This presentation is from a health awareness masterclass by Dr. Leju Benjamin Modi on 12th August 2023 via Zoom and YouTube Live stream as organised by Excellence Foundation for South Sudan. The science of wellbeing, focusing on three critical infectious diseases: Typhoid Fever, Malaria, and Viral Hepatitis. This masterclass aims to deepen your understanding of these diseases, their impact on global health, and explore strategies for prevention and management. Whether you are a healthcare professional, researcher, or simply curious about public health, this masterclass is designed to provide valuable insights and knowledge. Objectives: During this masterclass, participants will: Understand the epidemiology, pathogenesis, and clinical presentation of Typhoid Fever, Malaria, and Viral Hepatitis. Explore the risk factors associated with these diseases and their impact on vulnerable populations. Discuss effective prevention strategies, including vaccination programs, vector control, and community education. Examine the latest advancements in diagnosis, treatment, and management techniques. Analyze the global burden of these diseases and their implications on public health policies and interventions.

1. Malaria & typhoid
© DR LEJU BENJAMIN MODI (MBChB)
FOR EFSS AUDIENCE (ON ZOOM/YOUTUBE)
AUGUST 12 – 13, 2023

2. Disclaimer
The material shared in this presentation is strictly for
health awareness and information purposes to the
audience, and must not be used for making self
diagnosis and/or prescriptions!
This presentation does not contribute to any CPD points.

3. Outline
 Malaria
 What it is/cause.
 Transmission/signs and symptoms/diagnosis
 Complications/Treatment/Prevention
 Typhoid
 What it is/cause.
 Transmission/signs and symptoms/diagnosis
 Complications/Treatment/Prevention

4. MALARIA
 Derived from Italian words “mal” = bad, “aria” = air ➔ malaria
 Caused by the parasite Plasmodium; of four main species
➢ P. falciparum (the most dangerous and common)
➢ P. vivax
➢ P. malariae
➢ P. ovale
➢ (P. knowlesi; Southeast Asia, common in monkeys)
 Spread by the vector, female Anopheles mosquito
 Possible transmission through blood transfusion, organ transplant (liver), and
placentally
 Life cycle in blood (and organs like liver) and in the mosquito’s salivary glands

5. Incubation Period
Parasite Species Incubation Period (days) characteristic
P. falciparum 9 – 14 Fulminant; fever recurs
36 – 48hrly
P. vivax and
ovale
12 – 18 Fever spikes every
48hrs; latency in liver
P. Malariae 18 – 40 Fever recurs 72hrly

6. Epidemiology of Malaria
WORLD MALARIA REPORT, 2022
(WHO)
• 247M cases, 619,000 deaths
world wide in 2021
• 234M (95%) cases in Africa, with
593000 (96%) deaths; ~ 80% in <
5years old
• South Sudan accounted for 1.2%
of cases (2,964,000) and 1.2%
deaths (7,428)
• 20 people die of malaria daily in
South Sudan

7. Signs and Symptoms
 Signs and symptoms occur in
repetitive cycles (paroxysmal)
 Broadly grouped into three
stages:
 Cold stage – chills and
shivering
 Hot stage – warm/high fever,
headache,
 Sweating stage – weakness
Fever 96%
Chills 96%
Headache 79%
Muscle Pain 60%
Palpable liver 33%
Palpable Spleen 28%
Nausea or vomiting 23%
Abdominal pain/diarrhea 6%

8. Diagnosis
History of illness, including travel to areas of endemicity
Physical examinations – fever, etc.
Laboratory tests:
Blood microscopy (gold standard; thin/thick films); 2+ is severe
Rapid test kits; less effective if low parasites in blood
Others (Complete Blood Count (CBC), clotting, sugar levels, LP,
etc.)
PCR (at reference labs)

9. Complications
 Low red blood cells (anemia)
 Cerebral malaria (decreased consciousness; convulsions)
 Organ enlargement (spleen, liver)
 Kidney failure
 Acute respiratory distress syndrome
 Fluid accumulation (lung, brain)
 Shock
 jaundice
 Miscarriage/preterm birth (in pregnancy; P. falciparum!)

