This document provides information about malaria, including: - Malaria is caused by Plasmodium parasites and transmitted via mosquito bites. P. falciparum and P. vivax are most common in India. - Globally there were 219 million malaria cases in 2017, most in Africa. India had 844,558 cases in 2017, with P. falciparum causing 62.7% and 194 deaths. - Malaria signs and symptoms include fever, chills, headaches and more. Microscopy and rapid diagnostic tests are used to diagnose. Severe malaria involves impaired consciousness, respiratory distress and other dangerous complications. - Treatment depends on the Plasmodium species and severity.

1. Dr. Arkadeb Kar 1

2. Malaria
Dr. Arkadeb Kar 2

3. What is Malaria?
• Potentially life threatening parasitic disease
• Agent : P.vivax/falciparum/malariae/ovale/knowlesi
• P.vivax and P.falciparum commonly reported from India
• Transmitted by bite of infected female anopheline mosquitoes
• Man develops disease after 10-14 days of being bitten
Dr. Arkadeb Kar 3

4. Global scenario
• Total number of cases – 219 million
• Most malaria cases in 2017 were in the WHO African Region (200 million
or 92%), followed by the WHO South-East Asia Region
• The incidence rate of malaria - 59 cases per 1000 population at risk
• Plasmodium falciparum is the most prevalent malaria parasite in the WHO
African Region, accounting for 99.7% of estimated malaria cases in 2017,
as well as in the WHO regions of South-East Asia (62.8%)
• In 2017, there were an estimated 435 000 deaths from malaria globally
Dr. Arkadeb Kar 4

5. Indian scenario (2017)
• Total number of cases – 8,44, 558
• P. falciparum – 62.7%
• API – 0.64
• Deaths – 194
• ABER – 9.58
• SPR – 0.67
Dr. Arkadeb Kar 5

6. Indicators of Malaria:( 1/2)
• ABER=( No. of slide examined+ RDK Tested)X100
Population under surveillance
• API= (No. of Slide positive+ RDK positive)X1000
Population under surveillance
• TPR= (No. of slide positive+ RDK positive)X100
No. of slide examined+ RDK Tested
Dr. Arkadeb Kar 6

7. Indicators of Malaria: ( 2/2)
• Pf%= (No. pf. Positive in slide+ RDK positive)X100
No. of total positive in slide +RDK positive
• TFR= (No. of Pf positive in slide +RDK positive )X100
No Slide examined + RDK Tested
Dr. Arkadeb Kar 7

8. Agent factor
• Agent –
P. vivax
P. falciparum
P. malariae
P. ovale
Dr. Arkadeb Kar 8

9. Lifecycle of the malaria parasite
Dr. Arkadeb Kar 9

10. • Reservoir of infection – a human reservoir is one who harbours the sexual forms
of the parasite
• Criteria –
i. Must have gametocyte of both sexes
ii. The gametocytes must be mature
iii. They must be viable
iv. Gametocytes must be present in sufficient density
• Period of communicability –
As long as mature viable erythrocytes exist in circulation
Vivax gametocytes appear in blood after 4 – 5 days
Falciparum gametocytes appear in blood after 10 – 12 days
Dr. Arkadeb Kar 10

11. • Relapse –
• In case of vivax and ovale – sporozoite induced, liver schizonts
• In case of falciparum and malariae – low level persisting
erythrocyte schizogony
Dr. Arkadeb Kar 11

12. Host
1. Age – new born infants resistant to falciparum
2. Sex – male are more prone due to lifestyle
3. Race – sickle cell trait – milder falciparum, duffy negative – resistant to vivax
4. Pregnancy – increase chances of IUFD, abortion, premature labour
5. Socio-economic status
6. Housing
7. Population mobility
8. Occupation
9. Habits
10. Immunity
Dr. Arkadeb Kar 12

13. Environment
• Season – July to November
• Temperature – 20℃ - 30℃, <16℃ no development, >30℃ lethal
• Humidity – 60%
• Rainfall – increases humidity, provides breeding places
• Altitude – anophelines not found above 2000 – 2500 meters
• Man-made malaria
Dr. Arkadeb Kar 13

14. Vector
• Anopheles culicifacies – rural and peri-urban area
• An. stephensi – urban and industrial area
• An. fluviatilis – hilly areas, forests and forest fringes
• An. minimus – foot-hills of North-Eastern states
• An. dirus – forest vector in North-East
• An. epiroticus – Andaman and Nicobar
Dr. Arkadeb Kar 14

