Malaria is a mosquito-borne parasitic disease caused by Plasmodium parasites. It affects over 100 tropical and subtropical countries and puts hundreds of millions at risk each year, killing over 1 million people annually, primarily young children and pregnant women in sub-Saharan Africa. It is transmitted via the bites of infected female Anopheles mosquitoes. Symptoms vary depending on the Plasmodium species but can include fever, chills, sweats, headaches and anemia. Diagnosis involves blood smears while treatment focuses on antimalarial drugs. Prevention centers around vector control and the use of mosquito nets, repellents and chemoprophylaxis.

1. Dr. Sudhir Dev
Dept. G.P and Emergency Medicine
BPKIHS

2. What does Malaria mean?

The word “malaria” comes from the Italian
mala aria, meaning “bad air.” When the term
was coined, it was commonly believed that
malaria was caused by breathing in bad air.

3. Overview

 Malaria is a mosquito-borne parasitic disease caused
by genus Plasmodium, affecting over 100 countries
of the tropical and subtropical regions of the world.
 Around 400-900 million people are affected
 At least 2.7 million deaths annually.
 It is one of the major public health concerns

4. Epidemiology

 Around 300-500 million clinical cases of malaria are
reported every year, of which more than a million die of
severe and complicated cases of malaria.
 Malaria is known to kill one child every 30 sec, 3000
children per day under the age of 5 years.
 Malaria ranks third among the major infectious diseases
in causing deaths after pneumococcal acute respiratory
infections and tuberculosis, and accounts for
approximately 2.6% of the total disease burden of the
world.

5. 

6. Epidemiology (cont.)

 It mainly occurs throughout tropical regions
 515 million clinical cases per year
 An estimated 655,000 people died from malaria in
2010
 with two-thirds of these occurring in sub-Saharan
Africa
 especially amongst children and pregnant women
 the incidence of malaria was greatly reduced
between 1950 and 1960
 but since 1970 there has been resurgence.

7. Who is at Risk?

 Most people who get
malaria are travelers or
people who live in an
area with malaria
transmission.
 Young children and
pregnant women.
 Poor people that live in
rural areas who lack
knowledge, money and
the access to health care.

8. Causative Agent

 Malaria is caused by species of Plasmodium.
 The genus Plasmodium contains over 200 species
 at least 11 species infect humans. Most important are:
 Plasmodium falciparum
 Plasmodium malariae
 Plasmodium ovale
 Plasmodium vivax
 Plasmodium knowlesi
 Plasmodium parasites are highly
specific with female Anopheles mosquitoes

9. Vector

 Female mosquitos of genus Anopheles are primary
hosts and transmission vectors.
 There are approximately 460 recognized species
 Over 100 can transmit human malaria
 Only 30–40 commonly transmit parasites of the
genus Plasmodium
 Anopheles gambiae is one of the best known which
transmits Plasmodium falciparum

10. Vector (cont.)

Only female mosquitoes feed on blood while
the males feed on plant nectar and do not
transmit the disease.
The females of Anopheles genus prefer to
feed at night
They start searching for a meal at dusk and
continue throughout the night until they take
a meal

11. Life Cycle


12. Life Cycle & Pathogenesis

 Inside the vector (sexual reproduction):
 Young female mosquitoes ingest the malaria parasite by
taking a blood meal from an infected human carrier
 The ingested gametocytes will differentiate into male and
female gametes and then unite to form a zygote (ookinete)
in the mosquito’s gut
 The resulting ookinete penetrates the gut lining to form
an oocyst in the gut wall
 The oocyst ruptures to release sporozoites that migrate in
the mosquito’s body to the salivary glands and are ready
to infect new human hosts

13. Life Cycle & Pathogenesis

Inside humans:
 Malaria develops via two phases:
 Exoerythrocytic: involves infection of liver
 Erythrocytic phase: involves infection of RBC
(erythrocytes)

14. Life Cycle & Pathogenesis
 taking a blood meal.
 A mosquito infects a person by
 First, sporozoites enter the bloodstream, and migrate to
the liver. They infect liver cells (hepatocytes), where they
multiply into merozoites, rupture the liver cells, and
escape back into the bloodstream. (Exoerythrocytic phase
 Then, the merozoites infect red blood cells, where they
develop into ring forms, trophozoites and schizonts
which in turn produce further merozoites. (Erythrocytic
phase
 Sexual forms (gametocytes) are also produced, which, if
taken up by a mosquito, will infect the insect and
continue the life cycle.

