MALARIA. definition epedimiology and laboratory and managment

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1. Department of emergency and critical care nursing February 2024 BY ABIE ASCHALE 1

2. malaria Prepared by: Abie Aschale Moderator: B irhanu (Assistant professor)

3. Content BY ABIE ASCHALE 3 Introduction Definition Epidemiology Causes Transmission and risk factors Sign and symptoms Diagnosis Treatment Preventions and precaution

4. Objectives At the end of this session students are expected to: Define malaria Describe the Epidemiology of malaria Discuss the Causative agents for malaria List Transmission and risk factors of malaria list Sign and symptoms of malaria Identify Diagnosis modality of malaria List Treatment of malaria describe Preventions and precaution of malaria BY ABIE ASCHALE 4

5. introduction Ancient Egyptians (around 1550 B.C.) and ancient Greeks (around 413 B.C.) documented symptoms associated with malaria. These descriptions noted the connection between fevers and wet ground. In 1880, Alphonse Laveran, a French army doctor, described the malarial parasite and proposed that it caused malaria.  got Novel prize 1894 mason hypothesized mosquito transmitted the diseases BY ABIE ASCHALE 5

6. definition Malaria ” Italian phrase Mala  bad Aria.air linked to marshes and swamps. It is a communicable diseases caused by protozoal parasite Transmitted  anopheles mosquito Malaria , a mosquito-borne disease, is caused by  Plasmodium parasites . P rotozoans belong to the genus  Plasmodium   BY ABIE ASCHALE 6

7. Magnitude GLOBALLY In 2023, WHO reported 247 million cases and 245 million in 2020 619 thousand deaths Over 95 percent of the burden occurs in the WHO defined African region, Twenty-nine countries account for 96 percent of cases; Nigeria (27 percent), Democratic Republic of Congo (12 percent), Uganda (5 percent), Mozambique (4 percent), and Angola and Burkina Faso (each 3 percent) BY ABIE ASCHALE 7

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9. ETHIOPIAN MALARIA According to the Ethiopian National Malaria Strategic Plan (NMSP) the population of Ethiopia was 102.8 million in 2020. Malaria is found in nearly 70 percent of the E thiopia, about 52 percent of the population lived in areas at risk of malaria. Transmission is highly seasonal Geographically varies across the country. BY ABIE ASCHALE 9

10. BY ABIE ASCHALE 10 malaria distribution of ethiopia - Search Images (bing.com)

11. CONT….. P. Falciparum (~65 percent) and P. vivax (~35 percent) are the major malaria parasites. The highest malaria burden regions are usually areas of stable and intense malaria transmission with altitudes below 1,000 meters located mainly in areas of Gambella Benishangul- Gumuz Western Oromia, Amhara, some parts of (SNNP), and Tigray Regions. BY ABIE ASCHALE 11

12. prevalence BY ABIE ASCHALE 12 Very low (<100 cases per 1000 population or <1 percent parasite prevalence), Low 100 to 250 cases per 1000 or 1 to 10 percent prevalence), M oderate 250 to 450 cases per 1000 or 10 to 35 percent prevalence H igh >450 cases per 1000 or >35 percent prevalence) 

13. CAUSATIVE AGENTS Plasmodium vivax : It causes a less severe form of malaria. Plasmodium falciparum : The most dangerous species , responsible for severe malaria. Plasmodium ovale : leading to milder symptoms. Plasmodium malariae : Causes a less common form of malaria BY ABIE ASCHALE 13

14. Incubation period specious Incubation period Falciparum 7-14 days P. vivax 12- 17 days P. Ovale 9- 18 days P. malarea 13- 40 days BY ABIE ASCHALE 14

15. Affinity of parasite to RBC BY ABIE ASCHALE 15 specious Affinity Falciparum ALL AGE GROUP Also adhere to the endothelial lining of blood vessel result in obstruction, thrombosis and local ischemia P. vivax Young RBC P. Ovale Young RBC P. malarea Old RBC

16. transmission Vector transmission - female anopheles mosquito why not male Direct transmission Blood transfusion Use of contaminated needle and syrige Organ transplant Congenital transmission Mother to new born BY ABIE ASCHALE 16

17. Why only female mosquito transmit malaria ? BY ABIE ASCHALE 17 Blood Meals for Reproduction : Only female mosquitoes require blood to produce eggs for reproduction. Transmission Cycle : After feeding on an infected individual, mosquito becomes a carrier.. Male Mosquitoes: primarily feed on nectar and do not transmit malaria.

