BY

SARANYA P NAMBIAR
FINAL YEAR MBBS
DEPARTMENT OF GENERAL MEDICINE
 MALARIA
 Malaria is an infectious disease caused by
Protozoa
 Name is derived from Italian word Mal’ aria or
Bad air
History-Events on Malaria
• 1880-Charles Louis Alphonse Laveran
-discovered malarial parasite in wet
mount.

• 1898-Ronald Ross
life cycle of parasite
EPIDEMIOLOGY
 Malaria is widely distributed in tropics and subtropics of
Africa , Asia and Latin America
 Malaria affecting 400 million people world wide
 Malaria causing 2 million death each year.
Major Risk Factors
 Young children
 Non – immune pregnant women
 People with HIV/AIDS
 International travelers from
non – endemic areas
 Immigrants and their children
 Poor socioeconomic classes
 Rural, remote and forested areas
PREVALENT MAJOR EPIDEMIOLOGICAL TYPES
OF MALARIA IN INDIA
 TRIBAL MALARIA : Tribal area contributing about 50% of
P.falciparum cases. Limited health infrastructure;
 RURAL MALARIA: Irrigated areas of arid and semiarid
plains; Moderate to low endemicity. Moderate health infrastructure;
 URBAN MALARIA:15 major cities contributing about 80% of
malaria. Health infrastructure well developed; Low SEC;
 BORDER MALARIA: These areas have their own problems in
regard to malaria control. Mixing of populations;
 FOREST MALARIA : Forests and settlements in recently
deforested areas are known to harbor very efficient malaria vectors.
 ETIOLOGY
 Human malaria is caused by one of the protozoan parasites:

 Plasmodium falciparum –most common and dangerous (Malignant TERTIAN)

 Plasmodium vivax (Benign TERTIAN)

 Plasmodium ovale (TERTIAN)

 Plasmodium malariae (QUARTAN)

 Plasmodium knowlesi (QUOTIDIAN)

VECTOR: Female Anopheles mosquito ( An. Cucifacies, An. stephensi, An.

Fluviatilis, An. Minimus, An. Epiroticus)
 The transmission does not occur at temperature below 16c,or above 33c and at
altitudes > 2000mts.
 PATHOGENESIS
A. Life cycle:
 Malarial parasite passes its lifecycle in two hosts:
i. DEFINITIVE HOST : Female Anopheles mosquito
INTERMEDIATE HOST : Man
ii.
 Lifecycle comprises of two stages:
I. ASEXUAL PHASE : Occurring in humans , which act
as intermediate host
II. SEXUAL PHASE : Occurring in mosquito , which
serves as definitive host.
TYPES OF MALARIAL PARASITE
 CLASSIFICATION BASED ON CLINICAL
FEATURES…
1. BENIGN MALARIA
2. MALIGNANT TERTIAN MALARIA
a. Cerebral malaria
b. Blackwater fever
c. Algid malaria
d. Septicemic malaria

3. MEROZOITE INDUCED MALARIA

1. BENIGN MALARIA
 INCUBATION PERIOD:12-17 days
 Typical clinical feature: periodic bouts of fever with chill and
rigor , followed by anaemia, splenomegaly , hepatomegaly
 The classic febrile paroxysm comprises of three disinct stages:
 Cold stage
 Hot stage
 Sweating stage

 The periodicity is approximately 48 hours in tertian

malaria(in P.vivax , P.falciparum and P.ovale) and 72 hours in
quartan malaria(in P.malariae)
 2. MALIGNANT TERTIAN MALARIA
PATHOLOGY
 Red cells infected with malaria are prone to hemolysis.
 Anaemia may be profound and is worsened by
dyserythropoiesis, splenomegaly and depletion of folate
stores.
Post capillary venules (brain , kidney ,liver etc)