15. Relationship between life cycle of parasite and
clinical features of malaria
Cycle/ Feature

P. Vivax, P. Ovale P. Malariae P. Falciparum
Pre- Patent Period - 25 days - 30 days -25 days
(minimum
Incubation)
Asexual Cycle hrs synchronous hrs < 48 hrs
synchronous synchronous
Periodicity of Tertian Quartan Aperiodic
Fever
Exo Erythrocytic Persistent as Pre- Erythrocytic Pre- Erythrocytic
cycle hypnozoites only only
Delayed onset Common Rare Rare
Relapses Common upto 2 yrs Recrudescence Recrudescence
many yrs later upto 1year

16. 

17. Clinical Features

 P. Falciparum
 It is the most dangerous of the malarias
 Onset is insidious, with malaise, headache and
vomiting… commonly mistaken for influenza
 The fever has no particular pattern.
 Jaundice is common due to hemolysis & hepatic
dysfunction Hemoglobinuria (blackwater fever), a
darkening of the urine seen with severe RBC hemolysis
 There is hepatosplenomegaly
 Anemia develops rapidly

18. Clinical Features

 P. falciparum complications:
 Cerebral Malaria: the most grave complication, causing either confusion or coma
without localizing signs. Cerebral malaria develops when parasitized red blood cells
(PRBCs) adhere to the cerebral microvasculature, causing blockage of the blood's
pathway This blockage stops blood flow, leading to a shortage of oxygen and
nutrients those areas of the brain. Complications of cerebral malaria include:
 Convulsions
 Hypoglycemia
 Acute pulmonary edema
 Acure renal failure (Blackwater fever )
 Metabolic acidosis
 Aspiration pneumonia
 Severe anemia
 Coagulopathy/Spontaneous bleeding
 These severe manifestations may occur in travelers without immunity or in young
children who live in endemic areas.

19.  Hypoglycemia The aetiology is incompletely understood and is
likely to be multifactorial. Depletion of glucose stores due to
starvation, parasite utilisation of glucose, impairment of
gluconeogenesis have been implicated .
Hyperinsulinaemia, secondary to quinine therapy may cause
hypoglycemia.
 Convulsions: Cerebral hypoxia associated with cerebral
malaria, fever, hypoglycaemia, other metabolic disturbances such as
lactic acidosis and antimalarial drugs
 Pulmonary Edema: Such cases may be due to increased
permeability of pulmonary capillaries. Sequestration of red
cells and obstruction of pulmonary microcirculation and
disseminated intravascular coagulation may also play their
role.
 Coagulopathy May be due to thrombocytopnea. This
abnormality is seen in less than 5% of malaria.(Specially
Falciparum )

20. Clinical Features

 P. vivax & P. Ovale
 In many cases the illness starts with several days of
continued fever before the development of classical
bouts of fever on alternate days. Fever starts with a
rigor. The patient feels cold and the temperature
rises to about 40 C. After an hour hot or flush phase
begins. It lasts several hours and gives way to
profuse perspiration and a gradual fall in
temperature. The cycle is repeated 48 hours later.
 Anemia develops slowly

21. Clinical Features

P. malariae infection
 This is usually associated with mild symptoms and
bouts of fever every third day. Parasitemia may
persist for many years with the occasional recurrence
of fever, or without producing any symptoms.

22. Typical Features

 The characteristic, text-book picture of malarial illness is not
commonly seen. It includes three stages viz. Cold stage, Hot
stage and Sweating stage. The febrile episode starts with
shaking chills, usually at mid-day, and this lasts from 15
minutes to 1 hour (the cold stage), followed by high grade
fever, even reaching above 1060 F, which lasts 2 to 6 hours (the
hot stage). This is followed by profuse sweating and the fever
gradually subsides over 2-4 hours. These typical features are
seen after the infection gets established for about a week.

23. Typical Features

 In vivax malaria, this typical pattern of fever recurs
once every 48 hours and this is called as Benign
Tertian malaria. Similar pattern may be seen in ovale
malaria too (Ovale tertian malaria). In falciparum
infection (Malignant tertian malaria), this pattern may
not be seen often and the paroxysms tend to be more
frequent (Sub-tertian). In P. malariae infection, the
relapses occur once every 72 hours and it is called
Quartan malaria.

24. Typical Features

Temperature observations over four days, showing typical fever patterns in
malaria infection by different Plasmodium species.

