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• The name malaria comes from the
Italian mal (bad) and aria (air) – it was
originally thought the disease was
spread by the damp air from swamps.
• The link between the disease and the
Anopheles Mosquito was first made by
Ronald Ross, a Scottish army doctor,
working in India
• Malaria is a major public health
problem in warm climates
especially in developing countries.
• It is a leading cause of disease and
death among children under five
years, pregnant women and non-
• Malaria is defined as a mosquito-
borne infectious disease of humans
and other animals caused by
parasitic protozoans of the
genus Plasmodium transmitted via a
bite from an infected
female Anopheles mosquito.
Causes of Malaria
• Malaria is a disease caused by the
protozoan parasites of the genus
• There 4 species that commonly
infect man are as follows:
Species Major features
P. falciparum The most important species as it is responsible for 50% of all
malaria cases worldwide and nearly all morbidity and mortality
from severe malaria
Found in the tropics & sub-tropics
P. vivax The malaria parasite with the widest geographical distribution
Seen in tropical and sub-tropical areas but rare in Africa
Estimated to cause 43% of all malaria cases in the world
P. ovale This species is relatively rarely encountered
Primarily seen in tropical Africa, especially, the west coast, but
has been reported in South America and Asia
P. malariae Responsible for only 7% of malaria cases
Occurs mainly in sub-tropical climates
• A fifth species,
malaria in macaques
but can also infect
• The most dangerous
of the four is
Route of transmission
• Vector transmission:-bite by infective
female anopheles mosquitoes.
• Direct transmission
blood transfusion, the parasite can live
for 14 days in blood bottles under -4*C.
The use of contaminated needles.
• Congenital Transmission
Mother to newborn(via the placenta)
The Risk Factors
• Environmental Factor
• Human (host) Factor
• A warm, humid climate -
temperatures between 16°C and 40°C
and abundant rainfall have anopheles
• Vegetation nearby to provide shade
for the mosquito to hide during the
day and digest the blood meal from
the night before.
A high risk area – vegetation cover and standing water during
the wet season.
• Poor water supply and sanitation.
• People working in the fields and in
irrigation systems, near or on lakes and
• Migrants moving into malarial areas -
clearing land, looking for work, refugees
• Collecting water,
an essential fact
of life for
millions of people,
poses real risks of
Who is at high risk of getting
• Most at risk are the very young, who
have not yet developed any degree of
• pregnant women
• people with HIV/AIDS
• international travelers from non-
• Following the infective bite by the
Anopheles mosquito a period of time
(the "incubation period") goes by before
the first symptoms appear.
• The incubation period in most cases
varies from 7 to 30 days.
The life cycle of malaria parasite is
divided into four (4) phases which
• Transmission phase
• Pre-erythrocytic phase
• Erythrocytic phase (asexual
• Sexual reproduction (In mosquito)
Life cycle of malaria parasite
Click on the
the life cycle
Life cycle of malaria parasite
4. Sexual phase
Some merozoites differentiate into
male and female gametocytes, the
forms of Plasmodia infective to
mosquitoes. These are taken up by a
mosquito during another blood meal.
These fuse to form an ookinette in the
gut lumen of the mosquito. The
ookinette invades the stomach wall to
form the oocyst. This in turn
develops and releases sporozoites
which migrate to the salivary gland of
the mosquito. This mosquito then
goes on to infect another human host.
Listen and watch the
video in order to
understand the life of
Classification of malaria
Malaria is classified into two groups:
• Uncomplicated malaria
• Complicated malaria
The uncomplicated malaria is divided
into three stages:
• Cold stage (sensation of cold,
• Hot stage (fever, headaches,
vomiting, seizure in young children)
• Sweating stage (sweats, return to
normal temperature, tiredness)
• Cerebral malaria (seizures, coma)
• Severe anemia
• Renal and respiratory failure
• Cardiovascular collapse and shock
• may lead to death
A good history taking
Ask the patient number
of questions concerning:
such as fever.
•Recent travel history.
• Identify signs consistent with
malaria: fever, pallor, jaundice,
• Exclude other possible causes of
fever (e.g. signs of viral and bacterial
• Blood Film Examination:- Thick and
thin blood films (or “smears”) have
remained the gold standard for the
diagnosis of malaria.
