Malaria (Community Medicine Class)

This is meant for MBBS undergraduate teaching

1. MALARIA Dr.Benny PV Professor & HOD Department of Community Medicine

2. Malaria

3. HISTORY Intermittent fever: High incidence during rainy season, was first recognized by Romans and Greeks They postulated that intermittent fevers were due to ‘bad odour’ coming from marshy areas and thus gave the name ‘malaria’ (‘mal’= bad + ‘air’)

4. Scientists In 1880, a French army surgeon, Charles Louis Alphonse, first observed and described the malarial parasite in red blood cells In 1894, Sir Ronald Ross proved the complete life cycle of plasmodium in mosquitoes

5. History behind anti-malarial

6. BURDEN OF DISEASE Globally in 2016: 216 million cases 4,45,000 deaths Population at risk - 3.5 billion (half of world’s population) 91 countries had on-going malaria transmission REGION CASES DEATHS Sub-Saharan Africa 90% 91% SEAR 10% 7%

7. INDIA’S CONTRIBUTION TO MALARIA IN SEAR

8. Epidemiology Agent Host & Environment

9. Agent factors

10. Agent factors

11. Hepatic phase In case of Pf , the intrahepatic schizonts rupture almost simultaneously & there is no persistent tissue phase In Pv , Po, Pm they do not burst at same time & some hepatic forms persists and remain dormant in the hepatocytes – “Relapses”

12. Reservoir of infection

13. Period of communicability

14. Host factors

15. Host factors 1. Age 6. Housing 2. Sex 7. Population mobility 3. Race 8. Occupation 4. Pregnancy 9. Human Habits 5. Socio- economic development 10. Immunity

16. Environmental factors

17. Environmental factors

18. Vector

19. Vector factors Breeding habits-fresh water collections Feeding habits-zoophilic / anthrophilic Resting habits- endophilic/exophilic Time of biting-nocturnal Density Life span

20. Mode of transmission

21. Types of malaria

22. Clinical features

23. Stages of malaria Cold Stage Hot Stage Sweating Stage

24. Complications of malaria Cerebral malaria Anemia Dehydration Acute renal failure Liver damage GI symptoms Black water fever

25. Features of severe malaria Impaired consciousness / coma Repeated generalized convulsions Renal failure ( S.creatinine >3mg/dl ) Jaundice ( S.bilirubin >3mg/dl) Severe anaemia ( Hb < 5g/dl) Pulmonary oedema / ARDS Hypoglycemia ( Plasma glucose < 40mg/dl) Metabolic acidosis Circulatory collapse or shock - “Algid malaria” Abnormal bleeding / DIC Haemoglobinuria Hyperthermia ( Temperature >104 F) Hyper- parasitaemia

26. Diagnosis

27. Diagnosis of malaria

28. Microscopy Stained thick and thin blood smears Helps to quantify the parasite load Thick smear shows whether the slide is positive for MP or not Thin smear shows the species of the MP & the stages of development in red cells

29. Rapid diagnostic test (RDT) RDTs are based on the detection of circulating parasite antigens Several types of RDTs are available Cassettes, cards or dip sticks Some of them can only detect P.falciparum , while others can detect other parasite species also Bivalent RDTs (for detecting P.falciparum and P.vivax )

30. Serological test Malarial fluorescent antibody test Positive two weeks or more after primary infection Useful in Epidemiological studies

31. Treatment

32. Treatment Early diagnosis & treatment of malaria aims at Complete cure Prevention of progression of uncomplicated malaria to severe disease Prevention of deaths Interruption of transmission Minimizing risk of selection and spread of drug resistant malaria parasite

33. Treatment of P.vivax cases

34. Treatment of P.vivax cases

35. Paediatric dose

36. Treatment of uncomplicated P.falciparum cases In states other than NE states Artemisinin based Combination Therapy (ACT-SP) Artesunate: 4 mg/kg body wt daily for 3 days + Sulfadoxine (25 mg/kg body wt ) & Pyrimethamine (1.25 mg/kg body weight) on day 1 + Primaquine: 0.75 mg/kg body wt on day 2

37. Treatment of uncomplicated P.falciparum cases

38. In Children

39. In North-Eastern states

40. In Children

41. Treatment of uncomplicated P.falciparum cases in pregnancy

42. Treatment of mixed infections (P.vivax + P.falciparum ) cases All mixed infections should be treated with full course of age-specific ACT and Primaquine 0.25 mg/kg body wt daily for 14 days In NE states: ACT-AL for 3 days + Primaquine 0.25 mg per kg body wt daily for 14 days In other states: ACT-SP for 3 days + Primaquine 0.25 mg per kg body wt daily for 14 days.

43. Treatment of severe malaria cases

44. Prevention and control Malaria

45. Malaria control

46. Strategic action plan of malaria control in India

47. Strategic action plan of malaria control in India Supportive interventions Capacity building Behavioural change communication Intersectoral collaboration Monitoring & Evaluation Operational research & applied field research

48. Malaria indices Annual Parasite Incidence (API) Annual Blood Examination Rate (ABER) Annual falciparum incidence Slide positivity rate Slide falciparum rate

49. Vector indices Human Blood Index Sporozoite Rate Mosquito Density Man biting Rate Inoculation Rate

50. Surveillance Malaria is under regular surveillance under IDSP Active case detection(ACD) Carried out by MPWs/ ASHAs through fortnightly house visits Under NVBDCP, Pf specific RDT kits have been deployed in Pf predominant areas where microscopy results are not available in 24 hrs Since 2012, bivalent RDTs have been introduced Passive case detection All fever cases attending PHCs/hospitals should be screened for malaria

51. SHORT TERM CHEMOPROPHYLAXIS ( UPTO 6 WEEKS ) CHEMOPROPHYLAXIS FOR LONGER STAY ( MORE THAN 6 WEEKS ) Doxycycline Mefloquine 100 mg once daily & 1.5 mg/kg once daily for children 250 mg weekly for adults Should be started 2 days before travel & continued for 4 weeks after leaving the area Should be administered 2 weeks before & 4 weeks after exposure Contraindicated in pregnant women & children < 8 yrs Contraindicated in individuals with history of convulsions, neuropsychiatric problems & cardiac conditions

52. Vector control ANTI – ADULT MEASURES ANTI – LARVAL MEASURES PERSONAL PROTECTION Residual sprays Environmental Control Mosquito nets Space Sprays Chemical control Repellents Biological control

53. Anti-adult measures

54. Spraying

55. Anti-larval measures Environmental control Source reduction Chemical control Mineral oils, Paris green, Synthetic insecticides Biological control Gambusia affinis , Lebister reticulatus

56. Protection against mosquito bite Mosquito net Insecticidal treated nets (ITN) Long lasting insecticidal nets (LLIN) Screening Repellents Diethyltoluamide

57. Chemoprophylaxis

58. Chemoprophylaxis Chemoprophylaxis should be administered only in selective groups in high P.falciparum endemic areas Use of personal protection measures including Insecticide Treated bed Nets (ITN) / Long Lasting Insecticidal Nets (LLIN) should be encouraged for pregnant women and other vulnerable population including travellers for longer sta y

59. Malaria vaccine Completed phase 3 trials RTS, S/ASO1- P.falciparum circumsporozoite R+T segments of circumsporozoite protein + S ( HbSAg )= RT (S+ S) Adjuvant- ASO1 1 vial= 1 mL (2 patients)

60. Malaria vaccine 0.5 mL IM WHO recommends 4 doses 1st dose at 5 months Repeat at 6th and 7th months 4th dose at 18 months after 3rd dose

61. THANK YOU