25. Atypical Features

 In an endemic area, malaria often presents with atypical
manifestations
 Atypical features are more common in the following situations:
 Falciparum malaria
 Early infection
 Patients at extremes of age
 Patients who are immune-compromised (extremes of
age, malnourished, AIDS, tuberculosis, cancers, on
immunosuppressive therapy etc.)
 Patients on chemoprophylaxis for malaria
 Patients who have had recurrent attacks of malaria
 Patients with end stage organ failure
 Last but not the least, pregnancy.

26. Atypical Features

 Atypical Fever
 Headache, Bodyache and Joint pain
 Dizziness, Vertigo
 Altered Mental Status
 Cough, Chest pain
 Jaundice , Pallor, Puffiness of face
 Abdominal pain, diarrhoea
 Hepatospleenomegaly
 This list is not exhaustive and malaria may present in many other ways. In all the
above listed situations, patients may not have associated fever, thus confusing the
picture. In some, fever may follow these symptoms. Therefore, one should not wait
for the typical symptoms of malaria to get a blood test done; it is always better to
do a smear whenever reasonable doubt exists.

27. Classification:
 Malaria is divided into severe and uncomplicated by the World Health
Organization (WHO). Severe malaria is diagnosed when any of the following
criteria are present, otherwise it is considered uncomplicated.
 Decreased consciousness 
 Significant weakness such that the person is unable to walk
 Inability to feed
 Two or more convulsions
 Low blood pressure (less than 70 mmHg in adults or 50 mmHg
in children)
 Breathing problems
 Circulatory shock
 Kidney failure or hemoglobin in the urine
 Bleeding problems, or hemoglobin less than 5 g/dl
 Pulmonary edema
 Low blood glucose (less than 2.2 mmol/l / 40 mg/dl)
 Acidosis or lactate levels of greater than 5 mmol/l
 A parasite level in the blood of greater than 2%

28. Causes of severe malaria

 P. falciparum-infected erythrocytes sequester in blood
vessels, creating blockages.
 Infected erythrocytes also “stick to
endothelium, platelets, and other erythrocytes”
 Rosetting -- cohesion of erythrocytes
 Leads to immune evasion because of lack of
circulation through the spleen.
 Aids in the progression of the severity of malaria

29. Approach to Patient with Malaria.
 In patients with

suspected malaria, obtaining a
history of recent or remote travel to an endemic area
is critical. Asking explicitly if they traveled to a
tropical area at anytime in their life may enhance
recall. Maintain a high index of suspicion for malaria
in any patient exhibiting any malarial symptoms and
having a history of travel to endemic areas.
 Also determine the patient's immune status, age, and
pregnancy status; allergies or other medical
conditions that he or she may have; and medications
that he or she may be using.

30. Diagnostic Workup
endemic areas, malaria is
 In returning travelers from
suggested by the triad of thrombocytopenia,
elevated lactate dehydrogenase (LDH) levels, and
atypical lymphocytes. These findings should prompt
obtaining malarial smears.
 In general, blood cultures should be drawn in a
febrile patient. Patients from tropical areas may have
more than 1 infection; maintaining a high suspicion
for additional infections should be considered when
patients do not respond to antimalarials.

31. Rapid Test for Malaria with Kits( Optimal)

 Detects circulating
malaria antigens in
whole blood.
 15 minute test
 The only FDA cleared
rapid malaria test.
P. falciparum Sensitivity: 99.7% Specificity: 94.2%*
P. vivax Sensitivity: 93.5% Specificity: 99.8%

32. How the test works?

 The test targets the histidine-rich protein II (HRPII)
antigen specific to P. falciparum and a pan-malarial
antigen (aldolase), common to all four malaria
species capable of infecting humans - P.
falciparum, P. vivax, P. ovale, and P. malariae.
 It is intended to aid in the rapid diagnosis of human
malaria infections and to aid in the differential
diagnosis of Plasmodium falciparum infections from
other less virulent malarial infections. Negative
results must be confirmed by thin / thick smear
microscopy.

33. Other Investigation For Diagnosing Malaria

• Giemsa thick/thin smears GOLD STANDARD
• Density of parasitemia (>3% = inpatient)
• Fluorescent microscopy (QBC Quantitative Buffy Coat (QBC)
Test
• PCR POLYMERASE CHAIN REACTION
• (~100% sensitive/specific , but expensive/technical)
• Other Basic investigation like CBC, CXR, ECG, Electrolytes,
LFT, RFT , CT , USG could be done to rule out other
complication.

