Malaria - Everything you need to know about it

About the disease
Epidemiology
Clinical features and complications
Diagnosis
Management
Prevention
Summary

1. MALARIA
DISEASE
Here is where your
study begins

2. TABLE OF CONTENTS
Pathology C/f and complication
Diagnosis TREATMENT Prevention and control
About the Disease
01 02 03
0504 06

3. About the
Disease01

4. INTRODUCTION

Malaria is a life-threatening disease spread
to humans by some types of mosquitoes. It
is mostly found in tropical countries. It is
preventable and curable.

The infection is caused by a parasite and
does not spread from person to person.

5. ●It is a protozoan that cause malaria
●Has two host human and Anopheles mosquito where it complete its life cycle
●There are 5 Plasmodium parasite species that cause malaria in humans
●2 of these species – P. falciparum and P. vivax – pose the greatest threat.
●P. falciparum is the deadliest malaria parasite and the most prevalent on the
African continent.
●P. vivax is the dominant malaria parasite in most countries outside of
sub-Saharan Africa.
●The other malaria species which can infect humans are P. malariae, P. ovale
and P. knowlesi.
About plasmodium

6. ●Globally in 2022, there were an
estimated 249 million malaria cases
and 608 000 malaria deaths in 85
counties
●The WHO African Region carries a
disproportionately high share of the
global malaria burden.
●In 2022, the Region was home to 94%
of malaria cases (233 million) and 95%
(580 000) of malaria deaths.
●Children under 5 accounted for about
80% of all malaria deaths in the
Region.
Epidemiology

7. PREVALENCE

8. Malaria is distributed
unevenly across India, with
about 70% of cases occurring
in five states:
Odisha: 36% of cases, and 30%
of malaria deaths in India
Chhattisgarh: 12% of cases
Jharkhand: 9% of cases
Madhya Pradesh: 9% of cases
Maharashtra: 5% of cases

9. Pathology02

10. ●Plasmodium completes it life in two human and
mosquito.
●Have 3 parts
Exo - erthrocytic cycle
Erthrocytic cycle
Sporogonic cycle
Life cycle of plasmodium

11. Life cycle of plasmodium

12. C/f and
complications 03

13. ●Initially the pt are asymptomatic during the incubation period of Plasmodium
●After incubation period many mild to moderate non specific symptoms are
seen in pt
These symptoms are
1.Fever
2.Headache
3.Fatigue
4.Myalgia
5.Arthralgia
6.Ab. Pain
7.Nausea
8.Vomiting
9.Orthostatic hypertension
10.Palpable spleen and liver


Clinical features

14. Malarial parasite Incubation period
P.falciparum 9-14 days
P.vivax 8-17 days
P.ovale 16-18 days
P.malariae 18-24 days

15. ●It is defined as symptomatic malaria without the sign of severity or evidence of
organ dysfunction.
●Appropriately and promptly treated , in complicated Malaria (I.e pt can swallow
meds and food )carries a mortality rate <0.1℅
●However once the vital organ dysfunction occur or the proportion of
Erthrocytes infected increase to >2℅ (a level corresponds to 10∆12 parasites in
adult ) mortality rate rises steely
Uncomplicated and complicated Malaria

16. ●CEREBRAL MALARIA
Failure to localize or respond Appropriately to noxious stimuli , coma persisting for
>30min after generalized convulsions
●ACIDOSIS
Arterial ph<7.25
Manifest as deep breathing , respiratory distress

●SEVERE NORMOCHROMIC NORMOCYTIC ANEMIA
hematocrit <15
Hb<5g/dl
Parasitemia >10,000


Clinical Manifestation of complicated malaria

17. ●RENAL FAILURE
serum creatinine >3mg/dl
Urine output <400ml
No improvement with rehydration
●HYPOGLYCEMIA
plasma glucose <40mg /dl

18. ●HYPOTENSION /SHOCK
Systolic bp <50mm hg in children
<80 mm hg in adults
Capillary refill >2 sec
●BLEEDING
Manifest as significant bleeding from gums nose and GI tract
●EXTREME WEAKNESS
●HYPERPARASITEMIA
●HEMOGLOBINURIA
non specific , may occur in Un complicated Malaria
Black brown urine colour
●JAUNDICE
Serum bilirubin >3mg