18. Risk factors Environmental factor Warm humid climate temperature Vegetation nearby provide shed to mosquito BY ABIE ASCHALE 18 Human factor poor water supply and sanitation Working environment - irrigation system Travelers Young children Pregnant women

19. Life cycle (1)  Plasmodium-infected Anopheles mosquito bites a human and transmits sporozoites into the bloodstream.  (2)  Sporozoites migrate through the blood to the liver where they invade hepatocytes and divide to form multinucleated schizonts ( preerythrocytic stage).  (3)  Hypnozoites are a quiescent stage in the liver that exist only in the setting of P. vivax and P. ovale infection. This liver stage does not cause clinical symptoms, but with reactivation and release into the circulation, late-onset or relapsed disease can occur up to many months after initial infection.  (4)  The schizonts rupture and release merozoites into the circulation where they invade red blood cells. Within red cells, merozoites mature from ring forms to trophozoites to multinucleated schizonts (erythrocytic stage).  (5)  Some merozoites differentiate into male or female gametocytes. These cells are ingested by the Anopheles mosquito and mature in the midgut, where sporozoites develop and migrate to the salivary glands of the mosquito. The mosquito completes the cycle of transmission by biting another host BY ABIE ASCHALE 19

20. Life cycle BY ABIE ASCHALE 20

21. Life cycle BY ABIE ASCHALE 21

22. Stages 1. Liver Stage (Exoerythrocytic Phase) : When an infected mosquito bites a person,  sporozoites  in the mosquito’s saliva enter the bloodstream and migrate to the  liver . In the liver, they infect liver cells and mature into  schizonts . These schizonts rupture, releasing  merozoites . BY ABIE ASCHALE 22

23. 2. Blood Stage (Erythrocytic Phase) : Merozoites infect  red blood cells  (erythrocytes). Inside the red blood cells, the parasites multiply asexually, leading to the destruction of the cells. The  ring stage trophozoites  mature into schizonts, which then rupture, releasing more merozoites. Some parasites differentiate into  sexual erythrocytic stages  called  gametocytes . When a female Anopheles mosquito feeds on an infected person, it ingests these gametocytes. BY ABIE ASCHALE 23

24. 3. Mosquito Stage (Sporogonic Cycle) : Inside the mosquito’s stomach,  microgametes penetrate  macrogametes  (female), generating  zygotes . Zygotes elongate into  ookinetes , which invade the mosquito’s midgut wall and develop into  oocysts . Oocysts grow, rupture, and release  sporozoites . Sporozoites migrate to the mosquito’s salivary glands. When the mosquito bites another human, it injects sporozoites, perpetuating the malaria life cycle BY ABIE ASCHALE 24

25. Clinical manifestation Non specific symptoms - first symptoms Headache, fatigue Abdominal discomfort, muscle and joint aches, diarhea Fever- irregular/ intermittent Nausea, vomiting and orthostatic hypotension BY ABIE ASCHALE 25

26. Sever malaria Severe malaria is defined as presence of  P. falciparum  parasitemia and one or more of the manifestations Sever anemia Impaired consciousness Convulsion Hypoglycemia Jaundice Shock Renal impairment BY ABIE ASCHALE 26

27. BY ABIE ASCHALE 27 Stages characteristics Cold stages Duration – 15 to 60 min Shivering and feeling of cold Hot stage 2- 6 hours High grade fever up to 41 OC Flushed, dry skin and often headache, nausea and vomiting Sweeting stage 2- 4 hours Fever drops rapidly Sweeting Fever in malaria corresponding with the release of fresh merozoite

28. Anemia in malaria Severe anemia is very common during malaria (Hb become <6 g/dl) Anemia may caused by : intravascular hemolysis, increased clearance of malaria infected RBC (iRBC), and decrease in RBC production through dysregulated erythropoiesis BY ABIE ASCHALE 28