34. Prevention

 Medications (will be mentioned in treatment)
 Vector control
 Mosquito nets and bedclothes
 Immunity (natural & vaccines)
 Education

35. Vector Control

 Efforts to eradicate malaria by eliminating
mosquitoes have been successful in some areas.
Malaria was once common in the United States and
southern Europe, but vector control programs, in
conjunction with the monitoring and treatment of
infected humans, eliminated it from those regions.
 Malaria was eliminated from most parts of the USA
in the early 20th century by use of the pesticide DDT.

36. Mosquito nets

 Mosquito nets help keep mosquitoes away from people
and greatly reduce the infection and transmission of
malaria. The nets are not a perfect barrier and they are
often treated with an insecticide designed to kill the
mosquito before it has time to search for a way past the
net. Insecticide-treated nets (ITNs) are estimated to be
twice as effective as untreated nets and offer greater than
70% protection compared with no net. Since the
Anopheles mosquitoes feed at night, the preferred
method is to hang a large "bed net" above the center of a
bed such that it drapes down and covers the bed
completely.

37. Immunity

 Natural immunity occurs, but only in response to
repeated infection with multiple strains of malaria.
 A completely effective vaccine is not yet available for
malaria, although several vaccines are under
development.
 SPf66 was tested extensively in endemic areas in the
1990s, but clinical trials showed it to be insufficiently
effective.
 Other vaccine candidates, targeting the blood-stage of the
parasite's life cycle, have also been insufficient on their
own.
 Several potential vaccines targeting the pre-erythrocytic
stage are being developed.

38. Vaccines

First proposed in 1960s, still nothing fully effective
Difficulties include :
 Intracellular parasites
 Polymorphism and clonal variation
 Parasite induced immunosuppression
 Antigenic variation
 Evaluation and trials difficult to interpret
 High level of parasite mutation

39. Education
 symptoms of malaria
 Education in recognizing the
has reduced the number of cases in some areas of the
developing world by as much as 20%.
 Recognizing the disease in the early stages can also
stop the disease from becoming a killer.
 Education can also inform people to cover over areas
of stagnant, still water which are ideal breeding
grounds for the parasite and mosquito, thus cutting
down the risk of the transmission between people.
 This is most put in practice in urban areas where
there are large centers of population in a confined
space and transmission would be most likely in these
areas.

40. Treatment

 When properly treated, a patient with malaria can expect
a complete recovery. The treatment of malaria depends
on the severity of the disease; whether patients can take
oral drugs or must be admitted depends on the
assessment and the experience of the clinician.
 Uncomplicated malaria is treated with oral drugs. The
most effective strategy for P. falciparum infection
recommended by WHO is the use of artemisinins in
combination with other antimalarials artemisinin-
combination therapy, ACT, to avoid the development of
drug resistance against artemisinin-based therapies.

41. Treatment

 Severe malaria requires the parenteral administration of
antimalarial drugs. Until recently the most used treatment
for severe malaria was quinine but artesunate has been
shown to be superior to quinine in both children and
adults. Treatment of severe malaria also involves
supportive measures.
 Infection with P. vivax, P. ovale or P. malariae is usually
treated on an outpatient basis. Treatment of P. vivax
requires both treatment of blood stages (with chloroquine
or ACT(artemisinin based Combination) as well as
clearance of liver forms with primaquine.

42. Clinical classification of anti malarial drugs

 Casual prophylaxis (cause of infection): On pre
erythrocytic phase. Proguanil, Primaquine
 Suppressive cure: on blood schizontocidal
 Rapidly acting: Chloroquine, quinine, artemisinin
derivatives, mefloquine
 Slow acting: suphadoxine, pyrimethamine, doxycycline
 Radical cure: On latent tissue forms ie exoerythrocytic
stage hypnozoites: Primaquine
 Prevent transmission to Anopheles mosquito:
gameticidal. Primaquine, artemisinins

43. Treatment of Uncomplicated Malaria

Cholroquine sensitive strains of pl. vivax, malariae, ovale – chloroquine
600mg base(10 mg base/kg) stat followed by 300mg base (5 mg/kg at 12, 24
and 36 hrs).
Radical treatment for vivax and ovale infection – Primaquine 15 mg daily
for 14 days to eradicate hepatic hypnozoites and prevent relapse.
In mild-to-moderate G6PD deficiency, primaquine 0.75 mg base/kg body
weight given once a week for 8 weeks.
In severe G6PD deficiency, primaquine is contraindicated and should not
be used.
Glucose-6-phosphate dehydrogenase (G PD)

44. Treatment of Uncomplicated Malaria

In areas with chloroquine resistant P. vivax, artemisinin-based
combination therapies are recommended for the treatment of the same.
At least a 14-day course of primaquine is required for the radical
treatment of P. vivax.

