Project Paper on Malaria


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Project Paper on Malaria

  1. 1. 2011 Project paper on Malaria Department of Public Health Submitted by : Imran Ahmed [Type the company name] 1/1/2011
  2. 2. Contents: 1. Introduction. 2. Life cycle. 3. Causes, incidence, and risk factors. 4. Symptoms. 5. Diagnosis and tests. 6. Complications. 7. Malaria Situation in Bangladesh. 8. Treatments. 9. References. Page | 2
  3. 3. Introduction:Malaria is a mosquito-borne infectious disease of humans and other animals caused by eukaryoticprotists of the genus Plasmodium. The disease results from the multiplication of Plasmodium parasiteswithin red blood cells, causing symptoms that typically include fever and headache, in severe casesprogressing to coma or death. It is widespread in tropical and subtropical regions, including much ofSub-Saharan Africa, Asia, and the Americas.Five species of Plasmodium can infect and be transmitted by humans. Severe disease is largely caused byPlasmodium falciparum while the disease caused by Plasmodium vivax, Plasmodium ovale, andPlasmodium malariae is generally a milder disease that is rarely fatal. Plasmodium knowlesi is azoonosis that causes malaria in macaques but can also infect humans.Malaria transmission can be reduced by preventing mosquito bites by distribution of mosquito nets andinsect repellents, or by mosquito-control measures such as spraying insecticides and draining standingwater (where mosquitoes breed). The challenge of producing a widely available vaccine that provides ahigh level of protection for a sustained period is still to be met, although several are under development.A number of medications are also available to prevent malaria in travelers to malaria-endemic countries(prophylaxis).A variety of antimalarial medications are available. Severe malaria is treated with intravenous orintramuscular quinine or, since the mid-2000s, the artemisinin derivative artesunate, which is superiorto quinine in both children and adults. Resistance has developed to several antimalarial drugs, mostnotably chloroquine.There were an estimated 225 million cases of malaria worldwide in 2009. An estimated 781,000 peopledied from malaria in 2009 according to the World Health Organizations 2010 World Malaria Report,accounting for 2.23% of deaths worldwide.[9] Ninety percent of malaria-related deaths occur in sub-Saharan Africa, with the majority of deaths being young children. Plasmodium falciparum, the mostsevere form of malaria, is responsible for the vast majority of deaths associated with the disease.Malaria is commonly associated with poverty, and can indeed be a cause of poverty and a majorhindrance to economic development. Page | 3
  4. 4. Life Cycle:A female Anopheles mosquito carrying malaria-causing parasites feeds on a human and injects theparasites in the form of sporozoites into the bloodstream. The sporozoites travel to the liver and invadeliver cells.Over 5-16 days, the sporozoites grow, divide, andproduce tens of thousands of haploid forms, calledmerozoites, per liver cell. Some malaria parasitespecies remain dormant for extended periods in theliver, causing relapses weeks or months later.The merozoites exit the liver cells and re-enter thebloodstream, beginning a cycle of invasion of redblood cells, asexual replication, and release of newlyformed merozoites from the red blood cellsrepeatedly over 1-3 days. This multiplication canresult in thousands of parasite-infected cells in thehost bloodstream, leading to illness andcomplications of malaria that can last for months ifnot treated.Some of the merozoite-infected blood cells leave thecycle of asexual multiplication. Instead of replicating,the merozoites in these cells develop into sexualforms of the parasite, called male and female Figure 1: Life cycle of the Malaria Parasite.gametocytes, that circulate in the bloodstream.When a mosquito bites an infected human, it ingests the gametocytes. In the mosquito gut, the infectedhuman blood cells burst, releasing the gametocytes, which develop further into mature sex cells calledgametes. Male and female gametes fuse to form diploid zygotes, which develop into actively movingookinetes that burrow into the mosquito midgut wall and form oocysts.Growth and division of each oocyst produces thousands of active haploid forms called sporozoites. After8-15 days, the oocyst bursts, releasing sporozoites into the body cavity of the mosquito, from whichthey travel to and invade the mosquito salivary glands. The cycle of human infection re-starts when themosquito takes a blood meal, injecting the sporozoites from its salivary glands into the humanbloodstream Page | 4