15. • Density – there is a critical density, below which effective transmission can not occur
• Life span – vector must live 10-12 days after infective blood meal, before which it can
become infective
• Choice of host – some prefer human blood, some animal blood
• Resting habits – Rests during daytime
• endophily – rests on indoor walls after meal
• exophily – rest outdoors
• Breeding habits - Breeds in rainwater pools and puddles, borrowpits, river bed pools,
irrigation channels, seepages, rice fields, wells, pond margins, sluggish streams with sandy
margins.
Extensive breeding is generally encountered following monsoon rains
Dr. Arkadeb Kar 15

16. • Time of biting – nocturnal, between dusk and dawn
• Vectorial capacity – it is the combined effect of the density of the vector,
susceptibility to infection, life span and probability of feeding on man.
Incubation period
12 (9 – 14) days for falciparum malaria
14 (8-17) days for vivax malaria
28 (18-40) days for quartan malaria
14 (16-18) days for ovale malaria
Dr. Arkadeb Kar 16

17. Mode of transmission
• Vector transmission
• Direct transmission – blood transfusion, hypodermic needles
• Congenital malaria – rare
Dr. Arkadeb Kar 17

18. Clinical features
• Fever – intermittent or continuous ± chill and rigors
• Accompanied by -
headache,
myalgia,
arthralgia,
anorexia,
nausea and vomiting
• All clinically suspected malaria cases should be investigated
immediately by microscopy and/or Rapid Diagnostic Test (RDT)
Dr. Arkadeb Kar 18

19. Diagnosis
• Microscopy – gold standard
Thick slide – for finding parasite
Thin slide – for identifying parasite species
• Advantages –
• high sensitivity
• Quantify parasite load
• Can distinguish between different species and different stages of parasite
Dr. Arkadeb Kar 19

20. Diagnosis of severe malaria cases negative on
microscopy
• Microscopic evidence may be negative for asexual parasites in patients
with severe infections due to sequestration and partial treatment.
• These cases should be confirmed by RDT or repeat microscopy.
• However, if clinical presentation indicates severe malaria and there is
no alternative explanation, these patients should be treated
accordingly.
Dr. Arkadeb Kar 20

21. • Rapid diagnostic tests (RDT) - The NVBDCP has rolled out bivalent
RDTs.
Pf HRP-2 based kits may show positive result up to three weeks after
successful treatment and parasite clearance.
In these cases, results should be correlated with microscopic diagnosis.
Dr. Arkadeb Kar 21

22. Algorithm for diagnosis and treatment
Dr. Arkadeb Kar 22

23. Where microscopy result is not available within
same day and Bivalent RDT isused
Dr. Arkadeb Kar 23

24. Treatment of Vivax Malaria
Dr. Arkadeb Kar 24

25. • CQ (chloroquine) 250mg tablet contains 150mg base.
• PQ (primaquine) is contraindicated in pregnant women, infants and individuals
with known G6PD deficiency.
• Test for G6PD level is not mandatory for giving PQ to a patient.
• Patients should be instructed to report back in case of hematuria or high colored
urine/cyanosis or blue coloration of lips and Primaquine should be stopped in
such cases. Care should be taken in patients with anaemia.
• CQ & PQ should be taken after a meal and not on an empty stomach.
Dr. Arkadeb Kar 25

26. Treatment of uncomplicated P. falciparum
cases :
Dr. Arkadeb Kar 26

27. Treatment of uncomplicated P. falciparum
cases in pregnancy
• 1st trimester : Quinine salt 10mg/kg 3 times daily for 7days.
• May induce hypoglycemia – should not be taken in empty stomach.
• In severe malaria in first trimester of pregnancy, parenteral
quinine is the drug of choice.
• If quinine is not available, artemisinin derivatives may be given to
save the life of mother.
Dr. Arkadeb Kar 27

28. • 2nd and 3rd trimester: ACT-SP.
• Primaquine is contraindicated in pregnancy.
• In severe malaria during second or third trimester, parenteral
artemisinin derivatives are preferred.
Dr. Arkadeb Kar 28