Red cells with trophozoites

Adhere to vascular endothelium by knob poteins &

Form rosettes and rouleaux with uninfected red cell

Vessel congestion and organ damage

MALIGNANT TERTIAN MALARIA cont…
 INCUBATION PERIOD : 8-14 days
 Most serious and fatal type caused by P.falciparum –
complications:
a. CEREBRAL MALARIA : It is the most common complication
 Initial symptoms are nonspecific with fever , headache,
pain in back, anorexia and nausea
 Anaemia, Thrombocytopenia is common
 Diffuse symmetric encephalopathy like headache
, confusion , seizures , paralysis
 Muscle tone and tendon reflexes are reduced;
 Retinal haemorrhages.
 Hypoglycemia is common in patients following treatment
CEREBRAL MALARIA

Diffuse symmetric
encephalopathy
b . BLACKWATER FEVER(MALARIAL HEMOGLOBINURIA)
 Seen in patients , who have experienced repeated past
infections and inadequate treatment with quinine
 Clinical Manifestations :includes prostration and hemoglobinuria
(black colored urine) , bilious vomiting , with passage of
dark red or blackish urine
 Complications includes renal failure , acute liver failure and
circulatory collapse
c . ALGID MALARIA
 This syndrome is characterized by:
 Cold clammy skin.
 Peripheral circulatory failure
 Rapid thready pulse with
low blood pressure
 There may be severe abdominal pain ,
vomiting ,
diarrhea
and profound shock
d . SEPTICEMIC MALARIA
 It is characterized by high continuous fever with dissemination
of the parasite to various organs , leading to multi organ failure
 Death occurs in 80 % of the cases
3. MEROZOITE-INDUCED MALARIA
Natural malaria is sporozoite-induced , the infection being
transmitted by sporozoites introduced through the bite of
vector mosquitoes ( VECTOR TRANSMISSION )
 CONGENITAL MALARIA-Parasite is transmitted
transplacentally from mother to fetus; (CONGENITAL
TRANSMISSION)
 May occur in: (DIRECT TRANSMISSION) -
Transfusion malaria-If injection of blood or plasma by
hypodermic intramuscular and intravenous from infected
vector;
Renal transplacentation
Shared syringes
MALARIA IN PREGNANCY
 FETAL
 Still birth
 Prematurity
 Fetal distress

 MATERNAL
 Anaemia

 Higher chance for mortality due to

cerebral malaria.
CERTAIN RARE FACTS ABOUT MALARIA
 Chronic malarial infection may cause injury to renal
glomeruli causing nephrotic syndrome
 Malaria induced severe immunosuppression provoking EBV
to develop Burkitt’s Lymphoma in some countries.
 Sickle cell disease, fetal Hb, and Thalassemia hb are resistant
to malaria.
 RBC with G6PD deficiency are resistant to malaria.
 Duffy negative RBC people are resistant to P. vivax.
 MANAGEMENT:
 LABORATORY DIAGNOSIS
MICROSCOPIC DIAGNOSIS
 PERIPHERAL BLOOD SMEAR
 FLUORESCENT MICROCOPY
 QUANTITATIVE BUFFY COAT
ANTIGEN AND ANTIBODY DETECTION
 RAPID IMMUNOCHROMATOGRAPHIC DIPSTICK;RDT
 ELISA
MOLECULAR DIAGNOSIS
 PCR
 REAL TIME PCR
 Blood Smear : Two types of smears

 Thin film: It consist of an unbroken smear of a single layer

of red cells. Used for detecting the parasites and determining
the species.
Thick film: It concentrates 20-30 layers of blood cells in a

small area. More suitable for rapid detection of malarial

parasite, quantification and demonstration of pigment.

