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  2. 2. Introduction • 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
  3. 3. • 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- immune travellers/immigrants
  4. 4. Definition • 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.
  5. 5. Causes of Malaria • Malaria is a disease caused by the protozoan parasites of the genus Plasmodium. • There 4 species that commonly infect man are as follows:
  6. 6. 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
  7. 7. Newer species • A fifth species, Plasmodium knowlesi causes malaria in macaques but can also infect humans. • The most dangerous of the four is P.falciparum
  8. 8. 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)
  9. 9. The Risk Factors • Environmental Factor • Human (host) Factor
  10. 10. Environmental Factors • A warm, humid climate - temperatures between 16°C and 40°C and abundant rainfall have anopheles mosquitoes. • Vegetation nearby to provide shade for the mosquito to hide during the day and digest the blood meal from the night before.
  11. 11. ENVIRONMENTAL FACTORS Ideal breeding grounds for mosquitoes – still, shallow water.
  12. 12. ENVIRONMENTAL FACTORS A high risk area – vegetation cover and standing water during the wet season.
  13. 13. Human Factors • Poor water supply and sanitation. • People working in the fields and in irrigation systems, near or on lakes and reservoirs etc. • Migrants moving into malarial areas - clearing land, looking for work, refugees etc.
  14. 14. Human Factors • Collecting water, an essential fact of life for millions of people, poses real risks of being bitten.
  15. 15. Who is at high risk of getting malaria? • Most at risk are the very young, who have not yet developed any degree of natural immunity • pregnant women • people with HIV/AIDS • international travelers from non- endemic areas
  16. 16. Incubation Period • 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.
  17. 17. The life cycle of malaria parasite is divided into four (4) phases which are: • Transmission phase • Pre-erythrocytic phase • Erythrocytic phase (asexual reproduction) • Sexual reproduction (In mosquito)
  18. 18. Life cycle of malaria parasite Click on the diagram to explore different areas of the life cycle
  19. 19. Life cycle of malaria parasite
  20. 20. Life cycle of malaria parasite
  21. 21. Life cycle of malaria parasite
  22. 22. 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.
  23. 23. Listen and watch the video in order to understand the life of malaria parasite
  24. 24. Clinical Features of Malaria
  25. 25. Classification of malaria Malaria is classified into two groups: • Uncomplicated malaria • Complicated malaria
  26. 26. Uncomplicated malaria The uncomplicated malaria is divided into three stages: • Cold stage (sensation of cold, shivering) • Hot stage (fever, headaches, vomiting, seizure in young children) • Sweating stage (sweats, return to normal temperature, tiredness)
  27. 27. Severe malaria • Cerebral malaria (seizures, coma) • Severe anemia • Coma • Renal and respiratory failure • Cardiovascular collapse and shock • may lead to death
  28. 28. A good history taking Ask the patient number of questions concerning: •Current symptoms such as fever. •Current medications. •Recent travel history.
  29. 29. Physical examination • Identify signs consistent with malaria: fever, pallor, jaundice, splenomegaly • Exclude other possible causes of fever (e.g. signs of viral and bacterial infections)
  30. 30. Investigations • 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 by microscopy.
  31. 31. Thick blood film - • Used for detecting malaria: a larger volume of blood is examined allowing detection of even low levels of parasitaemia. • Also used for determining parasite density and monitoring the response to treatment.
  32. 32. Thin blood film • Gives more information about the parasite morphology and, therefore, is used to identify the particular infecting species of Plasmodium.
  33. 33. 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 speciation
  34. 34. Thin blood film A small drop of blood is spread across a microscope slide, fixed in methanol and stained with Giemsa stain. 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 parasitaemia
  35. 35. 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 10-15 minutes.
  37. 37. Other methods of diagnosis of malaria that are not routinely used in clinical practice include the followings: • PCR based techniques:- Detects DNA or RNA sequences specific to Plasmodium. • Fluorescent techniques:- Relatively low specificity and sensitivity. Cannot identify the parasite species. • Serologic tests:-Based on immunofluorescence detection of antibodies against Plasmodium species. Useful for epidemiologic and not diagnostic purposes. •
  38. 38. Management of malaria The management of malaria is based on the clinical presentation. • In severe malaria, anti malarial therapy must be given Intravenously or Intramuscularly, oral treatment should be substituted as early as possible • Doses must be calculated in on a mg/kg of body weight. • It is important to weigh the patient, this is particularly important for children
  39. 39. The management of malaria include the following aspect: • Nursing management • Chemotheraphy • Chemophylaxis
  40. 40. Nursing management • Good nursing care is vital in the management of malaria. • 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 patient condition. • Tepid sponge patient , remove clothing and on the fan inorder to reduce the body temperature.