  5. 5. Causes, incidents, and risk factors:Malaria is caused by a parasite that is passed from one human to another by the bite ofinfected Anopheles mosquitoes. After infection, the parasites (called sporozoites) travelthrough the bloodstream to the liver, where they mature and release another form, themerozoites. The parasites enter the bloodstream and infect red blood cells.The parasites multiply inside the red blood cells, which then break open within 48 to 72 hours,infecting more red blood cells. The first symptoms usually occur 10 days to 4 weeks afterinfection, though they can appear as early as 8 days or as long as a year after infection. Thesymptoms occur in cycles of 48 to 72 hours.Most symptoms are caused by:1. The release of merozoites into the bloodstream2. Anemia resulting from the destruction of the red blood cells3. Large amounts of free hemoglobin being released into circulation after red blood cells breakopenMalaria can also be transmitted from a mother to her unborn baby (congenitally) and by bloodtransfusions. Malaria can be carried by mosquitoes in temperate climates, but the parasitedisappears over the winter.The disease is a major health problem in much of the tropics and subtropics. The CDC estimatesthat there are 300-500 million cases of malaria each year, and more than 1 million people diefrom it. It presents a major disease hazard for travelers to warm climates.In some areas of the world, mosquitoes that carry malaria have developed resistance toinsecticides. In addition, the parasites have developed resistance to some antibiotics. Theseconditions have led to difficulty in controlling both the rate of infection and spread of thisdisease.There are four types of common malaria parasites. Recently, a fifth type, Plasmodium knowlesi,has been causing malaria in Malaysia and areas of southeast Asia. Another type, falciparummalaria, affects more red blood cells than the other types and is much more serious. It can befatal within a few hours of the first symptoms. Page | 5
  6. 6. Symptoms: Anemia Bloody stools Figure 2: Symptoms of Malaria Chills Coma Convulsion Fever Figure 3: Transfusing a child with severe anaemia due to Malaria Headache Jaundice Muscle pain Nausea Sweating Vomiting Figure 4: A patient suffering from jaundice due to severe malaria. Page | 6
  7. 7. Diagnosis and tests:In order to make a malaria diagnosis, the healthcare provider may ask a number of questionsconcerning: Current symptoms Medical conditions Family medical history Current medications Recent travel history.The healthcare provider will also likely perform a physical exam, looking for signs or symptomsof malaria. He or she may also order certain tests to help in diagnosing malaria or anothercondition.The doctor may suspect malaria based on the patients symptoms, and the physical findingsat examination; however, to make a definitive diagnosis of malaria, laboratory tests mustdemonstrate the malaria parasites, or their components.The best test available to diagnose malaria is called a bloodsmear. In this test, malaria parasites can be identified byexamining a drop of the patients blood under the microscope,spread out as a "blood smear" on a microscope slide. Prior toexamination, the specimen (blood) is stained to give to theparasites a distinctive appearance.There are other blood tests available that may be used alongwith a blood smear to confirm a malaria diagnosis. Figure 5: Blood smear testA malaria diagnosis can be difficult to make, especially in areas where malaria is not verycommon. A number of other conditions share similar symptoms with malaria. Some of theseconditions the healthcare provider will consider before diagnosing malaria include: Page | 7
  8. 8. The flu (influenza) Common cold Meningitis Typhoid fever Dengue fever Acute schistosomiasis (disease caused by worms) Bacteremia/septicemia (infection in blood) Hepatitis Viral gastroenteritis (stomach flu) Yellow fever (disease typically transmitted by mosquitoes).Complications:Malaria can be fatal, particularly the variety thats common in tropical parts of Africa. TheCenters for Disease Control and Prevention estimate that 90 percent of all malaria deaths occurin Africa — most commonly in children under the age of 5.In most cases, malaria deaths are related to one or more of these serious complications:Cerebral malaria. If parasite-filled blood cells block small blood vessels to your brain (cerebralmalaria), swelling of your brain or brain damage may occur.Breathing problems. Accumulated fluid in your lungs (pulmonary edema) can make it difficultto breathe.Organ failure. Malaria can cause your kidneys or liver to fail, or your spleen to rupture. Any ofthese conditions can be life-threatening.Severe anemia. Malaria damages red blood cells, which can result in severe anemia.Low blood sugar. Severe forms of malaria itself can cause low blood sugar, as can quinine —one of the most common medications used to combat malaria. Very low blood sugar can resultin coma or death.Recurrence may occurSome varieties of the malaria parasite, which typically cause milder forms of the disease, canpersist for years and cause relapses. Page | 8
