A vector-borne infectious disease caused by protozoan parasites. It is widespread in tropical and subtropical regions
A bite from an infective female Anopheles mosquito. Anopheles must be infected through a previous blood meal taken on an infected person to transmit malaria
<ul><li>Transmission differs in intensity and regularity depending on local factors such as: </li></ul><ul><li>rainfall patterns </li></ul><ul><li>proximity of mosquito breeding sites </li></ul><ul><li>mosquito species. </li></ul>
At risk for malaria: 40% of the world’s population more than 500 million are ill of malaria y early If treated in the early stages, malaria can be cured. Commonly associated with poverty
The cycle takes 9-21 days at 25°C or 77°F Warmer ambient temperatures shorten the duration of the extrinsic cycle, thus increasing the chances of transmission. Climate determines human behaviors
Plasmodium falciparum - most common and deadly type of malaria infection - can lead to cerebral malaria P.vivax - most common - causes relapse if treatment was not completed. P.malaria P.ovale.
<ul><li>Female Anopheles are: </li></ul>Anthropophilic : from humans Zoophilic : from animals Endophagic : prefer to bite indoors Exophagic : prefer outdoor biting
In the Philippines: Falciparum cases: 70% Vivax cases: 30% 9 th highest morbidity rate in the country. WHO: Philippines included in top 10 malaria endemic countries in the Western Pacific region Average of 3 filipinos die daily of malaria
DOH Magnitude of Malaria Prevalence CATEGORY A - > 1,000 cases per year; 25 provinces CATEGORY B - 100 to 1,000 cases per year; 22 provinces CATEGORY C - < 100 cases per year; 18 provinces CATEGORY D - malaria-free provinces; 13 provinces
Liver Stage . Human infection is initiated when sporozoites are injected with the saliva during mosquito feeding. The sporozoites enter the circulatory system and within 30-60 minutes will invade a liver cell. Host cell entry, as in all apicomplexa, is facilitated by the apical organelles. After invading the hepatocyte, the parasite undergoes an asexual replication. This replicative stage is often called exoerythrocytic (or pre-erythrocytic) schizogony . PATHOPHYSIOLOGY: In P. vivax and P. ovale some of the sporozoites do not immediately undergo asexual replication, but enter a dormant phase known as the hypnozoite . This hypnozoite can reactivate and undergo schizogony at a later time resulting in a relapse.
Blood Stage . Merozoites released from the infected liver cells invade erythrocytes. The merozoites recognize specific proteins on the surface of the erythrocyte and actively invade the cell in a manner similar to other apicomplexan parasites. After entering the erythrocyte the parasite undergoes a trophic period followed by an asexual replication. The young trophozoite is often called a ring form due to its morphology in Geimsa-stained blood smears. As the parasite increases in size this 'ring' morphology disappears and it is called a trophozoite . During the trophic period the parasite ingests the host cell cytoplasm and breaks down the hemoglobin into amino acids. A by-product of the hemoglobin digestion is the malaria pigment, or hemozoin. These golden-brown to black granules have been long recognized as a distinctive feature of blood-stage parasites.
The invasion has begun. Microscopic magnification shows Plasmodium falciparum —the most virulent of the four malaria parasites that infect humans—destroying red blood cells in the liver. It digests a cell's hemoglobin, multiplies inside to the point of rupturing the cell, and rapidly spreads a new generation of infection.
Nuclear division marks the end of the trophozoite stage and the beginning of the schizont stage. Erythrocytic schizogongy consists of 3-5 rounds (depending on species) of nuclear replication followed by a budding process. Late stage schizonts in which the individual merozoites become discernable are called segmenters . The host erythrocyte ruptures and releases the merozoites. These merozoites invade new erythrocytes and initiate another round of schizogony. The blood-stage parasites within a host usually undergo a synchronous schizogony. The simultaneous rupture of the infected erythrocytes and the concomitant release of antigens and waste products accounts for the intermittent fever paroxysms associated with malaria.
Sexual Stage . As an alternative to schizogony some of the parasites will undergo a sexual cycle and terminally differentiate into either micro- or macrogametocytes . Gametocytes do not cause pathology in the human host and will disappear from the circulation if not taken up by a mosquito. Gametogenesis, or the formation of micro- and macrogametes , is induced when the gametocytes are ingested by a mosquito. After ingestion by the mosquito, the microgametocyte undergoes three rounds of nuclear replication. The macrogametocytes mature into macrogametes. The highly mobile microgametes will seek out and fuse with a macrogamete. Within 12-24 hours the resulting zygote develops into an ookinete . The ookinete is a motile invasive stage which will transverse both the peritrophic matrix and the midgut epithelium of the mosquito.
