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  1. 1. Malaria
  2. 2. INTRODUCTION <ul><li>MALARIA IS A WORLDWIDE PROBLEM </li></ul><ul><li>2/3 of the world’s population living in this area </li></ul><ul><li>Could increase to 3/4 by 2010 </li></ul><ul><li>There are 250 million new infections per year </li></ul><ul><li>Problem: drug resistance, less money and effort for mosquito eradication programs </li></ul>
  3. 3. GENERAL INFORMATION <ul><li>Malaria is caused by plasmodia </li></ul><ul><li>Transferred by the female anopheles mosquito </li></ul><ul><li>There are 4 species of the malaria parasites: </li></ul><ul><li>a) P. Vivax - most wide spread in the world </li></ul><ul><li>b) P. Falciparum - most FATAL </li></ul><ul><li>c) P. Malariae - not common </li></ul><ul><li>d) P. Ovale - rare </li></ul><ul><li>These are all found in South East Asia </li></ul>
  6. 8. TYPICAL SYMPTOM OF MALARIA <ul><li>1. A VIOLENT FEVER: </li></ul><ul><li>Lasting 6-8 hours </li></ul><ul><li>Recurring every 2 or 3 days </li></ul><ul><li>Different species cause 2 types of intermittent fever: </li></ul><ul><li>a) A tertian fever has 1 day free of fever paroxysms </li></ul><ul><li>b) A quartana fever has two </li></ul>
  7. 9. TYPICAL SYMPTOM OF MALARIA <ul><li>2) ANAEMIA </li></ul><ul><li>3) ENLARGEMENT OF THE SPLEEN </li></ul><ul><li>notes: </li></ul><ul><li>2&3 develop as the diseases progresses </li></ul>
  8. 10. SIGNS & SYMPTOMS OF MALARIA VIVAX, MALARIAE OR OVALE <ul><li>There are no symptoms at first </li></ul><ul><li>8-30 days after the bite: feeling cold, aches, pains, weariness, nausea. </li></ul><ul><li>Attacks of fever, usually in 3 distinct phases </li></ul><ul><li>a) Cold stage; </li></ul><ul><li>Shivers and rigors for 1/4-1 hour as temperature rises, skin is cold , pale. Pulse rises, also often BP, diarrhea and urinary frequency may occur. </li></ul>
  9. 11. SIGNS & SYMPTOMS OF MALARIA VIVAX, MALARIAE OR OVALE <ul><li>b) Hot stage: </li></ul><ul><li>Patients feel hot for about 1 hour, temp. 40 o C or more, skin is hot and dry, pulse rises, BP often falls, headache, delirium, thirst and vomiting are common (“crisis”). </li></ul><ul><li>c) Sweating stage: </li></ul><ul><li>temperature, BP, and pulse become normal (“lysis”) </li></ul><ul><li>After 1-2 hours patient often goes to sleep and feels well on waking up </li></ul>
  10. 12. SI GNS & SYMPTOMS OF FALCIPARUM MALARIA <ul><li>There are no symptoms at first </li></ul><ul><li>8-14 days after bite, some hours to a few days: feeling cold, headache, backache, and pains all over, nausea, vomiting & diarrhea </li></ul><ul><li>The attack then occurs. The patient may appear to be very sick: </li></ul><ul><li>- pains in the head, bones and muscles are severe </li></ul><ul><li>- vomiting and diarrhea, mental confusion and delirium are common </li></ul>
  11. 13. SIGNS & SYMPTOMS OF FALCIPARUM MALARIA <ul><li>- temperature is usually raised but rigors may not occur </li></ul><ul><li>- sweating is often severe </li></ul><ul><li>- pulse is usually fast, BP is usually low </li></ul><ul><li>- respiration rate is usually fast </li></ul><ul><li>- anemia quickly develops, jaundice sometimes present </li></ul><ul><li>- spleen is usually enlarged and tender liver is often enlarged </li></ul>
  12. 14. COMPLICATIONS OF FALCIPARUM MALARIA <ul><li>Febrile fits (only in children) </li></ul><ul><li>Convulsions, unconsciousness, paralysis, psychotic behavior - CEREBRAL MALARIA </li></ul><ul><li>Acute anemia: - hypoxemia </li></ul><ul><li>Severe gastro intestinal disturbances </li></ul><ul><li>Shock </li></ul><ul><li>Hemolysis </li></ul><ul><li>Renal failure </li></ul><ul><li>Hypoglycaemia </li></ul>
  13. 15. PREVENTING COMPLICATIONS OF FALCIPARUM MALARIA <ul><li>If treatment is given, there is usually a good response within a few hours. If it is not given or not correct or if it is not given quickly enough, complications can occur. </li></ul>
  14. 16. DIAGNOSIS OF MALARIA <ul><li>History and clinical examination may suggest a likely parasite species candidate </li></ul><ul><li>Blood film microcopy </li></ul><ul><li>Take a precise travel history from the patient ( up to 2 years of history). Determine : </li></ul><ul><ul><li>when and where </li></ul></ul><ul><ul><li>was chemoprophylaxis taken </li></ul></ul><ul><ul><li>any previous attacks of malaria </li></ul></ul>
  15. 17. ANTI MALARIA PROPHYLAXIS <ul><li>GENERAL RULES </li></ul><ul><li>Fansidar as a prophylactic is no longer recommended due to side effect </li></ul><ul><li>Mefloquine (Larium) should be considered of the lack of consistent local availability, incidence of psychological and fine motor control side-effects (for short term is quite useful) </li></ul><ul><li>Always check for allergy to medication </li></ul><ul><li>Should be commenced 1-2 weeks before entering a malarious area and should be continued for 4 weeks after returning (except Doxycycline ) </li></ul>