• The films are stained and examined
Thick blood film -
• Used for detecting malaria: a larger
volume of blood is examined
allowing detection of even low levels
• Also used for determining parasite
density and monitoring the response
Thin blood film
• Gives more information about the
parasite morphology and, therefore,
is used to identify the particular
infecting species of Plasmodium.
Thick blood film
A drop of blood is spread
over a small area. When
dry, the slide is stained with
Field’s or Giemsa stains.
The red cells lyse leaving
behind the parasites.
• Used to detect
parasites, even if
parasitaemia is low
• Less useful for
Thin blood film
A small drop of blood is spread
across a microscope slide, fixed in
methanol and stained with Giemsa
The microscopist finds the area of
the film where red cells are lying
next to each other. The fine details
of the parasites can be examined
to determine the species.
• Used for speciation
• Does not detect low
Rapid Diagnostic Tests (RDTS)
• It is an antigen capture kits.
• A dipstick and a finger prick blood
sample is use.
• Similar to urine pregnancy test, but
the malaria diagnostic kits are
performed from 1-2 drops of blood
• Rapid test - results are available in
Other methods of diagnosis of malaria that are
not routinely used in clinical practice include
• PCR based techniques:- Detects DNA or RNA
sequences specific to Plasmodium.
• Fluorescent techniques:- Relatively low
specificity and sensitivity. Cannot identify the
• Serologic tests:-Based on immunofluorescence
detection of antibodies against Plasmodium
species. Useful for epidemiologic and not
Management of malaria
The management of malaria is based on the
• In severe malaria, anti malarial therapy must be
given Intravenously or Intramuscularly, oral
treatment should be substituted as early as
• Doses must be calculated in on a mg/kg of body
• It is important to weigh the patient, this is
particularly important for children
The management of malaria include
the following aspect:
• Nursing management
• Good nursing care is vital in the management
• Severe cases of malaria need admission while
the uncomplicated cases of malaria will be
treated on outpatient basics.
• Take vital signs of the patient half hourly or
hourly in order monitor the progress of the
• Tepid sponge patient , remove clothing and on
the fan inorder to reduce the body
• Administer prescribed antipyretic, if
temperature did not reduce after tepid
• Maintain adequate fluid balance, to avoid
overhydration or underhydration
• Administer precribed antimalaria and make
eat before administration.
• Do not give ACT on empty stomach
• The chemotherapy depend on the
type of malaria, severity of the
condition and the type of parasite
that cause the malaria.
General recommendations for the
management of un complicated malaria are
• Avoid starting Rx on empty stomach.,
• 1st dose given under observation.,
• Dose repeated if vomiting within 30
• Patient should report back if no
improvement after 48 hrs.
• Patient should be examined for
WHO 2010 guideline for the
treatment of uncomplicated
P. falciparum malaria.
WHO 2010 guideline for the treatment of
uncomplicated P. falciparum malaria consist of
two lines management.
• The first line management: is the use of ACT
for treatment of uncomplicated falciparum malaria .
• artemether plus lumefantrine,
• artesunate plus amodiaquine,
• artesunate plus mefloquine,
• artesunate plus sulfadoxine-pyrimethamine,
• dihydroartemisinin plus piperaquine
• The second line management is the use
of antimalaria and antibiotics e.g
• artesunate plus tetracycline or
doxycycline or clindamycin; any of
these combinations to be given for 7
• quinine plus tetracycline or doxycycline
or clindamycin; any of these
combinations should be given for 7 days
First line treatment
combination therapies (ACTs)
Artemether + Lumefantrine
• Artemether + Lumefantrine, 80 + 480mg P.O.
BID for 3 days
• Dosage forms: Tablet, 20mg +120mg
• Total number of tablets: 24 (Coartem 4 Tabs
BID for 3/7)
artesunate plus mefloquine
• 4 mg/kg/day artesunate given once a day
for 3 days
• and 25 mg/kg of mefloquine either split
over 2 days as 15mg/kg and 10mg/kg or
• over 3 days as 8.3 mg/kg/day once a day
for 3 days
• Available as 50 mg of artesunate and 250
mg base of mefloquine
artesunate plus sulfadoxine-
• 4 mg/kg/day artesunate given once a day for 3
• and a single administration of 25/1.25 mg/kg
sulfadoxine-pyrimethamine on day 1
• Available as 50 mg of artesunate tablet; and
tablets containing 500 mg of sulfadoxine and
25 mg of pyrimethamine
Second line antimalarial treatment
• alternative ACT known to be effective in the
• Artesunate +tetracycline or doxycycline or
clindamycine any of these combination to be given
for 7 days.