29. diagnosis Clinical diagnosis History Physical examination BY ABIE ASCHALE 29 Laboratory finding Direct methods Indirect method others

30. History Hyperendemic area and endemic area No laboratory resources not needed Fever or history of fever Poor sensitive and poor predictive value Overlap with other syndromes BY ABIE ASCHALE 30

31. Physical examination Anemia, splenomegaly, hepatomegaly BY ABIE ASCHALE 31

32. Laboratory investigation Direct Diagnosis This involves the direct demonstration of the malaria parasite. It can be done through: Peripheral Blood Smear (PBS) : A thin or thick blood smear is stained and examined under a microscope to identify the presence of malaria parasites. Quantitative Buffy Coat (QBC) Test : A fluorescent stain is used to detect malaria parasites in the buffy coat layer of centrifuged blood. BY ABIE ASCHALE 32

33. Rapid Diagnostic Tests (RDTs) : detect specific malaria antigens (such as histidine-rich protein 2 or lactate dehydrogenase) in blood samples. PCR (Polymerase Chain Reaction) : Molecular technique to detect and identify malaria DNA or RNA. BY ABIE ASCHALE 33

34. Lab cont.…… Indirect Diagnosis: These tests assess the host’s immune response to malaria infection: Serological Tests : Detect antibodies against malaria parasites. Useful for epidemiological studies but not for immediate diagnosis or treatment decisions. Antigen Detection Tests : Detect malaria-specific antigens (e.g., Plasmodium lactate dehydrogenase) in blood or urine samples. BY ABIE ASCHALE 34

35. Lab cont …… Other Investigations Complete Blood Count (CBC) : for anemia and thrombocytopenia Liver Function Tests (LFTs) : Elevated liver enzymes Renal Function Tests (RFTs) : Assess kidney function, G6PD (Glucose-6-Phosphate Dehydrogenase) Testing: Important before using primaquine for radical cure (P. vivax and P. ovale) BY ABIE ASCHALE 35

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37. Treatment Objectives Treat the patient and restore quality of life and productivity Prevent complication Prevent death Prevent the development and transmission of medicine resistance Decrease malaria transmission to others BY ABIE ASCHALE 37

38. non pharmacologic r x Control fever  Apply tepid sponging Correct the fluid and electrolyte imbalance Correct hypoglycemia, Identify the causative species and treat appropriately Treat the malaria aggressively to prevent complications Treat secondary bacterial infections Provide supportive care BY ABIE ASCHALE 38

39. Pharmacologic r x BY ABIE ASCHALE 39

40. uncomplicated P. Falciparum malaria First line Artemether + Lumefantrine, 20mg + 120mg in a fixed dose combination BY ABIE ASCHALE 40 Wieght in kg age dases 5- 14 kgs From 4 months to 2 years 1 tablet bid for 3 days 15- 24 kgs From 3 to 7 years 2 tablets bid for 3 days 25- 34 kgs From 8 to 10 years 3 tablets bid for 3 days > 35 kgs 10 years & above 4 tablets bid for 3 days It is not recommended for infants weighing < 5 KG and 1 st TM Px mothers Alternative Quinine dihydrochloride, 10mg quinine sulphate salt/kg TID for 7 days

41. BY ABIE ASCHALE 41 uncomplicated P. Vivax malaria First line Chloroquine phosphate, 1 g, then 500mg in 6 hours followed by 500mg P.O., QD for 2 days, or 1g at 0 and 24 hrs followed by 0.5g at 48 hrs P.O., Followed by Primaquine, 15mg base P.O., QD for 14 days. It is recommended for patients with limited risk of malaria infection in the future; Alternatives Artemether + Lumefantrine, 20mg + 120mg in a fixed dose combination OR Quinine dihydrochloride, 10mg quinine sulphate salt/kg TID for 7 days

42. uncomplicated Mixed infection First line Artemether + Lumefantrine Alternative Quinine dihydrochloride, 10mg quinine sulphate salt/kg TID for 7 days BY ABIE ASCHALE 42