  9. 9. Table 1: Indicators of severe malaria and poor prognosis [1,3-5]Manifestation FeaturesInitial World Health Organization criteria from 1990 [3]1. Cerebral malaria: Unarousable coma not attributable to any other cause, with a Glasgow Coma Scale score ≤9; Coma should persist for at least 30 min after a generalized convulsion2. Severe anemia Hematocrit <15% or hemoglobin < 50 g/l in the presence of parasite count >10000/µl3. Renal failure Urine output <400 ml/24 hours in adults (<12 ml/kg/24 hours in children) and a serum creatinine >265 µmol/l (> 3.0 mg/dl) despite adequate volume repletion4. Metabolic (Lactic) Metabolic acidosis is defined by an arterial blood pH of <7.35Acidosis/acidosis with a plasma bicarbonate concentration of <22 mmol/L; hyperlactatemia is defined as a plasma lactate concentration of 2-5 mmol/L and lactic acidosis is characterized by a pH <7.25 and a plasma lactate >5 mmol/L.5. Pulmonary edema or acute Breathlessness, bilateral crackles, and other features ofrespiratory distress syndrome pulmonary oedema. The acute lung injury score is calculated on(ARDS) the basis of radiographic densities, severity of hypoxemia, and positive end-expiratory pressure6. Hypoglycemia Whole blood glucose concentration of less than 2.2 mmol/l (less than 40 mg/dl).7. Hypotension and shock Systolic blood pressure <50 mmHg in children 1-5 years or <70(algid malaria) mm Hg in patients ≥5 years; cold and clammy skin or a core-skin temperature difference >100C8. Abnormal bleeding and/or Spontaneous bleeding from the gums, nose, gastrointestinaldisseminated intavascular tract, retinal haemorrhages and/or laboratory evidence ofcoagulation disseminated intravascular coagulation. Page | 9
  10. 10. 9. Repeated generalised ≥3 generalized seizures within 24 hoursconvulsions10. Haemoglobinuria Macroscopic black, brown or red urine; not associated with effects of oxidant drugs or enzyme defects (like G6PD deficiency)Added World Health Organization criteria from 2000 [4]11. Impaired consciousness Various levels of impairment may indicate severe infection although not falling into the definition of cerebral malaria. These patients are generally arousable12. Prostration Extreme weakness, needs support13. Hyperparasitemia 5% parasitized erythrocytes or > 250 000 parasites/µl (in nonimmune individuals)14. Hyperpyrexia Core body temperature above 400C15. Jaundice Serum bilirubin of more than 43m mol/l (2.5 mg/dl).(Hyperbilirubinemia)Other16. Fluid and electrolyte Dehydration, postural hypotension, clinical evidence ofdisturbances [5] hypovolemia17. Vomiting of oral drugs Patients with persistent vomiting may have to be admitted for parenteral therapy.18. Complicating or associated Aspiration bronchopneumonia, septicemia, urinary tractinfections infection etc.19. Other indicators of poor Leukocyte count >12,000/cumm; high CSF lactate (>6prognosis [5] mmol/l)and low CSF glucose; more than 3-fold elevation of serum enzymes (aminotransferases); increased plasma 5- nucleotidase; low antithrombin III levels; peripheral schizontemia; papilloedema/retinal oedema Page | 10
  11. 11. 20. Malarial Retinopathy A large, prospective autopsy study of children dying with cerebral malaria in Malawi found malarial retinopathy to be a better indicator of malarial coma. Similar retinopathy in an adult has also been reported.Malaria situation in Bangladesh:Malaria has been a major public health problem in Bangladesh. Approximately 33.6% of thetotal population are at risk of malaria Majority of malaria cases are reported from 13 out ofthe total 64 districts in the country. About 4 million populations living in 34 upazillas of eightof the thirteen districts live in the epidemic-prone border areas. Focal outbreaks occur everyyear, and the response to control the epidemic is inadequate. Malaria cases are grosslyunder-reported due to shortcomings in surveillance and information.Country is reporting on average 50,000 confirmed malaria cases with around 70% of Pf cases(killer malaria) and 450 malaria deaths annually. The case finding is very poor and <2%population at risk of malaria screened every year. In 2008-09, with the help of Global fundsenhanced surveillance and case finding activities including vector control through bednets andtreatment through ACTsresulted in a increase in labconfirmed cases and significantdecrease in malaria deaths. Country did not reaport anyprobable malaria case in 2009.Programme is promoting LLINs& ITNs amongst the communityas a vector control measure inthese areas which has increasedtremendously in last few years. Figure 6: : Trends of confirmed malaria cases in Bangladesh, 1970-2009Total 2.57 million bednets (LLINS+ ITNs) were distributed and 6.42 million people are covered by it. However, it’s coverage inhigh endemic districts ranges between 40% to 63%. Page | 11
  12. 12. Figure 7: Distribution of ACT and Number of malaria deaths in Bangladesh, 2005-2009Figure 8: 2Cumulative availability of effective LLINs & ITNs in Bangladesh, 2005-2009 Total financing for malaria in 2009 was approximately US$ 9.5 million, the main sources being the Government (US$ 555 000), the Global Fund (US$ 7.7 million), the World Bank (US$ 890 000) and WHO (US$ 230 000). Figure 9: Availability of funds by Source in Bangladesh, 2006-2009 Page | 12