19. Diagnosis 04

20. Physical Examination
Neuro
Face
Vitals
Skin
Abdomen
Others
●Coma
●Convulsions
●Altered mental status
●Abdominal distension
●Hepatomegaly
●Splenomegaly
●Cyanosis
●Jaundice
●Pallor
●Petechiae
Eyes
●Icteric sclera
●Pale conjunctiva
Nose
●Alar flare
●Temperature - fever
●Pulse rate - tachycardia
●BP - hypotension
●RR - tachypnea
●Intercoastal retraction
●Hematuria
●Cyanosis and edema in
extremeties

21. Thick blood smear
Thin blood smear

PfHRP2 Dip stick
Plasmodium LDH Dip stick
DIAGNOSIS
Microscopy Rapid diagnostic tests
“Malaria is not a clinical diagnosis”
If not available

22. Thick blood Smear
Erythrocytes are lysed
All stages of parasites released
More blood is used
Erythrocytes overlie one another
Facilitates diagnosis of low level parasitemia

23. ●Diagnosis ●Species●Quantify parasite load
(In P.falciparum infections)
Thin blood Smear
Used to confirm
Early stages-
All stages of
erythrocytic cycle
found
Ring forms seen
After 2 weeks- Gametocytes
- Harmless
- Persist after treatment
- Source for other mosquitoes
getting infected

24. ●A negative blood smear makes the diagnosis of malaria unlikely.
●If first smear is negative and high suspicion of malaria -
- Repeat PSMP should be performed every 12-24h for 2 days, if malaria is
strongly suspected.
●If all 3 are negative, the diagnosis of malaria has been essentially ruled out.

25. Rapid Diagnostic tests
●Extremely sensitive for falciparum malaria but less so for other species.
●Used when microscopy is unavailable or microscopist is inexperienced for
examining blood films.
● Less sensitive for low level parasitemia.
●Positivity may persist for 1 month or more.
OptiMAL Parasight-F
Plasmodium LDH PfHRP-2

26. Dengue fever Shigellosis
Leptospirosis Meningitis
Typhoid fever Severe sepsis
Scrub typhus Tuberculosis
Differential DIAGNOSIS

27. TREATMENT
Provide
Treatment to all cases of
malaria
Prevent
Progression to severe malaria
Deaths from severe malaria
Transmission of malaria

28. DAY 2
Non Falciparum malaria
Chloroquine
10mg/kg
Chloroquine
5mg/kg
Chloroquine
10mg/kg
DAY 1 DAY 3
Prima
quine
G6PD negative- 0.25mg/kg(14 days)
Mild-mod G6PD- 0.75mg/kg(weekly-8wks)
Severe def - Contraindicated

29. DAY 2
Uncomplicated Falciparum malaria
Artesunate 4mg/kg
Sulfadoxime 25mg/kg
Pyrimethamine 1.25mg/kg
Artesunate 4mg/kg
Artesunate 4mg/kg
DAY 1 DAY 3
Prima
quine
Artemisinin based combination therapy (act-SP)*
0.75 mg/kg Day 2

30. Other ACT regimens
●Artemether-Lumefantrine
●Artesunate-Mefloquine
●Artesunate-Amodiaquine
●DHA-Piperaquine
●Artesunate-pyronaridine
ACT-AL (used in north eastern states) X 3days
Primaquine
+
0.75mg/kg
2nd day
0.25mg/kg
14 days
P.falciparum Mixed infection

31. Quinine salt
10 mg/kg TID X 7 days
May induce hypoglycaemia
Area specific ACT
ACT-AL in NE states
ACT-SP in other states
Malaria in pregnancy
1st trimester 2nd & 3rd trimester

32. Complicated falciparum malaria
It’s an
emergency
Open airway should be secured in unconscious patients
Breathing and circulation should be assessed
Immediate measurements of blood glucose,
haemoglobin, parasitaemia, and renal function
should be done
Unconscious patients should have a lumbar
puncture done for CSF analysis
After rapid clinical assessment and confirmation of
diagnosis, full doses of parenteral anti-malarial
treatment should be started without delay

33. 12
hours
Complicated Falciparum malaria
Artesunate
2.4mg/kg IV
Artesunate
2.4mg/kg IV
Artesunate
2.4mg/kg IV
Stat
24
hours
Alter
native
●Artemether
3.2mg/kg stat IM

