Malaria

Introduction
Malaria is a serious and sometimes fatal
disease caused by a parasite that commonly
infects a certain type of mosquito which feeds on
humans as defined by the
organization.

It

is

world health

considered

the

important parasitic disease affecting man.

most

This parasite-caused disease is the 9th

leading cause of morbidity in the Philippines
according to the department of health.

Usually, people get malaria by being bitten by an

infective

female Anophelesmosquito.

Only

Anopheles mosquitoes can transmit malaria and they

must have been infected through a previous blood meal
taken from an infected person. When a mosquito bites
an infected person, a small amount of blood is taken in
which contains microscopic malaria parasites.

Malaria is not contagious but it is infectious.

Malaria is not spread from person to person like
a cold or the flu, and it cannot be sexually
transmitted. You cannot get malaria from casual
contact with malaria-infected people, such as
sitting next to someone who has malaria.

Epidemiology
World
The WHO estimates that in 2010 there were 219 million cases of malaria
resulting in 660,000 deaths. Others have estimated the number of cases
at between 350 and 550 million for falciparum malaria and deaths in
2010 at 1.24 million up from 1.0 million deaths in 1990. The majority of
cases (65%) occur in children under 15 years old. About 125 million
pregnant women are at risk of infection each year; in Sub-Saharan Africa,
maternal malaria is associated with up to 200,000 estimated infant
deaths yearly.

Malaria is presently endemic in a broad band around the

equator, in areas of the Americas, many parts of Asia, and
much of Africa; in Sub-Saharan Africa, 8590% of malaria
fatalities occur. An estimate for 2009 reported that countries
with the highest death rate per 100,000 of population
were Ivory

Coast (86.15), Angola (56.93)

and Burkina

Faso (50.66). A 2010 estimate indicated the deadliest countries

per population were Burkina Faso, Mozambique and Mali.

 map

Philippine setting
According to Roll Back Malaria, data averaged over 10 years (19912000) show that malaria is endemic in 65 of the 79 provinces, i.e.,
760 of the 1,600 municipalities and 9,345 of the 42,979 barangays
nationwide.
90% of the cases are found in 25 of the 65 endemic provinces, i.e., 348 of
the 760 endemic municipalities (districts), and 4, 407 of the
9,345 barangays (villages). The remaining 40 provinces, which accounts
for about 10% of reported malaria, are considered epidemic prone

MALARIA

Luzon ; 46%
Mindanao; 53%

Visayas; 1%

Luzon
Visayas
Mindanao

Malaria in the Philippines has an Incidence: 0.48

per 1000 (2000) having Total number of deaths:
536 (2000). Provinces with high endemnicity:
Palawan, Kalinga-Apayao, Ifugao and Agusan
del Sur. Cases of MDR falciparum malaria:
Davao

del

Palawan

Norte,

Compostela

Valley

and

Infectious Disease Process

Agent
According to the Center of disease control and
prevention Plasmodium falciparum, is found
worldwide in tropical and subtropical areas. It is
estimated that every year approximately 1 million
people are killed by P. falciparum, especially in
Africa where this species predominates.

 Plasmodiumvivax
found mostly in Asia, Latin America, and in
some parts of Africa. Because of the population
densities especially in Asia it is probably the
most prevalent human malaria parasite

Plasmodiumovale
found mostly in Africa (especially West Africa) and the islands
of the western Pacific. It is biologically and morphologically
very similar to P. vivax. However, differently from P. vivax, it
can infect individuals who are negative for the Duffy blood
group, which is the case for many residents of sub-Saharan
Africa. This explains the greater prevalence of P. ovale (rather
than P. vivax ) in most of Africa.

Duffy blood group

According to the journal dated october 11 2006 by
the Department of Hematology and Transfusion
Medicine, Santa Casa Medical School, So Paulo,
Brazil. The duffy blood group factor serves as a
receptor

for

plasmodium

vivax

parasites.

Individuals with the Duffy-negative phenotype

are resistant to P. vivax invasion,

 Plasmodiummalariae,
found worldwide, is the only human malaria
parasite species that has a quartan cycle (threeday cycle).
can cause serious complications such as the
nephrotic syndrome

Plasmodiumknowlesi
found throughout Southeast Asia as a natural
pathogen of long-tailed and pig-tailed macaques.

In the Philippines the most common

would be the
plasmodiumfalciparumspecie accounts
to >70%of the cases
plasmodiumvivaxwhich has < 30 %
Plasmodiummalariaewhich is <1 %
but there is a reported case in Palawan where in a plasmodium
ovale specie was found 1960s. As stated in the research of Dr.
Lansang

Reservoir
Humans are the known reservoir for malarial
infection. it has also been recognized that P.
knowlesi, a type of malaria that naturally infects
macaques in Southeast Asia.