  41. 41. • Administer prescribed antipyretic, if temperature did not reduce after tepid sponging. • Maintain adequate fluid balance, to avoid overhydration or underhydration • Administer precribed antimalaria and make eat before administration. • Do not give ACT on empty stomach
  42. 42. Chemotherapy • The chemotherapy depend on the type of malaria, severity of the condition and the type of parasite that cause the malaria.
  43. 43. General recommendations for the management of un complicated malaria are as follows: • Avoid starting Rx on empty stomach., • 1st dose given under observation., • Dose repeated if vomiting within 30 minutes • Patient should report back if no improvement after 48 hrs. • Patient should be examined for concomitant illness.
  44. 44. WHO 2010 guideline for the treatment of uncomplicated P. falciparum malaria.
  45. 45. 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 . Examples • artemether plus lumefantrine, • artesunate plus amodiaquine, • artesunate plus mefloquine, • artesunate plus sulfadoxine-pyrimethamine, • dihydroartemisinin plus piperaquine
  46. 46. • 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 days; • quinine plus tetracycline or doxycycline or clindamycin; any of these combinations should be given for 7 days
  47. 47. First line treatment Artemisinin-based combination therapies (ACTs)
  48. 48. 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)
  49. 49. Artemether + Lumefantrine
  50. 50. Artemether + Lumefantrine
  51. 51. Pediatric Dosage
  52. 52. Artesunate plus amodiaquine • 4 mg/kg/day artesunate and 10 mg/kg/day amodiaquine once a day for 3 days • Available as 50 mg of artesunate and 153 mg base of amodiaquine separately &
  53. 53. artesunate plus amodiaquine
  54. 54. Artesunate plus amodiaquine
  55. 55. 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
  56. 56. artesunate plus mefloquine
  57. 57. artesunate plus sulfadoxine- pyrimethamine • 4 mg/kg/day artesunate given once a day for 3 days • 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
  58. 58. Artesunate plus sulfadoxine- pyrimethamine
  59. 59. Dihydroartemisinin plus piperaquine • 4 mg/kg/day dihydroartemisinin and • 18 mg/kg/day piperaquine once a day for 3 days • Available as 40 mg of dihydroartemisinin and 320 mg of piperaquine
  60. 60. Dihydroartemisinin plus piperaquine
  61. 61. Dihydroartemisinin plus piperaquine
  62. 62. Second line antimalarial treatment • alternative ACT known to be effective in the region. • 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 days. • Addition of a single dose primaquine (0.75 mg/kg)to ACT treatment for uncomplicated falciparum malaria as an antigametocytes
  63. 63. 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 ml/minute). • 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
  64. 64. • 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 indicated above. • However, if a patient has a history of intake of Artemether + Lumefantrine before complications developed,. • Give Quinine tablets 10 mg salt per kg TDS to complete 7 days treatment.
  65. 65. 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.
  66. 66. 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
  67. 67. Chemoprophylaxis • The need for chemoprophylaxis depends on the risk in the destination for travel. • There are a number of medications for malaria prophylaxis: • Atovaquine and Proguanil (Malarone) • Doxycycline • Mefloquine • Chloroquine and hydroxychloroquine • Primaquine
  68. 68. Chemoprophylaxis • Chemoprophylaxis is for prevention only. • The Dosage does not apply to Malaria treatment • Chemoprophylaxis Schedule  Agents are started 1-2 weeks before travel  Agents are continued for 4 weeks after travel
  69. 69. Chemoprophylaxis • Chloroquine and hydroxychloroquine • Primaquine • 1-2 weeks before travel, weekly while in country, and for 4 weeks afterwards • Only used for prophylaxis in areas with p. vivax, and for terminal prophylaxis
  70. 70. Chemoprophylaxis • Atovaquone-Proguanil • Doxycycline • Mefloquine • 1-2 days before, daily while in country and 7 days after • 1-2 days before, daily in country and 4 weeks afterwards • 2 weeks before, weekly in country and weekly for 4 weeks afterwards
  71. 71. Complication of malaria • Splenomegaly (Enlarged spleen) • Cerebral malaria • Severe anaemia • Febrile convulsion • Thrombocytopaenia • Splenic rupture • Hyperparasitisation • Nephrotic syndrome is also said to be a long- term complication of P. malariae infection.
  72. 72. Malaria in pregnancy
  73. 73. Overview • 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.
  74. 74. • >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.
  75. 75. 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.
  76. 76. • 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 non-pregnant population. • More fatal • P. falciparum malaria in pregnancy is more severe, the mortality is also double (13 % ) compared to the non-pregnant population (6.5%).
  77. 77. • 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.
