Malaria

September 2010

Introduction:
- Protozoal disease caused by infection with parasites of genus
Plasmodium and transmitted to man by certain species of
female anopheles mosquito.
-

Disease is characterized by febrile paroxysms occurring

intermittently repeating every 3rd or 4th day depending on
infective species of parasite.

Epidemiology:
Agent Factors:
- Caused by 4 distinct species of malaria parasite:
p. vivax, p. falciparum, p. malariae, p. ovale.
- 70% of infections are due to p. vivax.
- Majority of rest are caused by p. falciparum.
- Very less proportion of infections are due to p. malariae, p.
ovale.
- P.falciparum is predominant in malaria in tribal areas
- P. Vivax is predominant in malaria in Rural as well as Urban
areas.

--

Reservoir Of Infection:
- Man is the only reservoir of infection.
-

Gametocytes are present in infected individuals and infect

mosquitoes.

Period of Communicability:
- As long as mature and viable gametocytes are present in
blood in sufficient density to infect the mosquito.
-

In Vivax infection gametocytes appear within 5 days of entry

of sporozoites.

In falciparum infection they do not appear until 10 days after

entry of sporozoites.

Relapses are common in vivax and ovale and uncommon in

falciparum after 2 years of first infection.

Host Factors:
- Affects all ages.
-

Males > Females.

Individuals with Sickle Hb have less severe malaria

compared to those who have normal Hb.

Ill ventilated and ill lighted houses provide ideal indoor

resting environment for mosquitoes.

Immunity is acquired only after repeated infection for

several years

Maternal Ab protect the infant for first 6 months of life.

Vector of Malaria:
- Major vectors transmitting the infection are:
Anopheles Culicifacies in rural areas
Anopheles Stephensi in Urban areas
- In absence of malaria vaccine vector control is the only
effective tool to control spread of infection
- The infected mosquito must remain alive for 10 days after an
infective blood meal to become infective.
-

The strategy in malaria eradication is to kill the vector

mosquito before it becomes infective.

Resting habits of vectors vary from endophily to exophily i.e.

some rest indoors and some outdoors after a blood meal.

Breeding habits also vary from species to species of vectors

An stephensi breed in wells, fountains, overhead tanks,
An sundaicus breed in brackish water
An fluviatalis breed in moving water

Nocturnal feeding habit.

Mode of Transmission:
- Vector transmission.
- Bite of infected female Anopheles mosquito.
- Mosquitoes are not infective until sporozoites are present
in them.
- May be transmitted directly but less commonly by IM and
IV injections of blood or plasma.
Incubation Period:
- Usually around 10 days.
- 12 days for falciparum
- 14 days for vivax malaria.
- 17 days for ovale malaria.

Clinical Features:
- Characterized by paroxysms of fever which correspond to
development of parasite in RBC.
- a typical attack comprises of 3 distinct stages:
1) Cold Stage:
- onset is with headache, nausea, chilly sensation followed by rigors in
short time.
- Parasites are detectable in blood.
- usually a short lasting stage.

2) Hot Stage:
- burning hot sensation.
- Skin is hot and dry
- headache is intense but nausea diminishes.
- respiration is rapid.
- usually lasts for 2 6 hours

3) Sweating Stage:
- Fever comes down with profuse sweating
- Temperature drops down rapidly and skin is cool and moist.
- patient feels relieved and falls asleep

These febrile paroxysms occur with definite intermittent

periodicity repeating every 3rd or 4th day.

Disease has a tendency to relapse and is characterized by

enlargement f spleen and secondary anemia.

In P. Falciparum fever is more irregular and even continuous

- Rarely classical periodicity gets established in Falciparum
- Headache, nausea and vomiting are more pronounced and
there is greater tendency to develop complications
hemolytic jaundice and anemia.
-

P. malariae attacks are similar to p. vivax but paroxysms

repeat every 72 hours.

Complications:
- Falciparum malaria is most likely to complicate to:
Severe anemia, cerebral malaria, acute renal failure, liver
damage, GI symptoms, dehydration, collapse, black water
fever.
-

Vivax and others complicate to:

anemia, Splenomegaly, liver damage, etc.

Diagnosis:
- Demonstration of parasite in blood.

1) Peripheral blood smear examination.

Thick smear and thin smear.
Thick smear is more reliable as large volume of blood is
examined under each microscope field.
Thin smear is more valuable in identifying species of parasite.

2) Malarial fluorescent antibody test:

- becomes positive 2 weeks after primary infection.
- by the time infection may have been cured.
- more important epidemiologically than clinically as it
suggests past infection of malaria.
3) Dipstick antigen capture assay:
- latest and rapid technique for detection of p falciparum.

Measurement of Malaria (Malariometric

Indices)
Measures the magnitude of malaria in a community.