Portal of entry/exit
Malaria enters its human hosts via the bite of
mosquitoes of the genus Anopheles. The malaria
parasites are present in the mosquitos saliva,
and enter into the human bloodstream when the
mosquito bites to take a blood meal.

Once in the human body, the malaria parasite then

undergoes a number of different life stages, involving
reproduction in the liver as well as inside red blood
cells. Once the malaria parasite has undergone
reproduction in the red blood cells, the new parasites
burst out and back into the blood stream, where they
can be ingested by another mosquito biting again.

Incubation period

The time between an infectious

mosquito bite and the first detection of
parasites in a blood smear is generally 6
16 days. Symptoms may not occur at that
time and the first presentation of the
infection may be delayed for weeks or
months.

Commonly, clinical symptoms occur after

714 days for P. falciparum,
730 days for P. malariae and
814 days for P. vivax and P. ovale

Mode of Transmission
A female Anopheles mosquito ingests gametocytes from
an infected human. The parasite must undergo 835
days of development within the mosquito before the
infective sporozoites are formed. The sporozoites are
transmitted to another person via the bite of an infected
mosquito. The disease may also be transmitted by blood
or congenitally in untreated or inadequately treated
cases.

Susceptible host
According to the World health organization,
Approximately half of the world's population is
at risk of malaria.

Specific population risk groups include:

Young children in stable transmission areas who have
not yet developed protective immunity against the most
severe forms of the disease;
Non-immune pregnant women as malaria causes high
rates of miscarriage and can lead to maternal death;

 Semi-immune pregnant women in areas of high transmission.

Malaria can result in miscarriage and low birth weight,
especially during first and second pregnancies;
Semi-immune HIV-infected pregnant women in stable
transmission areas, during all pregnancies. Women with
malaria infection of the placenta also have a higher risk of
passing HIV infection to their newborns; people with
HIV/AIDS;

 International travelers from non-endemic areas

because they lack immunity;
Immigrants from endemic areas and their children
living in non-endemic areas and returning to their
home countries to visit friends and relatives are
similarly at risk because of waning or absent immunity

Clinical Manifestations
Uncomplicated
The classical but rarely observed malaria attack lasts 6-10
hours. It consists of
a coldstage(sensation of cold, shivering)
a hotstage(fever, headaches, vomiting; seizures in young
children)and
sweating stage (sweats, return to normal temperature,
tiredness).

More commonly, the patient presents with a combination of

the following symptoms:
Fever
Chills
Sweats
Headaches
Nausea and vomiting
Body aches

Physical findings may include:

Elevated temperatures
Perspiration
Weakness
Enlarged spleen
Mild jaundice
Enlargement of the liver
Increased respiratory rate

severe
Cerebral malaria, with abnormal behavior,
impairment of consciousness, seizures, coma, or
other neurologic abnormalities
Severeanemiadue to hemolysis (destruction of
the red blood cells)
Hemoglobinuria (hemoglobin in the urine) due
to hemolysis

 Acute respiratory distress syndrome (ARDS), an

inflammatory reaction in the lungs that inhibits oxygen
exchange, which may occur even after the parasite counts
have decreased in response to treatment
Abnormalitiesinbloodcoagulation
Lowbloodpressurecaused by cardiovascular collapse
Acutekidneyfailure

 Hyperparasitemia, where more than 5% of the red

blood cells are infected by malaria parasites
Metabolicacidosis(excessive acidity in the blood and
tissue fluids), often in association with hypoglycemia
Hypoglycemia (low blood glucose). Hypoglycemia may
also occur in pregnant women with uncomplicated
malaria, or after treatment with quinine.

Diagnosis
Thickandthinbloodsmears
- drop of blood is applied to and spread onto a glass slide. It is
then treated with a special stain and examined under a
microscope.
- Typically, two thick smears and two thin smears are prepared.
- the "gold standard" for malaria detection and identification.
They require examination by a trained and experienced
laboratorian.

 Thicksmearsare a more sensitive test for malaria infection.

A greater volume of blood is examined under the microscope
and the parasites are therefore more likely to be seen.
Thin smears have fewer blood cells present and allow
identification of the type of Plasmodium species causing the
infection. The number of infected red blood cells can also be
calculated to determine the degree to which a person is
infected (parasite load).