  13. 13. Pogramme Goals and Targets:To reduce malaria morbidity and mortality until the disease is no longer a public healthproblem in the country. Targets Baseline data 2010 in 2005 To provide early diagnosis and prompt treatment (EDPT) 40% 80% with effective drugs to 80% of malaria patients To provide effective malaria prevention to 80% of 24% 80% population at risk To strengthen malaria epidemiological surveillance 60% 100% system To establish Rapid Response Team (RRT) at national and 80% 100% district levels and increase preparedness and response capacity for containment of outbreaks To promote community participation, and strengthen 25% 80% partnership with private sector and NGOs for malaria controlControl strategy: Malaria control activities are integrated with the general health services Active Case Detection (ACD) and Passive Case Detection (PCD) with laboratory diagnosis Prompt treatment Case management of severe malaria and complicated cases in hospital. Vector control minimal, no IRS with DDT since 1993. SEAR working group recommendation on revised control strategy has been adopted Due to spread of chloroquine resistance, drug regimen has been revised and COARTEM has been introduced by programme Strengthening programme management is of high priorityBest practices and success stories Establishment of partnership with NGO consortium. Promotion and use of ITNs/LLINs Quality diagnosis using RDT and effective treatment using ACTs Page | 13
  14. 14. Issues and Challenges: Inadequate access to treatment and diagnostic facilities especially in the remote areas Inadequate programme management capacity at various level and management of severe malaria in hospitals Poor coverage of prevention and control methods (IRS, ITN/LLIN coverage still low) in the community Referral system is weak and pre-referral treatment provisions are limited; Optimum treatment of cases of severe malaria in different categories of hospitals are inadequate Cross-border malaria at the Bangladesh India and Ban- Myanmar borderPartners and donors WHO World Bank Global fund BRAC and 14 member NGO Consortium 4 Local NGOs in Chittagong Hill Tract (CHT) Page | 14
  15. 15. Treatments:Preventing malaria - four stepsThere is an ABCD for prevention of malaria. This is: Awareness of risk of malaria. Bite prevention. Chemoprophylaxis (taking antimalarial medication exactly as prescribed). Prompt Diagnosis and treatment.Awareness of the risk of malaria:The risk varies between countries and the type of trip. For example, back-packing or travellingto rural areas is generally more risky than staying in urban hotels. In some countries the riskvaries between seasons - malaria is more common in the wet season. The main type of parasite,and the amount of resistance to medication, varies in different countries. Although risk varies,all travellers to malaria-risk countries should take precautions to prevent malaria.The mosquitoes which transmit malaria commonly fly from dusk to dawn and thereforeevenings and nights are the most dangerous time for transmission.Bite prevention:We can an effective insect repellent to clothing and any exposed skin. Diethyltoluamide (DEET)is safe and the most effective insect repellent and can be sprayed on to clothes. It lasts up tothree hours for 20%, up to six hours for 30% and up to 12 hours for 50% DEET. There is nofurther increase in duration of protection beyond a concentration of 50%. When bothsunscreen and DEET are required, DEET should be applied after the sunscreen has been applied.DEET can be used on babies and children over two months of age. In addition, DEET can beused, in a concentration of up to 50%, if anyone is pregnant. It is also safe to use if you arebreast-feeding.If we sleep outdoors or in an unscreened room, we should use mosquito nets impregnated withan insecticide (such as pyrethroid). The net should be long enough to fall to the floor all roundyour bed and be tucked under the mattress. We should check the net regularly for holes. Netsneed to be re-impregnated with insecticide every six to twelve months (depending on howfrequently the net is washed) to remain effective. Long-lasting nets, in which the pyrethroid isincorporated into the material of the net itself, are now available and can last up to five years.If practical, we should try to cover up bare areas with long-sleeved, loose-fitting clothing, longtrousers and socks - if we are outside after sunset - to reduce the risk of mosquitoes biting.Clothing may be sprayed or impregnated with permethrin, which reduces the risk of beingbitten through our clothes. Page | 15
