it includes introduction, causative agent, life cycle of malaria parasites, clinical presentation and treatment of uncomplicated malaria and severe malaria, and chemoprophylaxis and control measures for malaria.

1. MALARIA
K.APARNA
PHARM D
SVCP
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2. 2

3. MALARIA PARASITES
Malaria parasites are micro-organisms that belong to the
genus Plasmodium.
There are more than 100 species of Plasmodium, which can infect many
animal species such as reptiles, birds, and various mammals.
The species infecting humans are the following:
•P. falciparum
•P. vivax
•P. ovale
•P. malariae
•P. knowlesi
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4. 4
P.falciparum:
•Found worldwide in tropical and sub-tropical areas (& especially in Africa)
•Can cause severe malaria because it multiplies rapidly in the blood, & can thus cause anemia
•Infected parasites can clog small blood vessels. When this occurs in the brain, cerebral malaria results.
P.vivax:
•Found mostly in Asia, Latin America, & in some parts of Africa.
•Most prevalent human parasite.
• P.vivax (as well as P.ovale) has dormant liver stages (“hypnozoites”) that can activate & invade blood (“relapse”) several
months or years after the infecting mosquito bite.
P.ovale:
•Found mostly in Africa ( especially west Africa) & the islands of the western pacific.
•Biologically & morphologically very similar to P.vivax.
P.malariae:
•Found worldwide.
•Has a quartan cycle (3-day cycle)
•Can cause chronic infection that in some cases can last a lifetime. & serious complications such as the nephritic
syndrome.
P.knowlesi:
•found throughout Southeast Asia.
•Has a 24-hour replication cycle & so can rapidly progress from uncomplicated to severe malaria.
(continued)...

5. LIFE CYCLE OF MALARIA PARASITES
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6. INCUBATION PERIOD OF THE PARASITE
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INCUBATION PERIOD: Interval between inoculation of the sporozoites and appearance of the symptoms.
SPECIES INCUBATION PERIOD
P.falciparum 7-14 days
P.vivax 12-17 days
P.Ovale 15-18 days
P.malariae 18-40 days

7. UNCOMPLICATED MALARIA
 The classical (but rarely observed) malaria attack lasts 6–10 hours. It consists of
•A cold stage (sensation of cold, shivering)
•A hot stage (fever, headaches, vomiting; seizures in young children); and
•Finally a sweating stage (sweats, return to normal temperature, tiredness).
Classically (but infrequently observed) the attacks occur every second day with the “tertian” parasites (P.
falciparum, P. vivax, and P. ovale) and every third day with the “quartan” parasite (P. malariae).
Symptoms
• Fever
• Chills
• Sweats
• Headaches
• Nausea and vomiting
• Body aches
• General malaise
Physical findings
• Elevated temperatures
• Perspiration
• Weakness
• Enlarged spleen
• Mild jaundice
• Enlargement of the liver
• Increased respiratory rate
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8. Severe malaria is manifestated by one or more of the following:
• Cerebral malaria
• Severe anemia due to hemolysis
• Hemoglobinuria due to hemolysis
• Abnormalities in blood coagulation
• Low blood pressure caused by cardiovascular collapse
• Acute kidney injury
• Hyperparasitemia, where more than 5% of the red blood cells are infected by malaria parasites
• Metabolic acidosis, often in association with hypoglycemia
• Hypoglycemia. (Hypoglycemia may also occur in pregnant women with uncomplicated malaria, or after
treatment with quinine).
SEVERE MALARIA
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9. DIAGNOSIS
CLINICAL DIAGNOSIS MICROSCOPIC DIAGNOSIS ANTIGEN DETECTION
MOLECULAR DIAGNOSIS SEROLOGY DRUG RESISTANCE TESTS
• Based on symptoms & on physical
findings (but not specific).
• A complete blood picture & routine
chemistry panel:
- Useful in determining whether the
infection is uncomplicated or severe.
- Can detect severe anemia, hypoglycemia,
renal failure, hyperbilirubinemia, & acid-
base disturbances.
• Blood smear.
• Useful for identifying malaria.
parasites.
• Stain used: Giemsa stain.
• Gold standard for laboratory
confirmation of malaria.
• To detect antigens derived from malaria
parasites.
• Immunochromatographic tests [rapid
diagnostic tests (RDT)]:
-Often use a dipstick or cassette format.
- provide results in 2-15 minutes.
- indicate whether patient is infected with
P. falciparum or one of the other 3 species
of human malaria.
• polymerase chain reactions (PCR):
-Parasite nucleic acids are detected.
- most useful for confirming the species
of malarial parasite after the diagnosis
has been established by either smear
microscopy or RDT.
•either indirect immunofluorescence
(IFA) or enzyme-linked
immunosorbent assay (ELISA).
•Detects antibodies against malaria
parasites.
•Doesnot detect current infection but
rather measures past exposure.
•To assess the susceptibility to
antimalarial compounds of parasites
collected from a specific patient.
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10. Blood smear stained with Giemsa, showing a
white blood cell (on left side) and several red
blood cells, two of which are infected
with Plasmodium falciparum (on right side).
Indirect fluorescent antibody (IFA) test. The
fluorescence indicates that the patient serum
being tested contains antibodies that are
reacting with the antigen preparation
(here, Plasmodium falciparum parasites).
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11. TREATMENT : GENERAL APPROACH
1
The infecting
plasmodium species
● P.falciparum & P.knowlesi
can cause rapidly
progressive severe illness
or death.
● P.vivax & P.ovale infections
also require treatment for
hypnozoite forms.
● P.falciparum and p.vivax
have different drug
resistance patterns.
2
The clinical status of
the patient
● Uncomplicated malaria
can be effectively
treated with oral
antimalarials.
● Severe malaria treated
with parenteral anti-
malarial therapy.
The drug susceptibility
of the infecting parasite
● Knowledge of the
geographic area where the
infection was acquired
provides information on
the likelihood of drug
resistance of the infecting
parasite.
3
The previous use of
antimalarials.
● If malaria infection
occurred despite use of
chemoprophylaxis, that
medicine should not be
a part of the treatment
regimen.
4
Treatment should be guided by 4 main factors:
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12. TABLE 1. DOSES OF ANTI-MALARIALS
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Recommended Adult doses Recommended Pediatric doses
Artemether-lumefantrine (Coartem)
(1 tab: 20 mg artemether and 120 mg lumefantrine)
Adults: 4 tabs po per dose
Three-day course:
Day 1: Initial dose and second dose 8 h later
Days 2 and 3: 1 dose BID
Artemether-lumefantrine (Coartem)
(1 tab: 20 mg artemether and 120 mg lumefantrine)
5–<15 kg: 1 tab po per dose
15–<25 kg: 2 tabs po per dose
25–<35 kg: 3 tabs po per dose
≥35 kg: 4 tabs po per dose
Three-day course:
Day 1: Initial dose and second dose 8 h later
Days 2 and 3: 1 dose BID
Atovaquone-proguanil (Malarone)
(Adult tab: 250 mg atovaquone and 100 mg proguanil)
4 adult tabs po QD x 3 days
Atovaquone-proguanil (Malarone)
(Adult tab: 250 mg atovaquone and 100 mg proguanil;
Peds tab: 62.5 mg atovaquone and 25 mg proguanil)
5–<8 kg: 2 peds tabs po QD x 3 days
8–<10 kg: 3 peds tabs po QD x 3 days
10–<20 kg: 1 adult tab po QD x 3 days
20–<30 kg: 2 adult tabs po QD x 3 days
30–<40 kg: 3 adult tabs po QD x 3 days
≥40 kg: 4 adult tabs po QD x 3 days