  78. 78. Effects Of Malaria On Pregnancy • Abortion – placental sequestration • Anemia • Cerebral malaria • Low birth weight (Prematurity, IUGR) due to placental squestration • Stillbirth • Congenital infection • Puerperal sepsis • Maternal Mortality
  79. 79. Management of Malaria in Pregnancy Management of malaria in pregnancy involves three aspects that are of equal importance • Treatment of the malaria • Management of complications • Prevention of recurrence
  80. 80. Treatment Of Malaria In Pregnancy • Depends on severity of the disease Simple / Uncomplicated Complicated • Gestational age First trimester Second trimester Third trimester • Aims at bringing attack/pyrexia to an end.
  81. 81. How to recognizing malaria in pregnant women In Uncomplicated malaria, if the patient present with the followings: • Fever • Shivering/chills • Headaches • Muscle/joint pains • Nausea/vomiting (Can tolerate per os) • False labor pains • + / ++
  82. 82. In Complicated malaria, the patient present with the followings: • Signs of uncomplicated malaria, plus: • Dizziness • Breathlessness • Sleepy/drowsy • Confusion/coma • Sometimes fits, jaundice, severe dehydration • ++ / +++
  83. 83. Treatment of Simple / Uncomplicated Malaria • 1st trimester = Quinine ( safe and evidence- based) • 2nd and 3rd trimesters 1st Line = Arthemeter/Lumefantrine(Coartem) 2nd Line = Artesunate + Amodiquine Artesunate + fansider
  84. 84. Treatment of Complicated Malaria • In Complicated Malaria Parenteral Quinine is given in all trimesters then Orals • It is Absolutely safe!
  85. 85. Supportive Treatment in Management of Malaria in Pregnancy • Adequate calories • Correction of electrolyte imbalance • Blood transfusion / EBT in acute and severe cases • Oxygen + Diuretics in pulmonary oedema • Anticonvulsants • Monitoring of the fetal growth & health • If condition is critical patient should be nurse in ICU.
  86. 86. Intermittent Preventive Treatment (IPT) • 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 quickening) • Intermittent preventive treatment (IPT) given 3 times during pregnancy is effective for women with HIV/AIDS • Presently, the most effective drug for IPT is sulfadoxine-pyrimethamine (SP) combination
  87. 87. Intermittent Preventive Treatment (IPT) • A single dose is three tablets of sulfadoxine 500 mg + pyrimethamine 25 mg. • (Daraprim, the ‘Sunday-Sunday tablet’ is no longer effective) • Healthcare provider should dispense dose and directly observe client taking dose
  88. 88. Complication of malaria in pregnancy • Anemia • Acute pulmonary oedema:- • Hypoglycemia: • Immuno suppression • Congenital malaria:
  89. 89. Prevention of Malaria
  90. 90. Early and effective treatment • Children are at a high risk of malaria. • They have little immunity or defense against malaria. • 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.
  91. 91. Personal protection • Preventing the mosquitoes from entering the house – Close door / windows, especially toilets. • Well-constructed houses with window screens • Preventing the mosquitoes from hiding – Avoid dark corners/ hanging clothes in rooms • Mosquito Control – Avoid stagnant water, insecticide spraying etc.
  92. 92. Protection from mosquito bites – • Protective clothing, • Mosquito repellants (containing DEET), • Insect vaporizers (coils containing pyrethroids), • Insecticide treated bed nets (most effective), • Airconditioning
  93. 93. Malaria Vaccine • 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 Gambia
  94. 94. Malaria Vaccine • 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 US
  95. 95. Anti-larval measure • Using the anti larval measures such as oiling the collection of standing water or dusting them with paris green effectively controlled malaria • Some moderm larvicides such as temephos which confer long effect with low toxicity are more widely used
  96. 96. Vector control strategy • Residual spray: Spraying indoor surface of house with DDT/malathion.
  97. 97. 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
  98. 98. 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.
  99. 99. World Malaria Day • World Malaria Day (previously Africa Malaria Day) is now be commemorated every year on 25 April.
  100. 100. In conclusion • 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.
  101. 101. Reference • Adedapo .A (2014), Diagnosis and Management of Malaria retrieved on 28/04/2014 available on • Delage. D.E (2013), Malaria Prophylaxis – Travel Medicine retrieved on 29/04/2014 available on
  102. 102. Reference • Jamil.K.F(2011), Malaria recent management retrieved on 28/04/2014 available on • Mohanty .S(2014), Malaria retrieved on 28/04/2014 available on
  103. 103. Reference • Scott M (2014), Malaria retrieved on 25/04/2014 retrieved from • Sgarabotto. D (2014), How to manage Malaria in a Out-patient retrieved on 28/04/2014 retrieved from