Pre Eradication Era:

1)
Spleen Rate:
Defined as % of children between 2 10 years of age showing
enlargement of spleen.
Widely used for measuring endemicity of malaria in a
community.
2)
Average Enlarged Spleen:
Denotes the average size of splenic enlargement.
3) Parasite Index:
Defined as % of children between 2 10 years of age showing
malaria parasite in their blood stream.
4)
Parasite Density Index:
Indicates the average degree of parasitemia in a sample of well
defined group of population.
5) Infant Parasite Rate:
Defined as number of infants below one year of age showing
malarial parasites in their blood.
6) Proportionate Case Rate:
Defined as number of patients diagnosed as cases of malaria of
every 100 patients visiting the hospitals and clinics.

Current Indices:
1) Annual Parasite Index (API):
- It is defined as proportion of confirmed cases of malaria
during one year of the population under survey.
- Cases are confirmed by peripheral blood smear examination.
2) Annual Blood Examination Rate (ABER):
- It is the proportion of number of slides examined to total
population under study.
- It is the index of operational efficiency.
- Total number of slides examined per year should be at least
10%.
3) Others:
- Annual Falciparum Index
- Slide positivity rate
- Slide falciparum rate

Vector Index:
- A complete malaria survey includes investigations related to insect
vectors
1) Human Blood Index:
- Proportion of freshly fed human anopheline mosquitoes whose
stomach contain fresh human blood.
2) Sporozoite Rate:
- It is the proportion of female anopheline with sporozoites in their
salivary glands.
3) Mosquito Density:
- Number of mosquitoes per man hour catch.
4) Man Biting Rate:
- Defined as average incidence of anopheline bites per person per day
5) Inoculation Rate:
- The man biting rate multiplied by the infective sporozoite rate is
called the inoculation rate.

Malaria Control

1)
2)

Management of malaria cases

Active interruption of malaria transmission

1) Management:
Includes diagnosis and treatment.
Diagnosis is by clinical suspicion + peripheral smear
examination
Treatment is as per National Antimalaria Programme.
Treatment guidelines differ in high and low risk areas.
Chloroquine (CHQ) is the drug of choice inspite of
presence of drug resistant strains.
Best strategy to control the disease is diagnosis and
treatment on the same day.

In High risk areas: (P falciparum and Drug resistant areas):

1) Presumptive treatment:
- Of all suspected / clinical malaria cases
Day 1

Tab. CHQ
Tab. Primaquine

600 mg stat
45 mg stat

Day 2

Tab. CHQ

300 mg

Day 3

Tab. CHQ

300 mg

Day 4

Tab. CHQ

300 mg

2) Radical Treatment after Microscopic Confirmation:

- Continue Tab Primaquine 15mg for 5 days in c/o P falciparum.
- no further treatment apart from presumptive in c/o vivax.

3) In CHQ resistant cases:

- Single dose of 25 mg/kg BW of sulfadoxine
+
- Pyrimethamine 1.25 mg/kg BW.
- Followed by 45 mg every day for 5 days.

In Low Risk Areas:

1) Presumptive:
Tab CHQ 600 mg stat.
2) Radical:
P Vivax: Tab CHQ 600 mg stat
P. Falciparum: Tab CHQ 600 mg + Tab Primaquine
75 mg SD.

In Complicated and Severe Malaria:

- Cases are to be hospitalized and treated.
- Choice of antimalarial is Inj Quinine. 10 mg/kg BW IV in 5%
dextrose to be run over 4 8 hours.
- Switch to oral doses as soon as possible total duration of
therapy is 7 days.
Newer Drugs now used are Inj Artemisinin derivatives.
- Artesunate 1mg/kg BW IM or IV2 doses at 6 hour interval
on first day f/b once a day for 5 days.
-

Arteether 150 mg daily IM for 3 days.

Artemether 1.6 mg/kg BW IM at an interval of 6 hours f/b

once daily for 5 days.

Tab Mefloquine is to be used only in Pf cases resistant to CHQ.

Primaquine is contraindicated in pregnancy, infants and G6PD

deficiency individuals.

2) Active Interruption of Transmission:

- Vector control is the most effective measure.
a) Anti Adult Vector measures:
- Residual Sprays DDT, malathion, parathion.
- Spraying of indoor surfaces of houses especially in endemic
areas.
- At regular intervals.
b) Space Application:
- Application of pesticide in the form of fog or mist.
- To protect large areas from transmission of infection.

b) Anti Larval Measures:

Larvicides:
- Initially paris green was used to kill larvae in accumulations
of water
- Modern larvicides such as Temephos.
- Must be repeated at short intervals.
Vaccine for Malaria:
- In the developmental stages.
- A synthetic vaccine named SPf66 is a potential vaccine for
commercial use in near future.