45. Uncomplicated falciparum malaria

Artemisinin- based combination therapy [ACT]
 Artesunate100mg BD(4mg/kg/day for 3 days) – sulphadoxine 1500 mg
(25mg/kg)+ pyrimethamine 75 mg(1.25mg/kg) single dose
Quinine 600mg 3 times a day for 7 days followed by suphadoxine 1.5g
combined with pyrimethamine 75 mg (3 tabs of fansidar)
Who 2010 guidelines
Artemisinin-based combination therapies should be used in preference to
sulfadoxinepyrimethamine(SP)+amodiaquine (AQ) for the treatment of
uncomplicated P. falciparum malaria.
ACTs should include at least 3 days of treatment with an artemisinin
derivative.
Dihydroartemisinin+piperaquine (DHA+PPQ) is an option for the first-line
treatment of uncomplicated P. falciparum malaria worldwide.

46. Who 2010 guidelines cont.....

Non immune patients on malaria treatment should have daily parasite count
performed until negative thick films indicate clearance of parasites
If level of parasitemia does not fall below 25% of the admission value in 48 hrs
or if parasitemia has not cleared by 7 days, drug resistance is likely and regimen
should be changed
In multidrug resistant P. falciparum malaria
Artemether+lumifantrine
or
 Artesunate+mefloquine should be used.
.

47. Severe Falciparum malaria
Specific therapy: 
Artesunate iv or im( 2.4mg/kg stat followed by 2.4 mg/kg at 12 &
24 hrs and then daily for 7 days) + Tab doxycycline mg od x
days
Quinine dihydrochloride( 20mg/kg infused over 4 hrs followed by
10 mg/kg over 4 hrs every 8 hrs)
(Doxycycline is contraindicated in pregnant women and children under 8
years of age; instead, clindamycin 10 mg/kg bw 12 hourly for 7 days should
be used).
Patients receiving artemisinin derivatives should get full course of oral ACT.
However, ACT containing mefloquine should be avoided in cerebral malaria due
to neuropsychiatric complications.

48. Special Precautions
 Intensicve nursing care 
 quinine if injected rapidly can cause hypotension so administered
carefully by rate limiting infusion. All patients with iv quinine should
get a continuous infusion of 5-10% dextrose
 Acute renal failure or severe metabolic acidosis – hemofiltration and
hemodialysis
 If unconscious, blood glucose measured every 4-6 hrs, & if <40
mg/dl, iv dextrose should be started
Hematocrit measured every 6 hrs, if <20% then whole blood or packed
cells infused slowly
Spontaneous bleeding- fresh blood and IV vitamin K
Convulsions – IV or rectal benzodiazepines.

49. Special risk groups
Pregnancy

First trimester:
Quinine plus clindamycin to be given for 7 days (artesunate plus
clindamycin for 7 days is indicated if this treatment fails)
An ACT is indicated only if this is the only treatment immediately available,
or if treatment with 7-day quinine plus clindamycin fails or uncertainty of
compliance with a 7-day treatment.
Second and third trimester
ACTs known to be effective in the region or artesunate plus clindamycin to
be given for 7 days,

or
Quinine plus clindamycin to be given for 7 days.

50. Special risk groups
 standard
Lactating women: Should receive
antimalarial treatment (including ACTs) except for
dapsone, primaquine and tetracyclines.
Infants and young children: ACTs are first-line
treatment in infants and young children with attention
to accurate dosing and ensuring the administered dose is
retained

51. Chemoprophylaxis
Antimalarial tablets
dose
Chloroquine resistance high

Adult prophylactic Regimen
Mefloquine 250mg weekly Started 2-3 weeks before
travel and continued until
4 weeks after
or Doxycycline 100mg daily Started 1 week before and
continued until 4 weeks
after travel
Or Malarone 1 tablet daily From 1-2 days before
travel until 1 week after
return
Chloroquine resistance absent
Chloroquine 300mg base weekly Started 1 week before &
and proguanil 100-200mg daily continued until 4 weeks
after travel