• Fluorescent Microscope: Kawamoto technique -

Fluorescent microscopy with a standard light microscope, slide

stained with acridine orange dye, was used to detect malarial
parasites – nuclear DNA is stained green.
 Quantitative Buffy Coat: Red blood cells containing malaria parasites
being less dense concentrate just below the buffy coat. Nuclei of
parasitized RBC appear brilliant green. This method is faster and more
sensitive than thick blood smear.
 RDT: RDTs are lateral flow immuno-chromatographic antigen detection
test, which rely on the capture of dye- labelled antibodies to produce a
visible band.
 PCR: PCR is used for species specification and for detection of drug
resistance in malaria.
 Real Time PCR: Sensitive tool to detect low level malaria infections
and thus to evaluate the effect of these infections on birth outcomes.
QBC PCR

RDT
•TREATMENT
Treatment of uncomplicated malaria
1. Chloroquine 600mg (10mg/kg) followed by 300mg
(5mg/kg) after 8 hours then for next two days +
Primaquine 15mg (0.25mg/kg) daily
2. Quinine 600mg (10 mg/kg) 8 hourly for 7 days +
Doxycycline 100mg daily for 7 days + Primaquine
3. Artsunate 100mg BD (4 mg/kg/day) for 3 days +
Mefloquine 750mg (15mg/kg) on second day and
500mg (10mg/kg) on third day
4. Artrolane (as maleate) 150 mg + Pipraquine 750mg
once daily for 3 days
Chloroquine – The Wonder Drug!!
 During its development within the RBCs, the parasite
consumes large amount of Hb to meet its amino acids needs.
 But heme is toxic to the parasite and is neutralized by
polimerisation.
 Chloroquine interfere with this polymerizations.
Treatment of complicated malaria
1. Artsunate: 2.4mg/kg iv or im , followed by 2.4mg/kg
after 12 and 24 hours ,and then once daily for 7 days
2. Artemether 3.2 mg/kg im on the first day,followed by
1.6mg/kg daily for 7 days
3. Quinine dilute HCl : 20 mg/ kg (loading dose) diluted
in 10ml/kg 5% dextrose or dextrose-saline and infused iv
over 4 hours , followed by 10mg/kg (maintenance dose) iv
infusion over 4 hours(in adult) or 2 hours (in children)
every 8 hours, until patient can swallow
 WORLD MALARIA DAY..

World Malaria Day was established in may 2007 by 60th session of

the world health assembly.

The day was established to provide “education and

understanding of malaria” and spread information on “year-long
intensified implementation of national malaria control
strategies , including community based activities for malaria
prevention and provide treatment in endemic areas”
2019 theme – ZERO MALARIA STARTS WITH ME…
“MALARIA CONTROL ACTIVIIES IN INDIA”
 1953- National Malaria Control Programme (NMCP)
Government of India launched NMCP with a focus on
indoor residual spraying of DDT. With in five years, the
programme helped to reduce the annual incidence of
malaria.
 2005- Intensified Malaria Control Project (IMCP)
Global fund approved the project IMCP for malaria
control to accelerate the operational capacity and efficient
project management at state and district levels.
 2010- New Drug Policy

The National Drug Policy for malaria has been drafted keeping in view the
availability of more effective antimalarial drugs and drug resistance status in the
country.
 2017- National Strategic Plan for Malaria Elimination

The government launched a national strategic plan for elimination of malaria

and pledged to eradicate the vector –borne disease by 2027.

 STRATEGIES: case detection, early diagnosis, complete treatment,

sentinel surveillance; Integrated vector management (through Insecticide
treated bed-nets,ITNs, LLINs); Anti larval measures including source
reduction; Epidemic preparedness and early response and Supportive
interventions.
VACCINES AGAINST MALARIA
RTS,S/AS01 (RTS,S) is the first and, to date, the only vaccine
to show partial protection against malaria in young children. It
acts against P. falciparum, the most deadly malaria parasite
globally. Among children who received 4 doses in large-scale
clinical trials, the vaccine prevented approximately 4 in 10 cases
of malaria over a 4-year period.
TAKE HOME POINTS
 Malaria – HISTORY
 EPIDEMIOLOGY
 ETIOLOGY
 LIFE CYCLE
 CLASSIFICATION
 COMPLICATIONS
 MANAGEMENT
 PREVENTION AND CONTROL
REFERENCE
 Davidson MEDICINE
 Park Social And Preventive Medicine
 Parasitology Apurba Sankar Sasthri
 Tripathi Pharmacology
 www.who.int
 www.cdc.gov