I am one the medical student doctors of jamhuuriy university in somalia , muqdisho.

1. MALARIA
Dr. Ali-Dahir mohamed
Abdulle
Medical student of JUST

2. WHO IS THIS ?

3. Definition :
Malaria is an acute and chronic parasitic disease transmitted by the
bite of infected mosquitoes and it is confined mainly to tropical and
subtropical areas.

4. Epidemiology
Malaria is a worldwide problem with transmission in more than
100 countries with a combined population of more than 3.2 billion people.
Malaria is an important cause of fever and morbidity in the tropical
world.
The principal areas of transmission are sub-Saharan Africa, southern Asia,
Southeast Asia, and Central and South America. Approximately 1,500–
2,000 imported cases are recognized annually in the United States,

5. Etiology
Malaria is caused by obligate intracellular protozoa of the genus
Plasmodium, including
P. falciparum
P. malariae
P. ovale
P. vivax
P. knowlesi

6. Transmission rout
The parasites usually are transmitted to humans
by female Anopheles mosquitoes.
Malaria also can be transmitted through
blood transfusion, via contaminated needles,
and transplacentally to a fetus.

7. Life cycle
Plasmodium has a complex life cycle that enables survival in different cellular
environments in the human host and in the mosquito vector.
There are two major phases in the life cycle,
an asexual phase (schizogony) in humans
a sexual phase (sporo b gony) in mosquitoes.

8. Cont..
The erythrocytic phase of Plasmodium asexual development begins when
the merozoites released from exoerythrocytic schizonts in the liver penetrate
erythrocytes.
When inside the erythrocyte, the parasite transforms into the ring form,
which enlarges to become a trophozoite.
These latter two forms can be identified with Giemsa stain on blood smear,
which is the primary means of confirming the diagnosis of malaria

13. Clinical Manifestations
The incubation period ranges from 7–30 days, depending on the
Plasmodium species.
The most characteristic clinical feature of malaria;
The classic symptoms of the febrile paroxysms of malaria include
high fever
Rigors
sweats
headache.

14. Short-term relapse describes the recurrence of symptoms after a primary
attack that is due to the survival of erythrocyte forms in the bloodstream.
Long-term relapse describes the renewal of symptoms long after the
primary attack, usually due to the release of merozoites from an
exoerythrocytic source in the liver. Long-term relapse occurs with P. vivax
and P. ovale because of persistence in the liver

15. In children
Uncomplicated malaria:
1. Fever maybe continuous
2. Convulsions.
3. gastrointestinal symptoms are prominent (nausea, abdominal pain,
vomiting and diarrhoea.)
4. Hepatosplenomegaly
Severe malaria:
•Respiratory distress
•Hypoglycaemia
•Cerebral malaria: reduced GCS, seizures,
altered respiration

17. Indicators of sever or complicated malaria
• Impaired consciousness or seizures
• Respiratory distress
• Respiratory acidosis (pH less than 7.3)
• Hypoglycemia (blood glucose less than 2.2mmol/l)
• Severe anaemia (hemoglobin less than 80g/l)
• Prostration
• Parasitemia greater than 2% (red blood cells parasitized)

19. Diagnosis
The diagnosis of malaria is established by the identification of organisms on
stained1. smears of peripheral blood.
Thick smears are used to scan large numbers of erythrocytes quickly.
Thin smears allow for positive identification of the malaria species and
determination of the percentage of infected erythrocytes, called parasitemia
2. Rapid diagnostic tests are available as point-of-care tests.
Such tests provide results in 15–20minutes and are
particularly useful in areas where reliable microscopic
diagnosis is not available.

20. cont;.
The rapid tests are able to detect P. falciparum but are unable to
differentiate between P. vivax, P. ovale, and P. malariae.
Sensitivity is low for non-falciparum species and in patients with low-
level parasitemia. For these reasons, as well as to guide management
decisions, all rapid tests should be followed by microscopic examination
regardless of the results.

21. Others Investigation
• Full Blood Count. (Thrombocytopenia is
highly suggestive of malaria)
• Arterial Blood gas
• LFT's, U&E's, blood glucose and clotting
studies
• G6PD screen (required prior to primaquine
in case of P.vivax)

22. Differential Diagnosis
● Typhoid fever
● Tuberculosis
● Brucellosis
● Relapsing fever
● Infective endocarditis
● Influenza
● Poliomyelitis
● Yellow fever
● Trypanosomiasis
● Kala-azar
● Amebic liver abscess.

24. TREATMENT
1. First line treatment for malaria with artemether–lumefantrine (AL)
 Make clinical diagnosis based on symptoms of fever.
 Take temperature. If > 37.5° or history of fever, then do a RDT, and
microscopy if available..
 If RDT +ve, treat with artemether–lumefantrine (AL), first dose under
DOT and follow up doses at home. Give quinine not AL to treat pregnant
women in the first trimester (see 1.1).
 If RDT –ve do not give antimalarials

25. Cont;
● Give one dose of primaquine by mouth on day 1 for all cases of Plasmodium
falciparum.
● If RDT + for P. vivax, request Pv treatment from malaria programmed.
SYMPTOMATICAL TREATMENT
● Give paracetamol if fever above 38.5°.
● Other causes of acute febrile illness should also be looked for.
● Give fluids. Patients with fever need more fluids. Encourage mothers to
provide extra breastfeeding.
● If there is diarrhea, assess and treat as per the diarrhea guidelines.
● Ask the patient to come back immediately in case of danger signs or after
2 days if persisting fever.