11. Treatment
Pain/fever relief (paracetamol); tepid sponging
Artemisinin combination therapy (ACTs) – coartem, lumartem,
etc. (artemether/lumefantrine)
Quinine (preferable in pregnancy)
Fansidar (sulfadoxine-pyrimethamine)
Chloroquine; hydroxychloroquine
Atovaquone-proguanil
Other symptomatic treatment (transfusion, etc.)
If severe, injections then oral regimen

13. Prevention – 3 prong
Attack Parasite
in Human Body:
 Diagnose and
treat promptly
as above
Reduce contact between
humans and mosquitos/parasites:
 Repellants (lotion, mosq coil)
 Mosquito net (ITN)
 Use preventive anti-malarials –
doxycycline, mefloquine,
primaquine, etc.
 Close doors/windows; wear
long-sleeves/socks dusk to
dawn
 Mosquirix malaria vaccine
(WHO recommended 2021 for
high burden Africa countries)
Decrease mosquito
population:
 Bury stagnant
water.
 Insecticides
(Doom)

14. Comments/Questions?
Health break

15. Typhoid (Enteric) Fever
 Mainly caused by the bacterium, Salmonella typhi. Other species,
S. paratyphi A, B, & C are relatively infrequent
 Humans the only host – may be a case (infectious as long as
bacterium appears in stools/urine) or a carrier (who may be
temporary or incubatory, excreting bacteria for 6 – 8 weeks; or
chronic carrier, excreting for over a year)
 Main/primary source of infection = feces (and urine) of cases;
secondary source = contaminated water, food, fingers, flies
 Incubation period = 10 – 14 days, but may be as short as 3 days or
as long as 21 days, depending on dose of bacteria

16. Mode of transmission
• Faeco-oral or uro-oral
• Worsened by human
activities:
• Open area
defecation/urination
• Contamination of
drinking water
supplies/food
• Vegetables/crops
grown in sewage water
• Low personal hygiene
Faeces and
urine from
cases or
carriers
Water
Soil
Flies
Fingers
Foods raw
or half-
cooked
Mouth of
well persons

17. Signs and symptoms
First week:
 Characteristic “step-
ladder”, fever over 4
– 5 days; mostly
afternoon hrs
 Headache, vague
abdominal pain;
constipation
 Weakness; muscle
pains; relative
decrease in heart
rate
Second week:
 Mild organ
(liver, spleen)
enlargement –
in majority
patients
 Skin rash (rose
spots) may
appear;
diarrhea
Third week:
 Patient appears in
the “typhoid
stage” – prolonged
apathy, toxemia,
disorientation/com
a, apparent
diarrhea
 If untreated, 5 –
10% risk of intestinal
perforation and
bleeding

19. Diagnosis
Widal test – tests for antibodies to antigens of the bacterium
Unreliable as some of the antibodies not specific to S. typhi (cross-
reactivity); other antibodies rise late in the illness; false positive/false
negative results
Cultures – gold standard, different as illnesses progresses
1st week – blood culture – useful since high bacterial load in blood
early in infection
3rd week – stool culture
4th week – urine culture

20. Complications
General – toxemia, shock
Digestive system – intestinal bleeding/perforation (3rd or 4th
week)
Nervous system – deranged, coma, meningitis
Miscellaneous – organ injury – heart, liver, kidneys, lungs,
bone infection (if sickle cell)

21. Treatment
Antibiotics – oral fluoroquinolones (e.g., ciprofloxacin);
chloramphenicol; amoxicillin; ampicillin;
If resistance to fluoroquinolones – azithromycin; 3rd
generation cephalosporins (e.g., ceftriaxone)
Chronic carrier state – prolonged (4 weeks) fluoroquinolone;
gall bladder removal in some patients
Supportive treatment – pain/fever medications, adequate
hydration, appropriate nutrition

22. Prevention of Enteric Fever
Control of sanitation
• Protection and
purification of drinking
water supplies
• Promotion of food
hygiene (wash fruits!)
• Improvement of basic
sanitation

23. Immunization/Vaccination
of
• Those living in endemic
areas
• At risk, e.g., school children,
hospital staff
• Household members
• Food handlers (restaurants)
Two types of vaccines
• The injectable typhoid
vaccine (TYPHIM – Vi)
• The live oral vaccine
(TYPHORAL)

24. Vaccination
Injectable Typhim Vi TYPHORAL
• Single dose injectable vaccine;
• Subcutaneous or intramuscular
• For children 2years and over
• One capsule taken by mouth with
water/milk on 1st, 3rd, and 5th, days;
no antibiotic to be taken at this
time (live attenuated vaccine)
• For 6 years old and over
• Booster dose after 3 years

25. Summary
 Malaria (caused by a parasite, Plasmodium), is not always associated
with typhoid (caused by a bacterium, Salmonella typhi); double
diagnosis often incorrect
 A true typhoid infection has a characteristic presentation a clinician
should be able to discern and make the correct diagnosis
 Best test for typhoid is culture; Widal test is unreliable
 First line treatment for typhoid is oral fluoroquinolones; use of
ceftriaxone should be minimized to prevent antibiotic resistance
 Personal and environmental hygiene can prevent typhoid, practice it!
 Vaccination facilities and cost in Juba? Let’s all find out!

26. Thank you for listening
Questions/Comments?