• Quinine +tetracycline or doxycyline or
clindamycine any of these should be given for 7
• Addition of a single dose primaquine (0.75
mg/kg)to ACT treatment for uncomplicated
falciparum malaria as an antigametocytes
Treatment of Severe and complicated
P. falciparum malaria
• Quinine dihydrochloride:
• Loading dose:- 20 mg/kg in 500 ml of isotonic
saline or 5 % dextrose over 4 hours (4
• Maintenance dose :-should be given 8 hours
after the loading dose at 10 mg / kg and it
should be given 8 hourly diluted in 500 ml of
isotonic saline or 5 % dextrose over 4 hours
• The parenteral treatment should be changed
to orally as soon as the patient‘s condition
improves and if there is no vomiting.
• Oral treatment should be given with
Artemether + Lumefantrine in the doses as
• However, if a patient has a history of intake of
Artemether + Lumefantrine before
• Give Quinine tablets 10 mg salt per kg TDS to
complete 7 days treatment.
Treatment of P. vivax malaria
• P.vivax cases should be treated with
chloroquine for three days and Primaquine
for 14 days
• Chloroquine: 25 mg/kg body weight divided
over three days i.e. 10mg/kg on day 1,
10mg/kg on day 2 and 5mg/kg on day 3.
• Primaquine: 0.25 mg/kg body weight daily
for 14 days.
Treatment of mixed infections
(P.vivax + P.falciparum) cases
• All mixed infections should be treated with full
course of ACT and Primaquine 0.25 mg per kg
body weight daily for 14 days
• The need for chemoprophylaxis
depends on the risk in the destination
• There are a number of medications for
• Atovaquine and Proguanil (Malarone)
• Chloroquine and hydroxychloroquine
• Chemoprophylaxis is for
• The Dosage does not apply to
• Chemoprophylaxis Schedule
Agents are started 1-2 weeks
Agents are continued for 4
weeks after travel
• Chloroquine and
• 1-2 weeks before travel,
weekly while in
country, and for 4
• Only used for
prophylaxis in areas
with p. vivax, and for
• 1-2 days before, daily while
in country and 7 days after
• 1-2 days before, daily in
country and 4 weeks
• 2 weeks before, weekly in
country and weekly for 4
Complication of malaria
• Splenomegaly (Enlarged spleen)
• Cerebral malaria
• Severe anaemia
• Febrile convulsion
• Splenic rupture
• Nephrotic syndrome is also said to be a long-
term complication of P. malariae infection.
• More than 45 million women (30
million in Africa) become pregnant
in malaria endemic areas each year.
• Every minute, about 12 Nigerian
women become pregnant (WHO)
• All are predisposed to dangers of
Malaria in Pregnancy.
• >50 million pregnant women
exposed to malaria each year.
• 11% of Maternal death is due to
Malaria (NPC/UNICEF - Nigeria)
• Pregnant women constitute the main
adult risk group for malaria.
Effects of Pregnancy on Malaria
• More common.
• Malaria is more common in pregnancy
compared to the general population probably
due to Immuno suppression and loss of
acquired immunity to malaria.
• More atypical.
• In pregnancy, malaria tends to be more
atypical in presentation probably due to the
hormonal , immunological and
haematological changes of pregnancy.
• More severe.
• Probably for the same reason, the parasitemia
tends to be 10 times higher and as a result, all
the complications of falciparum malaria are
more common in pregnancy compared to the
• More fatal
• P. falciparum malaria in pregnancy is more
severe, the mortality is also double (13 % )
compared to the non-pregnant population
• Selective treatment
• Some anti malarial are contra indicated in
pregnancy and therefore the treatment may
become difficult, particularly in cases of
severe P. falciparum malaria.
• Other problems
• Management of complications of malaria may
be difficult due to the various physiological
changes of pregnancy.
Effects Of Malaria On Pregnancy
• Abortion – placental sequestration
• Cerebral malaria
• Low birth weight (Prematurity, IUGR) due to
• Congenital infection
• Puerperal sepsis
• Maternal Mortality
Management of Malaria in
Management of malaria in pregnancy involves
three aspects that are of equal importance
• Treatment of the malaria
• Management of complications
• Prevention of recurrence
Treatment Of Malaria In Pregnancy
• Depends on severity of the disease
Simple / Uncomplicated
• Gestational age
• Aims at bringing attack/pyrexia to an end.