29. Treatment of mixed infections
• Mixed infections should be treated with full course of ACT (like
falciparum malaria) and Primaquine 0.25mg per kg body weight daily
for 14 days (like vivax malaria).
Dr. Arkadeb Kar 29

30. Severe malaria: clinical features
• Impaired consciousness/coma [A Glasgow coma score <11 in adults or a
Blantyre coma score <3 in children.]
• Repeated generalized convulsions [ >2 episodes within 24 hours]
• Prostration: Generalized weakness
• Renal failure (Serum Creatinine >3 mg/dl.)
• Jaundice (Serum Bilirubin >3 mg/dl)
• Severe anaemia (Hb <5 g/dl)
Dr. Arkadeb Kar 30

31. Severe malaria: clinical features
• Pulmonary oedema/acute respiratory distress syndrome [Radiologically
confirmed or oxygen saturation <92% in room air with a respiratory rate >30/min,
often with chest in drawing and crepitations on auscultation.]
• Hypoglycaemia - Plasma Glucose <40 mg/dl
• Metabolic acidosis - A base deficit of >8 mEq/L or, if not available, a plasma
bicarbonate level of <15 mmol/L or venous plasma lactate of <15 mmol/L. Severe
acidosis manifests clinically as respiratory distress (rapid, deep, labored
breathing).
Dr. Arkadeb Kar 31

32. Severe malaria: clinical features
• Circulatory collapse/shock - Systolic BP <80 mm Hg, <50 mm Hg in children
with evidence of impaired perfusion (cold peripheries or prolonged capillary refill)
• Abnormal bleeding and Disseminated intravascular coagulation (DIC)
Significant bleeding including recurrent or prolonged bleeding from the nose,
gums or venepuncture sites; hematemesis or melaena.
• Haemoglobinuria
• Hyperpyrexia (Temperature >106°F or >42°C)
• Hyperparasitaemia (>5% parasitized RBCs ).
Dr. Arkadeb Kar 32

33. Antimalarials for severe malaria cases:
One of the following four treatments Follow-up treatment, when patient can take oral
medication following parenteral Rx
Artesunate: 2.4 mg/kg i.v. or i.m. given on
admission (time=0), then at 12 hr and 24 hr,
then once a day
Full oral course of Area-specific ACT is to be given after
parenteral therapy.
Treat with ACT-SP for 3 days+PQ single dose
Artemether: 3.2mg/kg bw i.m. given on
admission, then1.6mg/kg per day
Arteether: 150mg daily i.m. for 3 days in adults
only (not recommended for children).
Quinine : 20mg quininine salt per kg body weight
on admission (IV infusion or divided IM injection);
then maintanace dose of 10mg/kg 8 hourly. Infusion
rate upto 5mg/kg per hour. If patient has already
received quinine loading dose should not be given
10mg/kg orally three times a day with doxycycline100mg
once a day or clindamycin.
(Doxycycline is contraindicated in pregnant & lactating
women and children< 8 years of age)
Complete 7 days of treatment.
Dr. Arkadeb Kar 33

34. • The parenteral treatment in severe malaria cases should be given for minimum of
24 hours once started, irrespective of patient’s ability to take oral medication
earlier than 24 hour. [In parenteral treatment with quinine it should be minimum 48
hours].
• Each dose of parenteral quinine must be administered as a slow, rate-controlled
infusion (usually diluted in 5% dextrose and infused over 4 hr).
• If intramuscular quinine is to be given, give it to anterior thigh; and should not
be given in buttock in order to avoid sciatic nerve injury. The first dose should be
split, with 10mg/ kg into each thigh.
Dr. Arkadeb Kar 34

35. Treatment of patients co-infected with HIV:
• In people who have HIV/ AIDS and uncomplicated P. falciparum
malaria –
avoid artesunate + SP if they are being treated with co-trimoxazole.
avoid artesunate + amodiaquine if they are being treated with efavirenz or
zidovudine
Dr. Arkadeb Kar 35

36. Additional consideration for clinical
management:
• Antipyretics: Antipyretics should be used if the core temperature is > 38.5℃.
Paracetamol at a dose of 15 mg/kg every 4 hr.
• Anti-emetics: Antiemetics like domperidone or 5 HT3 antagonists like ondansetron
• Management of seizures: If the seizure continues, the airways should be maintained and
anticonvulsants given (inj valproate @20 mg/kg loading followed by maintenance @ 10
mg/kg 12 hrly).
There is no evidence that prophylactic anticonvulsants are beneficial.
• Fluid therapy
Dr. Arkadeb Kar 36

