monitoring with quinine therapy Dextrose administered to decrease risk of hypoglycemia

21. Severe & Complicated Falciparum Malaria

22. Prevention Destruction of watery and bushy places favoring breeding of mosquitoes. Use of insecticides Use of mosquito repellant creams Biological control Chemoprophylaxis for travellers to endemic areas.

23. Chemoprophylaxis

24. Drug Resistance P. falciparum resistance to Chloroquine and Sulfadoxine-pyrimethamine A rtemisinin (partial ) resistance and partner drug resistance, has been reported ACTs have been integral to the recent success of global malaria control , and protecting their efficacy for the treatment of malaria is a global health priority.

25. Insecticide resistance In 2016, resistance to one or more insecticides was present in all WHO regions Resistance to pyrethroids – the only insecticide class currently used in ITNs – is widespread. R eported pyrethroid resistance increased from 71% in 2010 to 81% in 2016 . ITNs continue to be an effective tool for malaria prevention Multicountry 5 year evaluation: No significant association between malaria disease burden and pyrethroid resistance across study locations in 5 countries

26. prognosis Uncomplicated cases: resolution of fever within 1 to 2 days with mortality of about 0.1% In developed world, malaria deaths is mostly in adults and often follows extended illness and secondary complication Malaria in pregnancy repeatedly associated with poor outcomes: increased prematurity, low birth weight and mortality

27. References Rosenthal J. Philip. CURRENT Medical Diagnosis & Treatment, 57th ed. : Mc Graw Hill, Lange; 2018.  Dockrell D.H, Sundar S, Angus B.J, Hobson R.P. Davidson's Principles & Practice of Medicine, 22nd ed. Replika Press Pvt. Ltd, India: Churchill Livingstone, Elsevier; 2014 . World malaria report 2017. Geneva: World Health Organization; 2017. Licence: CC BY-NC-SA 3.0 IGO. Thank You