1.6mg/kg qd

Then daily
if required*
●Quinine dihydrochloride
20mg of salt/kg infused over 4h

10mg of salt/kg infused over 2-8h q8h

34. Adjunctive care
●Maintain airway
●Exclude other causes of coma
- hypoglycaemia, meningitis
●Intubate if necessary
Hyperpyrexia
●Tepid sponging ,
fanning, cooling blanket
●Antipyretics(PCM)
Convulsions
●Maintain airway
●Treat promptly with
diazepam/ paraldehyde
inj.
Metabolic acidosis
●Exclude/treat hypoglycaemia,
hypovolemia, sepsis
●Fluid resuscitation
●Give oxygen
Spontaneous bleeding
●Transfuse screened
fresh whole blood
●Vit. K injection
Hypoglycaemia
●Measure blood glucose
●50% dextrose inj. 10%
dextrose infusion
Coma

35. treatment failures
Recurrence can be due to ●Re-infection
●Recrudescence
Fever and parasitemia
Failed to resolve Recur within 2 weeks
Failure of treatment
●Results from drug resistance,poor adherence or inadequate drug exposure
●Must be confirmed parasitologically

36. Very unusual
Treated with
●Alternate ACT effective in
particular region
●Artesunate
Considered as new infections,
especially in the areas of high
transmission
Treated with first line ACT

Management
Failure within 14 days Failure after 14 days
Quinine
Tetracycline
Doxycycline
Clindamycin
+
7 days

37. PREVENTION
1. Early case Detection
and Prompt Treatment
(EDPT)
2. Vector Control
(i) Chemical Control
(ii) Biological control
(iii) Personal prophylactic
measures that
individuals/communities
take up


3. Community
participation
4. Environmental Management
& Source Reduction Methods
5. Monitoring and Evaluation
of the programme

38. 1. Early case Detection and Prompt Treatment (EDPT)

●EDPT is the main strategy of malaria control - radical treatment is
necessary for all the cases of malaria to prevent transmission of malaria.

●Chloroquine is the main anti-malaria drug for uncomplicated malaria.

●Drug Distribution Centres (DDCs) and Fever Treatment Depots (FTDs)
have been established in the rural areas for providing easy access to
antimalarial drugs to the community.

●Alternative drugs for chloroquine resistant malaria are recommended as
per the drug policy of malaria

39. 2. Vector Control
(i) Chemical Control
●DDT is the insecticide of choice for residual spray.
●If vector resistant to DDT then malathion is the alternative choice.
●In case of resistance to both DDT and malathion, then synthetic pyrethroids is
the choice.
●Use of Indoor Residual Spray (IRS) with insecticides:- Pyrethrum, ULV
●Use of chemical larvicides like Abate in potable water.
●Aerosol space spray during day time.
●Malathion fogging during outbreaks.
●Pyrethrum extracts for indoor Aerosol space sprays.
●Mineral oils ( cuts off O2 supply ), Paris green ( stomach
poison kills anopheles larvae ), Synthetic insecticides ( OP
compounds like fenthion, abate, chlorpyrifos )

40. (ii) Biological control
●Use of larvivorous fish like GAMBUSIA , POECILIA, LEBISTER,
COELOMOMYCES in ornamental tanks, fountains etc.
●Use of biocides.

Gambusia affinis Poecilia reticulata

41. (iii) Personal prophylactic measures that
individuals/communities take up
●Use of mosquito repellent creams- Diethyltoluamide (DEET), liquids,
coils, mats etc.
●Screening of the houses with wire mesh
●Use of bed nets treated with insecticide
●Wearing clothes that cover maximum surface area of the body

3. Community participation
●Sensitizing and involving the community for detection of Anopheles
breeding places and their elimination
●NGO schemes involving them in programme strategies

42. 4. Environmental Management & Source Reduction Methods
●Source reduction i.e. filling of the breeding places
●Proper covering of stored water
●Channelization of breeding source

5. Monitoring and Evaluation of the programme
●Monthly Computerized Management Information System(CMIS)
●Field visits by state National Programme Officers
●Field visits by Malaria Research Centres and other ICMR Institutes
●Feedback to states on field observations for correction actions.

43. Short term chemoprophylaxis (up to 6 weeks)- Doxycycline ( daily ),
chloroquine ( weekly )
●Day before arrival in endemic area: doxycycline
●Week before arrival in endemic area: chloroquine

Long term chemoprophylaxis (more than 6 weeks)-Mefloquine
●2-3 weeks before arrival in endemic area: mefloquine

All drugs are taken during the period of stay and till 4 weeks after departure.

CHEMOPROPHYLAXIS

44. ●Mosquirix is the only approved vaccine. It was approved in 2015.