37. • Pre-referral treatment options
• Where complete treatment of severe malaria is not possible but injections are
available, give adults and children a single dose of artesunate injection and
then refer to an appropriate facility for further care.
Dr. Arkadeb Kar 37

38. Initiation of treatment and advice to the
patient/caretaker
• Once a suspected case is diagnosed positive by RDT or microscopy, treatment is started.
The first dose is always taken in the presence of the health volunteer/worker.
• Caretakers are informed that
If the treatment is not completed as prescribed, the disease may manifest again with more
serious features and may be more difficult to treat.
To come back immediately, if there is no improvement after 24 hours, if the situation gets
worse or the fever comes back.
That regular use of a mosquito net (preferably insecticide treated net) is the best way to
prevent malaria.
Dr. Arkadeb Kar 38

39. • If the patient is a child under 5 years or pregnant,
Ask the patient to wait for 15 minutes after taking the first dose.
If it is vomited within this period, let the patient rest for 15 minutes, and then
give the first dose again i.e. open a new blister-pack and discard what remains
of the old.
 If the patient vomits the first dose again, it is considered a case of severe
malaria, refer the patient immediately to the nearest Block PHC/ RH/Hospital
Dr. Arkadeb Kar 39

40. General recommendations for the management of
uncomplicated malaria
• Avoid starting treatment on an empty stomach. The first dose should be given
under observation.
• Dose should be repeated if vomiting occurs within half an hour of antimalarial
intake after antiemetics.
• The patient should be asked to report back, if there is no improvement after 48
hours or if the situation deteriorates.
• The patient should also be examined and investigated for concomitant illnesses.
Dr. Arkadeb Kar 40

41. Don’ts in severe malaria :
• Do not use
adrenaline·
corticosteroids·
intravenous mannitol·
heparin (as anticoagulant)
• Do not overhydrate the patient.
Dr. Arkadeb Kar 41

42. • MONOTHERAPY OF ORAL ARTEMISININ DERIVATIVES IS BANNED
IN INDIA
Injectable artemisinin derivatives should be used only in severe malaria,
followed by oral combination therapy.
• The presently recommended ACT for the North-Eastern States is fixed
dose combination of Artemether-Lumefantrine (AL).
• Adult dose: 4 tablets twice daily for 3 days (80 mg/ 480 mg per dose).
It may be required in case of malaria imported from the NE
States.
Dr. Arkadeb Kar 42

43. • In a case of uncomplicated falciparum malaria, resistance should be
suspected
If in spite of full treatment with no history of vomiting or diarrhoea, patient
does not respond within 72 hours, clinically and parasitologically;
If danger signs of severe malaria develops even after one day of therapy.
Such cases not responding to ACT, should be treated with oral quinine with
Tetracycline / Doxycycline, or in the line of severe Malaria if signs of severe
Malaria have appeared.
These instances should be reported to the concerned Dy.CMOH-II / DDHS
(Malaria).
Dr. Arkadeb Kar 43

44. Guideline for administration of injectable
Artesunate for Severe Malaria
Dr. Arkadeb Kar 44

45. Dr. Arkadeb Kar 45

46. Dr. Arkadeb Kar 46

47. Dr. Arkadeb Kar 47

48. Dr. Arkadeb Kar 48

49. Dr. Arkadeb Kar 49

50. Chemoprophylaxis
• Recommended for travellers from non-endemic areas.
• Use of personal protection measures including Insecticide Treated bed Nets
(ITN) / Long Lasting Insecticidal Nets (LLIN) should be encouraged for
pregnant women and other vulnerable population including travelers for
longer stay.
• For longer stay of Military and Para-military forces in high Pf endemic
areas, the practice of chemoprophylaxis should be followed wherever
appropriate
Dr. Arkadeb Kar 50

51. • Short term chemoprophylaxis (up to 6 weeks)
Doxycycline: 100 mg once daily for adults and 1.5 mg/kg once daily for children
(contraindicated in children below 8 years).
 Should be started 2 days before travel and continued for 4 weeks after leaving the area.
It is not recommended for pregnant women and children less than 8 years.
• Chemoprophylaxis for longer stay (more than 6 weeks)
Mefloquine: 250 mg weekly for adults and should be administered two weeks before,
during and four weeks after exposure.
Mefloquine is contraindicated in individuals with history of convulsions, neuropsychiatric
problems and cardiac conditions.
Dr. Arkadeb Kar 51