  16. 16. Sleeping in an air-conditioned room reduces the likelihood of mosquito bites, due to the roomtemperature being lowered. Doors, windows and other possible mosquito entry routes tosleeping accommodation should be screened with fine mesh netting. we should spray the roombefore dusk with an insecticide (usually a pyrethroid) to kill any mosquitoes that may havecome into the room during the day. If electricity is available, we should use an electricallyheated device to vaporize a tablet containing a synthetic pyrethroid in the room during thenight. The burning of a mosquito coil is not as effective.Herbal remedies have not been tested for their ability to prevent or treat malaria and aretherefore not recommended. Likewise, there is no scientific proof that homoeopathic remediesare effective in either preventing or treating malaria, and they are also not recommended.Antimalarial medication (chemoprophylaxis):Antimalarial medication helps to prevent malaria. The best medication to take depends on thecountry you visit. This is because the type of parasite varies between different parts of theworld. Also, in some areas the parasite has become resistant to certain medicines.There is a possibility of antimalarials that we may buy in the tropics or over the Internet, beingfake. It is therefore recommended that we obtain our antimalarial treatment from our doctorssurgery, a pharmacist or a travel clinic. Medications to protect against malaria are not fundedby the NHS. We will need to buy them, regardless of where we obtain them.The type of medication advised will depend upon the area you are travelling to. It will alsodepend on any health problems we have, any medication you are currently taking, the length ofour stay, and also any problems we may have had with antimalarial medication in the past.We should seek advice for each new trip abroad. Do not assume that the medication that wetook for your last trip will be advised for your next trip, even to the same country. There is achanging pattern of resistance to some medicines by the parasites. Doctors, nurses,pharmacists and travel clinics are updated regularly on the best medication to take for eachcountry.We must take the medication exactly as advised. This usually involves starting the medicationup to a week or more before you go on your trip. This allows the level of medicine in our bodyto become effective. It also gives time to check for any side-effects before travelling. It is alsoessential that we continue taking the medication for the correct time advised after returning toour home (often for four weeks). The most common reason for malaria to develop in travellersis because the antimalarial medication is not taken correctly. For example, some doses may bemissed or forgotten, or the tablets may be stopped too soon after returning from the journey. Page | 16
  17. 17. Symptoms of malaria (to help with prompt diagnosis):Symptoms are similar to flu. They include fever, shivers, sweating, backache, joint pains,headache, vomiting, diarrhoea and sometimes delirium. These symptoms may take a week ormore to develop after you have been bitten by a mosquito. Occasionally, it takes a year forsymptoms to develop.This means that we should suspect malaria in anyone with a feverish illness who has travelledto a malaria-risk area within the past year, especially in the previous three months.Special situations: Pregnant women are at particular risk of severe malaria and should, ideally, not go to malaria-risk areas. Full discussion with a doctor is advisable if you are pregnant and intend to travel. Most antimalarial medications are thought to be safe to the unborn child. Some, such as mefloquine, should be avoided in the first twelve weeks of pregnancy. Non-pregnant women taking mefloquine should avoid becoming pregnant. You should continue with contraception for three months after the last dose. If you are given doxycycline and are also taking the combined oral contraceptive pill (COCP) or using the patch, then you should use alternative contraception for the first three weeks of taking the doxycycline. This is because doxycycline may interfere with the effectiveness of the COCP (or patch). After three weeks you will not need to use any additional contraception. If you have epilepsy, kidney failure, some forms of mental illness, and some other uncommon illnesses, you may have a restricted choice of antimalarial medication. This may be due to your condition, or to possible interactions with other medication that we may be taking. If we do not have a spleen (if you have had it removed) or our spleen does not work well, then we have a particularly high risk of developing severe malaria. Ideally, we should not travel to a malaria-risk country. However, if travel is essential, every effort should be made to avoid infection and we should be very strict about taking our antimalarial medication. Travellers going to remote places far from medical facilities sometimes take emergency medication with them. This can be used to treat suspected malaria until proper medical care is available. Page | 17
  18. 18. References: Page | 18