52. Common Mistakes
Misdiagnosis
In an endemic area, there may be a tendency to diagnose all
cases of fever as malaria, forgetting to even consider other
causes. Whereas presumptive treatment with chloroquine in
Over-diagnosis cases of fever is well accepted, sometimes, doctors may go
Obsession with malaria and beyond that and indulge in presumptive treatment with newer
forgetting the OTHER causes drugs, (reserved for multi drug resistance falciparum malaria),
even if the MP test is repeatedly negative. Most often such cases
of fever turn out to be non-malarial fevers. Therefore, DO NOT FORGET
THE OTHER CAUSES OF FEVER.
1. Malaria may not be considered as a possibility in places where
it is not common-history of travel to malarious area should be
elicited.
2. It may not be considered in patients on chemoprophylaxis for
Under-diagnosis malaria. Chemoprophylaxis does not offer 100% protection and
Forgetting malaria malaria should be therefore looked for in these patients.
3. Malaria can always co-exist with other infections in an
endemic area. Therefore, it should be considered even in
patients with other obvious infections causing fever.

53. Common Mistakes
Misreport
Artifacts may be read as malarial parasites on peripheral smear as well as
QBC test. Dirty slides, contaminated stains, inexperienced microscopist,
recycled QBC tubes may be the causes.
False positive
Malarial parasites may be missed and the test reported as negative.
Inadequate smear, dirty stains, contaminated/deteriorated stains, wrong
buffer pH, inexperienced technician, incomplete examination of the slide,
storage of blood in anticoagulant before preparing the smear etc. may
contribute to this problem.
False negative

54. Mis-judgement of severity
Panic reaction to P. falciparum malaria is common among patients and not
uncommon among doctors, resulting in over-reaction to the situation and
over-treatment. Mild anemia, mild icterus, headache etc. are common in
falciparum malaria and need not necessarily imply severe malaria. Such
patients need not be treated with parenteral or second line antimalarial drugs.
Also it should not be forgotten that some of the manifestations could be due
to fever, drugs etc., and not necessarily due to severe malaria.
P. falciparum malaria can cause dramatic complications and therefore one
should be always looking for them. Patients who are at increased risk for
development of complications should be ideally admitted for observation.
Any indication of complication should be properly managed. Neglecting the
signs like high fever, prostration, significant pallor and jaundice, dehydration
etc. may prove costly. Hypoglycemia may be easily missed.

55. Common Mistakes
Mismanagement
Over-treatment (1.) Use of parenteral antimalarials when not needed can cause
unnecessary hardship to patient. (2.) Using 2nd line antimalarials
when not indicated- this only adds to the cost of therapy and to the
adverse effects. It also depletes our stock of reserve antimalarial
drugs and exposes them to the risk of development of resistance. (3.)
Using 2-3 antimalarial drugs concurrently (4.) Higher dose and
longer duration: Antimalarial drugs do not offer better efficacy at
higher dose, this only adds to the adverse effects. (5.) Failure to
switch to oral therapy: Unnecessary continuation of parenteral
therapy may increase the adverse effects and also cost of therapy. (6.)
Rapid intravenous infusions of chloroquine and quinine may be fatal.
(7.) Over-hydration and fluid overload: Enthusiastic administration
of fluid and/or blood may precipitate acute pulmonary oedema. (8.)
Unnecessary endotracheal intubation in comatose patients who can
be managed with conservative measures. (9.) Use of potentially
dangerous ancillary therapies: Corticosteroids, anti-inflammatory
agents, dextran, heparin, adrenaline, prostacycline etc. should be
avoided

56. Common Mistakes
Under-treatment (1.) Delay in starting treatment: Delay in initiating treatment in a
case of severe malaria may prove costly. In such cases, if the
suspicion of malaria is high, treatment should be started even
without waiting for the report or even if the initial report is negative.
Also non-availability of a particular dug should not delay the
initiation of therapy. (2.) Withholding antimalarial drug for fear of
toxicity etc. (3.) Inadequate dosage: Dose should always be
calculated as per the body weight of the patient. Inadequate dose
may not be effective. (4.) Miscalculation of the dose due to base-salt
confusion. (5.) Failure to identify the need for parenteral therapy in
severe malaria and to identify therapeutic priorities in severe
malaria (6.) Oral therapy in severe malaria (7.) Stopping antimalarial
therapy for minor side effects is unjustified. Always weigh the
benefits and risks. (8.) Failure to control convulsions (9.) Failure to
recognize and treat severe anemia (10.) Delay in starting mechanical
ventilation in patients with ARDS, metabolic acidosis etc. (11.) Delay
in starting dialysis in cases of renal failure (12.) Delay in considering
obstetrical intervention.

57. 

58. Thank You!