52. Strategies for malaria elimination
• Early diagnosis and treatment
• Case based surveillance
• Integrated vector management
• Epidemic preparedness and early response
• Supportive interventions
• Capacity building
• BCC
• Monitoring and evaluation
Dr. Arkadeb Kar 52

53. Surveillance
• Based on active case detection (ACD) and passive case detection (PCD)
• ACD is carried out by trained community level health care workers
(MPHW/ANM) through fortnightly house-to-house visits and testing people
with current or recent fever and chills in past 14 days with bivalent antigen
detecting RDTs
• PCD is the detection of malaria cases among people who go at their own
initiative to a health facility (subcentre, PHC etc.) to get treatment.
Dr. Arkadeb Kar 54

54. Integrated vector management
• To control adult mosquitoes – indoor residual spray – primary method of vector
control in rural settings.
 IRS should aim at a coverage of minimum 80% of targeted households
The insecticides used are DDT, Malathion and a range of synthetic pyrethroids
Two rounds of spraying are done for DDT and synthetic pyrethroids and three
rounds of Malathion during the entire transmission season
• Limitations – low acceptance due to white marks on walls, acrid smell of
malathion
Dr. Arkadeb Kar 55

55. Integrated vector management
 Personal protection – Insecticide Treated bed Nets (ITN) / Long Lasting Insecticidal
Nets (LLIN)
Areas with API > 5 is to be covered by LLINs
Areas with API ≥ 2 covered with conventional nets treated with insecticides and IRS
For areas with API between 2 to 5 are covered conventional nets treated with insecticides
Universal coverage with LLINs of all subcentres with API > 1
In subcentres with API >1, if not covered with LLIN, two regular rounds of supervised
IRS
Dr. Arkadeb Kar 56

56. • Antilarval measures – primary method in urban areas.
Habitat modification - permanent alteration to the environment, including
landscaping, surface water drainage, filling and land reclamation, coverage of
water storage containers with mosquito-proof lids or permanent slabs and
coverage of the water surface with a material impenetrable to mosquitoes
Habitat manipulation - recurrent activity including water level manipulation
(e.g. stream flushing, keeping drains clear of vegetation so that water can flow
too fast to support mosquitoes)
Dr. Arkadeb Kar 57

57. • Larviciding is the regular application of biological or chemical insecticides to
water bodies.
Used only as a supplement to IRS or LLINs
Chemicals such as Temephos is used for polluted and non-polluted water
bodies mainly in urban areas
• Biological control is the introduction of natural predators into water bodies.
In some urban areas larvivorous fish like Gambusia and Guppy are also used
in certain situations where the chemical control is not feasible.
 Biological larvicide, Bacillus thuringiensis israelensis either wettable powder
or aqueous suspension are also used
Dr. Arkadeb Kar 58

58. Epidemic preparedness and early response
• If there is a suspicion of malaria outbreak –
Conduct a rapid fever survey by blood smear examination / RDTs
Compare the TPR obtained in the rapid fever survey and TPR of the current month to
the TPR of the corresponding month of previous year
Compare the current year’s month-wise malaria incidence to that of preceding three
years.
Collect information on epidemic supportive factors like climatic conditions,
vulnerability, receptivity, vector density, etc
An outbreak/epidemic is confirmed if there is doubling or > 5% increase in TPR in
period under investigation compared to corresponding period of previous year
Dr. Arkadeb Kar 59

59. Control of epidemic
• Delineation of the affected area
• Estimation of the population involved
• Anti-vector measures –
• Indoor space spray with pyrethrum for 7 to 10 consecutive days, preferably in early
morning or evening hours
• IRS should be started simultaneously
• Follow up
Close surveillance for 1 month
Strengthening of case detection and treatment services
Dr. Arkadeb Kar 60

60. Behaviour change communication
1. Early recognitions of signs and symptoms of malaria
2. Early treatment seeking from appropriate provider
3. Adherence to treatment regimes
4. Ensuring protection of children and pregnant women
5. Use of ITNs / LLINs
6. Acceptance of IRS
Dr. Arkadeb Kar 61