Sporogony . After reaching the extracellular space between the epithelial cells and the basal lamina, the ookinete develops into an oocyst . The oocysts undergo an asexual replication, called sporogony, which culminates in the production of several thousand sporozoites . This generally takes 10-28 days depending on species and temperature. Upon maturation the oocyst ruptures and releases the sporozoites which cross the basal lamina into the hemocoel (body cavity) of the mosquito.
Signs & symptoms: The pathology and clinical manifestations associated with malaria are almost exclusively due to the asexual erythrocytic stage parasites. Tissue schizonts and gametocytes cause little, if any, pathology. Plasmodium infection causes an acute febrile illness which is most notable for its periodic fever paroxysms occuring at either 48 or 72 hour intervals. The severity of the attack depends on the Plasmodium species as well as other circumstances .
Exoerythrocytic schizogony and prepatent and incubation periods 2000 15,000 10,000 40,000 Merozoites produced 12-16 9 6-8 5-7 Merozoite maturation (days) 18-40 16-18 12-17 7-14 Incubation period (days) 15-18 10-14 8-12 6-9 Prepatent period (days) P. malariae P. ovale P. vivax P. falciparum
Sometimes the incubation periods can be prolonged for several months in P. vivax, P. ovale, and P. malariae . All four species can exhibit non-specific prodromal symptoms a few days before the first febril attack. These prodromal symptoms are generally described as 'flu-like' and include: headache, slight fever, muscle pain, anorexia, nausea and lassitude. The symptoms tend to correlate with increasing numbers of parasites.
These prodromal symptoms will be followed by febrile attacks also known as the malarial paroxysms. The Malarial Paroxysm The malarial paroxysm will usually last 4-8 hours <ul><li>profuse sweating </li></ul><ul><li>declining temperature </li></ul><ul><li>exhausted and weak -> sleep </li></ul><ul><li>lasts 2-4 hours </li></ul><ul><li>intense heat </li></ul><ul><li>dry burning skin </li></ul><ul><li>throbbing headache </li></ul><ul><li>lasts 2-6 hours </li></ul><ul><li>feeling of intense cold </li></ul><ul><li>vigorous shivering </li></ul><ul><li>lasts 15-60 minutes </li></ul>sweating stage hot stage cold stage
The fever paroxysm corresponds to the period of infected erythrocyte rupture and merozoite invasion.
Disease Severity and Duration Modified from Markell and Voge's Medical Parasitology cerebral renal Complications ++++ ++ + ++ Anemia 6-17 months 20-50+ years 12-20 months 5-8 years Maximum Infection Duration (untreated) 2-3 weeks 3-24 weeks 2-3 weeks 3-8+ weeks Symptom Duration (untreated) 2,500,000 20,000 30,000 50,000 Maximum Parasitemia (mm 3 ) 50,000-500,000 6,000 9,000 20,000 Average Parasitemia (mm 3 ) severe moderate to severe mild moderate to severe Initial Paraoxysm Severity falciparum malariae ovale vivax
In contrast to the other three species, P. falciparum can produce serious disease with mortal consequences. This increased morbidity and mortality is due in part to the high parasitemias associated with P. falciparum infections. These potentially high parasitemias are due in part to the large number of merozoites produced and the ability of P. falciparum to invade all erythrocytes.
Other Physical symptoms: Fever: Fever can be very high from the first day. Temperatures of 40°C and higher are often observed. Fever is usually continuous or irregular. Classic periodicity may be established after some days. Hepatomegaly: The liver may be slightly tender. Splenomegaly: Splenomegaly takes many days, especially in the first attack in nonimmune children. In children from an endemic area, huge splenomegaly sometimes occurs. Anemia: Prolonged malaria can cause anemia, and malarial anemia causes significant mortality. Jaundice: With heavy parasitemia and large-scale destruction of erythrocytes, mild jaundice may occur. This jaundice subsides with the treatment of malaria. Dehydration: High fever, poor oral intake, and vomiting all contribute to dehydration.