●It is RTS,S/AS01.

●It requires 4 dose schedule, with 3 doses administered to children between 5
and 9 months of ages, followed by 4th dose 15-18 months later.

●Its reported vaccine efficacy against clinical malaria was 39% for those who
received all 4 doses and 26% for those with 3 doses.

MALARIA VACCINE

45. National framework plan for malaria elimination
(NFME) in India 2016-2030
●Eliminate malaria (zero indigenous cases) throughout the entire
country by 2030; and

●Maintain malaria-free status in areas where malaria transmission
has been interrupted and prevent re-introduction of malaria.

PUBLIC HEALTH STRATEGIES

46. 1.Phases under national framework for malaria elimination
API ( Annual parasite index )
Confirmed cases during 1 year X 1000
Population under surveillance

API >2/1000 population/year: high risk areas

47. Municipal health officer


District health officer


Senior malaria officer


Malaria inspector/assistant malaria inspector Field worker DBC
2. Hierarchy of malaria control in delhi

48. In second floor of the hospital building


Patient comes after OPD evaluation


Diagnosis by microscopy


If positive treatment initiation, notification and follow up

3. Malaria clinic ( in gtbh, delhi )

49. ●Malaria is an infection of liver and
RBCs.
●Diseases is spread by 9 Anopheles
species out of which 6 are primary
vectors.
Host factors
●Affect all ages.
●Sex: malaria more in males.
●Race: milder illness in AS Hb (sickle cell
trait) in Pf infection.
●Socio economic development: man made
malaria, population mobility.
●Housing: ill ventilated, ill lighted houses.
●Human habits: refusal of spraying.

summary

50. New Features in Malaria Epidemiology
• Resistance of Pf to chloroquine and other
antimalarials.
• Vector resistance to insecticides
• Pronounced exophillic vector behavior
• Increase in proportion of Pf cases

51. Signs and symptoms
Shaking chills followed by fever and profuse sweating Hemolytic anemia.
Jaundice Splenomegaly Headache
Dry cough Dark pigmented urine Weight loss

CNS
Cerebral malaria
(coma,
convulsions)
RENAL
Hemoglobinuria
Oliguria
ARF

BLOOD
Severe hemolytic
anemia
DIC
ARDS
METABOLIC
Hypoglycemia
Metabolic acidosis
GIT/LIVER
Diarrhea
Jaundice
Splenic rupture
OTHER
Shock-hypotension
Hyperpyrexia

52. ●Microscopy is the gold standard.
●Both microscopy and bivalent RDT are recommended for
diagnosis
●RDT-hard to reach and remote areas of the country.
●Microscopic examinations of thick and thin blood smears -
at PHC/CHC/District hospitals.
diagnosis

53. A) Positive P. vivax cases
Day-1-chloroquine 600 mg
Day-2-chloroquine 600 mg
Day-3-chloroquine 300 mg
Primaquine-15 mg for 14 days
B) Positive P. falciparum cases: (ACT-SP)
Day-1 Artesunate (200 mg) + Sulphadoxine (1500 mg) +
Pyrimethamine (75 mg)
Day-2 Artesunate (200 mg) + Primaquine (45 mg)
Day - 3 Artesunate (200 mg)
C) Positive P. falciparum cases: ACT-AL in North Eastern States


treatment

54. Treatment of uncomplicated cases in pregnancy

A) P. Falciparum
1st Trimester: Quinine salt.
2nd and 3rd trimester:
ACT-AL in North Eastern States
ACT-SP in Other States
B) P. Vivax
Treated with chloroquine

55. vaccine
● Mosquirix

●4 dose schedule, with 3 doses
administered to children
between 5 and 9 months of
ages, followed by 4th dose
15-18 months later.


chemoprophylaxis
●Short term chemoprophylaxis
(up to 6 weeks)- Doxycycline

●Chemoprophylaxis for longer
stay (more than 6
weeks)-Mefloquine

56. REFERENCES
●Harrison’s principles of internal medicine , 21st edition
●Davidson’s principle and practice of Medicine , 24th edition
●WHO guidelines for the treatment of malaria(2010) , 2nd edition
●Diagnosis and treatment of malaria 2013 , NVBDCP

57. OUR TEAM
Anmol Garg
Roll no 31
Ankur sharma Ansh singh
Roll no 32Roll no 30
Dr. Shiva narang
Professor
Dr. Pranjjal
Senior resident

58. THANKS!
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