26. CONT;
Treat for severe malaria if any danger signs (unable to drink, repeated
vomiting, anaemia, drowsiness, jaundice, convulsions, unconscious,
passing no urine, weak or rapid pulse, severe dehydration, bleeding,
difficulty breathing, neck stiffness).
If not improving on the treatment given but no danger signs, change
treatment to oral quinine.
Artemether–lumefantrine
Each tablet contains a combination of 20 mg artemether and 120 mg
lumefantrine. A six-dose regimen of artemether–lumefantrine is
administered twice a day for 3 days.

27. Side effects: Common: Weakness, dizziness, headache
Rare: Palpitations, jaundice, rash, prolonged QT interval
Precaution: AL should not be given to women in early pregnancy
or infants aged less than 2 months and to people with known allergy
to AL. Instead they are treated with quinine (see 1.1)

28. Treatment with quinine if treatment not successful with AL

29. Treatment with primaquine
● Give all adults with P falciparum a single dose of primaquine by mouth,
15mg tablet, on day 1 of treatment with AL.
● This treats the early form of the malaria parasite. Give children a single
dose, 0.25mg/kg, primaquine by mouth.
● Note: that primaquine should not be given to anyone previously
diagnosed with G6PD deficiency.

30. Treatment of persisting malaria
● A thick film should be taken and examined for all patients with persisting
symptoms of malaria. (a second RDT should NOT be done as it will remain
+ for 21 days following infection).
● If the thick film is + for malaria they need treatment with quinine

31. First line treatment of severe malaria with artesunate
● If any danger signs are present, then treat with artesunate.
● Give artesunate 2.4 mg/kg body weight IV or IM given on diagnosis,
repeated 12 hours later then once the next day then change to oral AL
unless the patient is still in a critical state and unable to take oral
medication.
● Mix the vial of artesunate powder with 1 ml of 5% sodium bicarbonate
solution (provided) and shake for 2–3 minutes.

32. Administrationof Artesunate
● IV administration: add 5 ml of 5% glucose or normal saline to make
the concentration of artesunate as 10 mg/ml and administer by slow
infusion, giving 2.4mg/kg IV
● .Example, if a patient weighs 30 kg, the required dose can be calculated
as: 2.4 mg/kg × 30 kg body weight = 72 mg This patient will then need
7.2 ml given IV.
● IM administration: add 2 ml of 5% glucose or normal saline to
make the concentration of artesunate 20 mg/ml.
● Example, if a patient weighs 20 kg, the required dose can be calculated as:
2.4 mg/kg × 20 kg body weight = 48 mg. This patient will then need 2.4
ml given IM.

33. ● Dose chart by age for artesunate 50 mg and 200 mg rectal capsules as
suppositories

34. Second line treatment of severe malaria with quinine
● If artesunate is not available or a person is allergic to artesunate, then the
second line treatment with quinine is given instead.
● Loading dose: 20 mg quinine/kg. Omit the loading dose if the patient
has had an adequate dose of quinine (>40 mg/kg) in the previous 2 days. The
loading dose should be given as an IV infusion over 4 hours.
● Maintenance dose: 10 mg quinine/kg. The maintenance dose must be
given every 8 hours. The maintenance dose should be given as slow infusion
over 4 hours.
● If IV therapy is still required after 48 hours, the maintenance dose should be
reduced to 7 mg/kg to avoid the risk of accumulation.
● A minimum of three doses of IV quinine should be given before changing to
follow-on oral treatment with AL

35. Conti..
● Quinine can be diluted in 5% dextrose, 10% dextrose or normal (0.9%)
saline
● Dilute quinine to a total volume of 10 ml/kg (the same volume is used
for both loading and maintenance doses) and infuse over 4 hours
● Quinine can cause Hypoglycaemia, therefore blood glucose should be
monitored every 4 hours.

36. Cerebral malaria
Cerebral malaria is a form of severe malaria that may present with coma
and convulsions.
The treatment is as for severe malaria.
If there are convulsions, then treat these with diazepam (see 4.1). Do not
give steroids or any other medication. Follow hospital standing operating
procedures for managing a patient in coma.

37. Complications
● Cerebral malaria
● Splenic rupture
● Renal failure,
● Severe hemolysis (blackwater fever)
● Pulmonary edema
● Hypoglycemia
● Thrombocytopenia
● Algid malaria (sepsis syndrome with vascular collapse)
● Death

38. Prevention
● There are two components of malaria prevention:
● reduction of exposure to infected mosquitoes
● chemoprophylaxis.(Mefloquine, doxycycline, chloroquine, and
atovaquone, proguanil are commonly prescribed medications)

39. SUMARRY
● Malaria is caused by a parasite that is injected into the body through the bite of infected
anopheles mosquitos which spread the disease.
● The parasite destroys the red blood cells and causes fever and symptoms of malaria
such as headache, chills, sweating, body pains.
● In children it commonly presents with vomiting and diarrhea.
● Malaria is a very dangerous disease that causes complications including anaemia,
miscarriage, enlarged spleen, convulsions and death.
● It is diagnosed by a history of fever and confirmed with the Rapid Diagnostic Test, RDT
and/or thick film.
● RHC and H staff should do everything to support prevention programmes in the
community.
● Malaria is more common in some parts of the country and may come in seasons
especially after the rain.

40. Thank you
FOR YOUR ATTENTION