43. Severe and complicated P. falciparum malaria Objectives Administer medicines parenterally Provide urgent treatment for life threatening problems e.g. convulsions, hypoglycemia, dehydration, renal impairment Prevent death from malaria BY ABIE ASCHALE 43

44. Treatment of Severe MALARIA NON- PHARMACOLOGICAL A- Clear and maintain the airway. Position semi-prone or on side. Weigh the patient and calculate dosage. Make rapid clinical assessment. Exclude or treat hypoglycemia (more so in pregnant women). Assess state of hydration. Measure and monitor urine output. If necessary insert urethral catheter. Measure urine specific gravity. Open IV line for 8 hours of intravenous fluids including diluents for antimalarial medicine, glucose therapy and blood transfusion. If rectal temperature exceeds 39°C, remove patient's clothes, use tepid sponge, Consider other infections. Consider need for anti-convulsant treatment BY ABIE ASCHALE 44

45. Treatment of Severe MALARIA First line Artesunate, 2.4mg/Kg IV on admission (time = 0), then repeat at 12 hours, and 24 hours, then once a day for up to 5 days. Alternatives Artemether, IM 3.2mg/kg loading dose on the first day followed by 1.6mg/kg daily for five days OR Quinine dihydrochloride: Loading dose: 20mg/kg in 500ml of isotonic saline or 5% dextrose ( Better for pregnant women) The parenteral treatment should be changed to P.O., only after 24 hours and if tolerate BY ABIE ASCHALE 45

46. Pregnancy and malaria Maternal mortality is 50% higher than in the non-pregnant period. The commonest complications are; maternal anemia spontaneous abortion, still birth, premature labors, and low birth weight. . BY ABIE ASCHALE 46

47. Severe or complicated: P. falciparum and P. vivax: First line Artesunate, IV, 2.4mg/kg at 0, 12 and 24 hours, then daily thereafter. oral artesunate 2mg/kg (or IM artesunate 2.4mg/kg) once daily, plus clindamycin. If oral artesunate is not available, use quinine 600mg TID and clindamycin at 450mg TID for 7 days. BY ABIE ASCHALE 47

48. Alternative Quinine, IV 20mg/kg loading dose (no loading dose if patient already taking quinine or mefloquine) in 5% dextrose over 4 hours and then 10mg/kg IV over 4 hours TID plus clindamycin IV 450mg TID (max. dose quinine 1.4g). Oral quinine 600mg TID 5–7 days and oral clindamycin 450mg TID for 7 days. BY ABIE ASCHALE 48

49. preventions BY ABIE ASCHALE 49 Integrated vector control approach Integrated vector control approach is the present trend for vector control defined as utilization of all appropriate technological and management techniques to bring out an effective degree of vector suppression in a cost effective manner and also to avoid the over use of one of the methods

50. Vector control 1. Habitat and environment control Removing or reducing areas where vectors can easily bred can limit their growth  stagnant water removal  mosquito breed environment 2. Personal protection prevent contact between the human body and insects Repellents Protect clothing Insecticide Impregnated mosquito nets BY ABIE ASCHALE 50

51. Chemical control Larvicides : used to control  larvae  of mosquitoes. They target the immature stages of insects before they become adults. Insecticides : chemicals designed to kill or repel insects. Repellents : discourage pests from approaching or landing on surfaces. BY ABIE ASCHALE 51

52. Biological control - Natural enemies Larvivores fish Size : small  to survive in shallow water where mosquito larvae breed. Feeding Behavior : surface feeders  and primarily  carnivorous , targeting mosquito larvae. Survival : These fish should be able to survive even in the absence of mosquito larvae. Ease of Rearing : easy to rear BY ABIE ASCHALE 52

53. P. Falciparum First line Mefloquine, 5mg base per kg weekly (1tablet for adults >50kg, begin > 2weeks before travel to malariuos area, take weekly on the same day while in the area and for 4 weeks after leaving the area. BY ABIE ASCHALE 53 Chemo-prophylaxis