How to recognizing malaria in
In Uncomplicated malaria, if the patient present
with the followings:
• Muscle/joint pains
• Nausea/vomiting (Can tolerate per os)
• False labor pains
• + / ++
In Complicated malaria, the patient present
with the followings:
• Signs of uncomplicated malaria, plus:
• Sometimes fits, jaundice, severe dehydration
• ++ / +++
Treatment of Simple / Uncomplicated
• 1st trimester = Quinine ( safe and evidence-
• 2nd and 3rd trimesters
1st Line = Arthemeter/Lumefantrine(Coartem)
2nd Line = Artesunate + Amodiquine
Artesunate + fansider
Treatment of Complicated Malaria
• In Complicated Malaria Parenteral Quinine is
given in all trimesters then Orals
• It is Absolutely safe!
Supportive Treatment in Management
of Malaria in Pregnancy
• Adequate calories
• Correction of electrolyte imbalance
• Blood transfusion / EBT in acute and severe
• Oxygen + Diuretics in pulmonary oedema
• Monitoring of the fetal growth & health
• If condition is critical patient should be nurse in
Intermittent Preventive Treatment
• All pregnant women should receive at least two
doses of IPT after quickening at ANC visits (WHO
recommends a schedule of four visits, three after
• Intermittent preventive treatment (IPT) given 3 times
during pregnancy is effective for women with
• Presently, the most effective drug for IPT is
sulfadoxine-pyrimethamine (SP) combination
Intermittent Preventive Treatment
• A single dose is three tablets of sulfadoxine 500 mg +
pyrimethamine 25 mg.
• (Daraprim, the ‘Sunday-Sunday tablet’ is no longer
• Healthcare provider should dispense dose and directly
observe client taking dose
Complication of malaria in pregnancy
• Acute pulmonary oedema:-
• Immuno suppression
• Congenital malaria:
Early and effective treatment
• Children are at a high risk of malaria.
• They have little immunity or defense
• So be sure to:
• Diagnose malaria early. In malaria areas,
any child with a fever may have malaria.
• Treat children with malaria promptly.
• Use a combination of medicines, so there
is less resistance to the treatment.
• Preventing the mosquitoes from entering the
house – Close door / windows, especially
• Well-constructed houses with window
• Preventing the mosquitoes from hiding –
Avoid dark corners/ hanging clothes in rooms
• Mosquito Control – Avoid stagnant water,
insecticide spraying etc.
• At the moment, there is no effective vaccine
against malaria, although scientists all over
the world are trying to develop one.
• A vaccine developed in columbia (SPF 66)
advanced to phase 3 trials in africa but failed
to show efficacy in chiildren under 1
• Another vaccine (RTS, S/AS02) with the
potential to prevent infection and ameliorate
disease is being tested by GlaxoSmithKline
and the MVI at PATH in Phase I trial in
• In phase II in 2002 trials of the vaccine are
being conducted among the children in
Mozambique, which suffers from year-round
malaria transmission offering a better
opportunity to evaluate vaccine performance
• This vaccine has been safely tested in adult
volunteeers in Belgium, Gambia, kenya and
• Using the anti larval measures such as oiling
the collection of standing water or dusting
them with paris green effectively controlled
• Some moderm larvicides such as temephos
which confer long effect with low toxicity are
more widely used
Vector control strategy
• Residual spray: Spraying indoor surface of
house with DDT/malathion.
Global policy for diagnosis and
treatment of malaria
• The Govt of every country affected by malaria
has a National control policy covering
prevention and case management
The Objectives are
• Reduce morbidity and mortality, including
malarial related anemia
• Prevent the progression of uncomplicated
malaria into severe disease
• Reduce the impact of malarial infection on the
fetus during pregnancy. E.t.c
Roll Back Malaria
• Malaria control added a initiative , that was
launched by WHO,UNICEF,UNDP and world
bank in 1998 .
• Aim:-to reduce the Deaths and incidence To
75% by 2015.
World Malaria Day
• World Malaria Day (previously
Africa Malaria Day) is now be
commemorated every year on 25 April.
• Malaria is a serious disease that kills up to 1 million
people a year.
• But malaria can be prevented.
• And malaria can be treated.
• We need to work together to prevent malaria and
to encourage prompt and effective treatment.
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