Examine blood under microscope (geimsa stain) chest x-ray : helpful if respiratory symptoms are present CT scan : to evaluate evidence of cerebral edema or hemorrhage Medical intervention:
Polymerase chain reaction (PCR) -determine the species of plasmodium dipstick test - not as effective when parasite levels are below 100 parasites/mL of blood Blood smears - repeated over a 72-hour period RDT's (rapid diagnostic tests)
<ul><ul><li>Other tests: </li></ul></ul><ul><ul><li>CBC </li></ul></ul><ul><ul><li>electrolyte panel </li></ul></ul><ul><ul><li>renal function tests </li></ul></ul><ul><ul><li>pregnancy test </li></ul></ul><ul><ul><li>urinalysis </li></ul></ul><ul><ul><li>urine and blood cultures </li></ul></ul><ul><ul><li>and thick and thin blood smears </li></ul></ul>Antibody tests are not usually helpful
Antimalarial drugs: chloroquine (Aralen) – DOC - except for chloroquine-resistant Plasmodium strains combination of quinine and tetracycline - for Falciparum strains suspected to be resistant to chloroquine
<ul><li>useful in areas where there is known to be a high level of resistance to Chloroquine, Mefloquine and sulfa drug combinations with pyrimethamine </li></ul>Quinine <ul><li>less effective and more toxic as a blood schizonticidal agent than Chloroquine </li></ul><ul><li>used in post-exposure treatment </li></ul>
For quinine resistance other treatments include clindamycin (Cleocin), mefloquin (Lariam), or sulfadoxone/pyrimethamine (Fansidar). primaquine prevent relapses after recovery from P. vivax or P. ovale artemisinin-based combination therapies (ACTs) - derived from an ancient Chinese herbal remedy
<ul><li>Most persons receive an antibiotic for seven days </li></ul><ul><li>Intensive care </li></ul><ul><li>intravenous (IV) malaria treatment for the first three days. </li></ul><ul><li>NO vaccine is currently available </li></ul><ul><li>Red blood cell transfusions </li></ul><ul><li>Kidney dialysis </li></ul><ul><li>Assistance breathing </li></ul>
Alternative treatment qiinghaosu (artemisinin) usually combined with another antimalarial drug (mefloquine) to boost its effectiveness. Wormwood (Artemesia annua) Western herb that is taken as a daily dose
<ul><li>Herbs that protect the liver or used as preventive treatment : </li></ul><ul><li> goldenseal (Hydrastis canadensis) </li></ul><ul><li> Chinese goldenthread (Coptis chinensis) </li></ul><ul><li>milk thistle (Silybum marianum) </li></ul>
<ul><li>NURSING INTERVENTIONS: </li></ul><ul><ul><li>Maintain a clear airway. In cases of prolonged, deep coma, endotracheal intubation may be indicated. </li></ul></ul><ul><li>Turn the patient every two hours. </li></ul><ul><li>Avoid soiled and wet beds. </li></ul><ul><li>Position in semi-prone to prevent aspiration </li></ul>
<ul><ul><li>Maintain strict intake/output record. </li></ul></ul><ul><ul><li>O bserve for high colored or black urine. </li></ul></ul><ul><ul><li>Observe for changes in levels of sensorium and occurrence of convulsions </li></ul></ul><ul><ul><li>Naso-gastric aspiration to prevent aspiration pneumonia </li></ul></ul><ul><ul><li>Monitor vital signs every 4-6 hours. </li></ul></ul>
<ul><ul><li>TSB if the temperature is above 39 0 C </li></ul></ul><ul><ul><li>Urethral catheter can be inserted for monitoring urine output as indicated </li></ul></ul><ul><ul><li>NSAIDs should be used with caution if bleeding disorder or hemolysis is suspected. </li></ul></ul>
<ul><li>If evidence of life-threatening hemolytic anemia is determined: </li></ul><ul><li>establish large-bore intravenous (IV) lines </li></ul><ul><li>initiate fluid resuscitation </li></ul><ul><li>administer transfusion of type-specific packed RBCs. </li></ul>
<ul><li>Health teachings: </li></ul><ul><li>Use topical insect repellent (30-35% diethyltoluamide or [DEET]) esp. at dusk to dawn </li></ul><ul><li>D EET - toxic in large amounts; children = < 35% </li></ul><ul><li>DEET should not be inhaled </li></ul><ul><li>not be rubbed onto the eye area, on any broken or irritated skin, or on children's hands </li></ul><ul><li>should be thoroughly washed off after coming indoors </li></ul>
<ul><li> Remain indoors in well-screened areas between dusk and dawn </li></ul><ul><li> Sleep inside pyrethrin or permethrin repellent-soaked mosquito nets. </li></ul><ul><li> Avoid wearing perfumes and colognes. </li></ul><ul><li> Wear appropriate clothing: long-sleeved shirts and long pants. </li></ul>
<ul><li>Remove or poison breeding grounds </li></ul><ul><li>Swamp draining </li></ul><ul><li>Use of Indoor Residual Spraying of long-acting insecticide (IRS) </li></ul><ul><li>use of pesticide DDT – certain issues </li></ul>
<ul><li>Consult physician for proper prophylaxis before traveling to endemic areas </li></ul><ul><li>usually anti-malarial drugs starting a day or two, usually chloroquine or mefloquine </li></ul><ul><li>Treatment - continued through at least four weeks after leaving the endemic area </li></ul><ul><li>Seek medical help : if having flu-like symptoms </li></ul>