Other diagnostics
Rapid diagnostic tests (antigen testing)
Molecular tests (Polymerase chain reaction, PCR)
Antibody tests (serology)
Susceptibility testing

Treatment

Drugregimen

Indication

Chloroquine

Drug of choice
P. ovale,
P.malariae,
P. vivax,
Uncomplicated P. falciparum

Sulfadoxine-pyrimethamine combination
and/or Quinine
Quinine Sulfate+Tetracycline or
Clindamycin

Chloroquine resistant or
MDR falciparum malaria

Mefloquine
Halofantrine
Quinine

Drug of choice for malaria in

Pregnancy

Drug regimen

Indication

Artemisinin and its derivatives artesunate

and artemether (parenteral)

Severe malaria

Quinine or Quinidine

Drug of choice
Severe falciparum malaria

Primaquine

Relapsing vivax or ovale malaria

Control and prevention

Preventivemeasures
Travelers should be advised of the four principles of malaria
protection:
be aware of the risk, the incubation period, and the main
symptoms
avoid being bitten by mosquitoes, especially between dusk and
dawn
take antimalarial drugs (chemoprophylaxis) to suppress infection
where appropriate
immediately seek diagnosis and treatment if a fever develops one
week or more after entering an area where there is a malaria risk.

Personal protection against mosquito bites remains the first line of

defense against malaria. Measures to recommend include:
avoiding outdoor exposure between dusk and dawn
wearing long, loose clothing after dusk, preferably in light colors
avoiding perfumes and colognes
using effective insect repellents
using knock-down sprays, mosquito coils, or plug-in vaporizing devices
indoors
Using mosquito nets preferably pre-treated with an appropriate insect
repellent.

Controlofcase
Isolation of the case is not required. Mosquito contact with
the patient should be prevented, especially in tropical areas
of Australia where mosquitoes capable of transmitting the
disease are present. The country of acquisition of the
disease should be determined. It is important to exclude
acquisition from an unusual source, such as a blood
transfusion, that would need further investigation.
Treatment is complex and advice should be sought from an
infectious disease physician.

Controlofcontacts
Travelling companions or recipients of any blood
transfusion from the case should be warned that
they may also be at risk of developing the disease
and should seek help promptly if suggestive
symptoms develop.

Updates , Case reports, News Articles

1. Fast-changing genes help malaria hide in human body

Date: December 18, 2014
Source: Wellcome Trust Sanger Institute
A study of the way malaria parasites behave when they live in human
red blood cells has revealed that they can rapidly change the proteins
on the surface of their host cells during the course of a single
infection in order to hide from the immune system.
the findings, which overturn previous thinking about the Plasmodium
falciparum parasite's lifecycle, could explain why so many attempts
to create an effective vaccine have failed and how the parasites are
able to survive in the human body for such long periods of time.

2. Malaria to be eradicated in the Philippines by 2015

May 29, 2014 Lorenzo V. Encenzo.
GINGOOG CITY, Philippines (May 30, 2014) Malaria, an infectious disease of humans
causing symptoms that typically include fever and headache, which in severe cases can
progress to coma or death brought by the bites of an infected female Anopheles mosquito,
will be eradicated completely next year in the entire country, said health authorities, here
as they joined the nation recently in the observance of World Malaria Day.
Asst. City Health Officer Agnes Centino, M.D. said the 15-year program implemented
since the year 2000 will culminate soon with multi-billion pesos worth of expenditures by
the Department of Health (DOH) until 2015.
Out of the 78 provinces throughout the country, previously endemic of malaria, 68 have
been declared malaria-free as of May, 2014. Of the 1,600 cities and municipalities, 760 are
now malaria-free or of the 42,972 barangays all over the country, only 9,345 remain
endemic.

 It was learned that the World Malaria Day on April 25, 2014 has a theme
Invest in the Future. Defeat Malaria. It was aimed at elevating to the
higher level the worlds awareness on Malaria as a killer disease.
The global efforts to control and eliminate malaria have saved an estimated
3.3 million lives since 2000, reducing malaria mortality rates by 42%
globally. Increased political commitment and expanded funding have
helped to reduce malaria incidence by 25% worldwide.
Every year, more than 200 million malaria cases occur. Most of these cases
are never tested or registered. Emerging drug and insecticide resistance
threaten to reverse recent gains. (LOR VILLA ENCENZO)

3. Chronic infection. Hidden costs of infection:

chronicmalariaaccelerates telomere degradation and senescence in wild
birds.
Asghar M,Hasselquist D,Hansson B,Zehtindjiev P,Westerdahl H,Bensch S.
Abstract

Recovery from infection is not always complete, and mild chronic infection may persist.
Although the direct costs of such infections are apparently small, the potential for any
long-term effects on Darwinian fitness is poorly understood. In a wild population of great
reed warblers, we found that low-level chronic malaria infection reduced life span as well
as the lifetime number and quality of offspring. These delayed fitness effects
of malaria appear to be mediated by telomere degradation, a result supported by
controlled infection experiments on birds in captivity. The results of this study imply that
chronic infection may be causing a series of small adverse effects that accumulate and
eventually impair phenotypic quality and Darwinian fitness.