  16. 18. ANTI MALARIA PROPHYLAXIS <ul><li>Doxycycline (Vibramycin) : alternative for short stays (up to 6 weeks) can be supplemented with weekly Chloroquine (it is not for children & pregnant women) </li></ul><ul><li>Taking supplements of vitamin B 2 weeks before hand </li></ul><ul><li>The medicine should enough to last trip (stay) </li></ul>
  17. 20. SUMMARY OF TREATMENT MALARIA VIVAX,MALARIAE, OVALE <ul><li>Chloroquine 10mg/kg BW for adult, followed by chloroquine 300 mg 6 hours later </li></ul><ul><li>Then Chloroquine 300 mg day 2, 300 mg day 3 </li></ul><ul><li>PLUS Primaquine 15 mg daily for 14 days </li></ul><ul><li>OR Primaquine 45 mg weekly for 8 weeks if G6PD deficient </li></ul>
  18. 21. SUMMARY OF TREATMENT MALARIA FALCIPARUM <ul><li>Quinine 10 mg/kgBW three times a day for 7-10 days </li></ul><ul><li>PLUS Fansidar 3 tablets on day 2 </li></ul><ul><li>OR Mefloquine 750 mg (3 tablets) at once & 500 mg 6 hours later </li></ul>
  19. 23. SPECIAL CONSIDERATIONS <ul><li>The following drugs should not be used if there is a : </li></ul><ul><li>Fansidar and similar drugs if it is a history of allergy to sulfa drugs </li></ul><ul><li>Chloroquine if there is history of psoriasis </li></ul><ul><li>Mefloquine or quinidine if taking beta blockers, digoxin, calcium-channel blockers. </li></ul>
  20. 24. SPECIAL CONSIDERATIONS <ul><li>If mefloquine prophylaxis is used, do not use mefloquine or Quinine for treatment </li></ul><ul><li>After mefloquine treatment, patient should not drive, operate machinery, or pilot aircraft for 3 weeks </li></ul><ul><li>People with a history of psychiatric or epileptic disorder should not take mefoqluine </li></ul><ul><li>People with a history of epilepsy should not take chloroquine </li></ul>
  21. 25. LABORATORY DETECTION OF MALARIA PARASITES <ul><li>When to draw blood for a smear ? </li></ul><ul><li>Do a fingerstick anytime you suspect malaria </li></ul><ul><li>Don’t worry about fever spikes or time of day </li></ul><ul><li>If you really suspect, but the smears are negative, keep doing smears </li></ul><ul><li>The worse the symptom are the more frequent the smears to be done </li></ul><ul><li>Once an hour should be the maximum frequency </li></ul>
  22. 26. LABORATORY DETECTION OF MALARIA PARASITES <ul><li>Obtaining blood : </li></ul><ul><li>Freshly drawn blood is required </li></ul><ul><li>The blood may be obtained by fingerstick or venous puncture </li></ul><ul><li>Wipe the area with a dry cotton/sterile gauze </li></ul><ul><li>Lance the finger with a sterile lancet </li></ul><ul><li>Allow the blood freely, do not milk the finger </li></ul><ul><li>Wipe the first drop and touch the next drop to slide </li></ul>
  23. 27. LABORATORY DETECTION OF MALARIA PARASITES <ul><li>Making Malaria Slide: </li></ul><ul><li>for routine malaria microscopy,a thin and a </li></ul><ul><li>thick film are made on the same slide. </li></ul><ul><li>for the procedure see hand out. </li></ul>
  24. 28. LABORATORY DETECTION OF MALARIA PARASITES <ul><li>Thick smears </li></ul><ul><li>Using the corner of a clean slide, spread blood from the first slide to about the size of a dime. </li></ul><ul><li>The drop should be just thick enough to read newspaper print through it. </li></ul>
  25. 29. LABORATORY DETECTION OF MALARIA PARASITES <ul><li>Thin smears </li></ul><ul><li>It is best to spread this slide first </li></ul><ul><li>After obtaining the second the slide,immediately smear it. </li></ul><ul><li>Intact red blood cells are important because they are needed to compare with the size of malarial parasites. </li></ul>
  26. 30. LABORATORY DETECTION OF MALARIA PARASITES <ul><li>Examination thin films </li></ul><ul><li>Put immersion oil on the slide </li></ul><ul><li>Switch to oil-immersion objectives </li></ul><ul><li>Focus with 100x10 objectives on the thin terminal </li></ul><ul><li>end of the film where the red blood cells are in one </li></ul><ul><li>cells are in one layer </li></ul><ul><li>For examining malaria parasites,at least 200 field </li></ul><ul><li>field should be examined </li></ul>
  27. 31. LABORATORY DETECTION OF MALARIA PARASITES <ul><li>Examination thick films </li></ul><ul><li>Put immersion oil on the slide </li></ul><ul><li>Focus on the film with 100X10 objective </li></ul><ul><li>Search for the plasmodium at least 100 fields. </li></ul><ul><li>Malaria parasites can be found (see leaflet as your guidance) </li></ul>