54. Alternatives Atovaquone/Proguanil: 250mg/100mg P.O., daily for adults; begin 1-2 days before travel to malarous area and daily while in the areas and for 7 days after leaving the area. OR Doxycycline, 100mg daily for adults; 2.2mg/kg daily for children >8yrs; begin 1-2 days before travel to malarious areas, to be taken daily while at the area and for 4 weeks after leaving the area. BY ABIE ASCHALE 54 For P. vivax Primaquine phosphate, 15mg base P.O., QD for 14 days after travel

55. elimination Countries that have achieved at least 3 consecutive years of zero indigenous cases of malaria are eligible to apply for the  WHO certification of malaria elimination. BY ABIE ASCHALE 55 African countries that have been certified malaria-free by the World Health Organization (WHO): Algeria  (certified in  2019 ) Cabo Verde  (certified in  2024 ) Mauritius  (certified in  1973 )

56. WHO response The WHO  Global technical strategy for malaria 2016–2030, The strategy sets achievable global targets, including: Reducing malaria case incidence by at least 90% by 2030 Reducing malaria mortality rates by at least 90% by 2030 Eliminating malaria in at least 35 countries by 2030 Preventing a resurgence of malaria in all countries that are malaria-free. BY ABIE ASCHALE 56

57. WHO’s global efforts to control and eliminate malaria by: Playing a leadership role in malaria, Shaping the research agenda and promoting new tools and strategies Developing ethical and evidence based global guidance on malaria National malaria programme and other relevant stakeholders; and Monitoring and responding to global malaria trends and threats BY ABIE ASCHALE 57

58. vaccination RTS,S ( Mosquirix ) : This is the  first approved malaria vaccine . It requires at least  three doses  in infants by age 2, and a fourth dose extends protection for another  1–2 years . RTS,S reduces hospital admissions from severe malaria by around  30% . It was developed by the  PATH Malaria Vaccine Initiative (MVI)  and  GlaxoSmithKline (GSK)  with support from the  Bill and Melinda Gates Foundation . The vaccine consists of the  Plasmodium falciparum circumsporozoite protein (CSP)  from the pre-erythrocytic stage.  It aims to prevent hepatocyte invasion and elicit a cellular response to destroy infected hepatocytes. R21/Matrix-M : This vaccine has shown an impressive  77% efficacy rate  in initial trials, surpassing the WHO’s goal of a malaria vaccine with at least  75% efficacy . It is the  second malaria vaccine  recommended by the WHO.  In April 2023, Ghana approved its use for children aged between  five months and three years old , and Nigeria provisionally approved it as well. BY ABIE ASCHALE 58

59. summery Bill Gates : “There are more people dying of malaria than any specific cancer.”  Tedros Adhanom Ghebreyesus : “ Prevention is the best cure for malaria.”  BY ABIE ASCHALE 59 Eliminating malaria in at least 35 countries by 2030 The experience of the malaria-free African country (voanews.com)

60. references Balaji S, Deshmukh R, Trivedi V. Severe malaria: Biology, clinical manifestation, pathogenesis and consequences. J Vector Borne Dis. 2020;57(1):1–13. CDC. CDC in Ethiopia/Global Health. 2023;(February). Available from: https://www.cdc.gov/globalhealth/countries/ethiopia/%0AThe Melkie DA, Internist, Teferra DE, Pediatrician, Assefa DM, Oncologist, et al. Food , Medicine and Healthcare Administration and Control Authority of Ethiopia Standard Treatment Guidelines For General Hospital Diseases Investigations Good Prescribing & Dispensing Practices for Better Health Outcomes. Fmhaca Addis Ababa. 2014;(3):360. MoH Ethiopia. Ethiopia Malaria Profile. 2022;2:1–20. Tangpukdee N, Duangdee C, Wilairatana P, Krudsood S. Malaria diagnosis: A brief review. Korean J Parasitol . 2009;47(2):93–102. WHO. World Malaria Report: 20 years of global progress and challenges [Internet]. World Health Organization. 2020. 300 p. Available from: https://www.who.int/publications/i/item/9789240015791 WHO. Country Disease Outlook- Ethiopia 2023. WHO Reg Off Afric . 2023;17(22):4. BY ABIE ASCHALE 60

61. Thank you BY ABIE ASCHALE 61