13. Recommended Adult doses Recommended Pediatric doses
Quinine sulfate plus doxycycline , tetracycline , or
clindamycin
Quinine sulfate: 542 mg base (650 mg salt) po TID x 3
or 7 days
Doxycycline: 100 mg po BID x 7 days Tetracycline: 250
mg po QID x 7 days Clindamycin: 20 mg/kg/day po
divided TID x 7 days
Quinine sulfate plus doxycycline , tetracycline , or
clindamycin
Quinine sulfate: 8.3 mg base/kg (10 mg salt/kg) po
TID x 3 or 7 days
Doxycycline: 2.2 mg/kg po BID x 7 days
Tetracycline: 25 mg/kg/day po divided QID x 7 days
Clindamycin: 20 mg /kg/day po divided TID x 7 days
Mefloquine
Dose 1: 684 mg base (750 mg salt) po
Dose 2 at 6 to 12 h: 456 mg base (500 mg salt) po
Mefloquine
Dose 1: 13.7 mg base/kg (15 mg salt/kg) po
Dose 2 at 6 to 12 h: 9.1 mg base/kg (10 mg salt/kg) po
Chloroquine phosphate (Arale and generics)
Dose 1: 600 mg base (1,000 mg salt) po
Doses 2 to 4 (3 additional doses) at 6, 24 and 48 h:
300 mg base (500 mg salt) po per dose;
Chloroquine phosphate (Arale and generics)
Dose 1: 10 mg base/kg (16.7 mg salt/kg) po
Doses 2 to 4 (3 additional doses) at 6, 24 and 48 h: 5
mg base/kg (8.3 mg salt/kg) po per dose;
(continued)...
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14. Recommended Adult doses Recommended Pediatric doses
Hydroxychloroquine (Plaquenil and generics)
Dose 1: 620 mg base (800 mg salt) po
Doses 2 to 4 (3 additional doses) at 6, 24 and 48 h:
310 mg base (400 mg salt) po per dose
Hydroxychloroquine (Plaquenil and generics)
Dose 1: 10 mg base/kg (12.9 mg salt/kg) po
Doses 2 to 4 (3 additional doses) at 6, 24 and 48 h: 5
mg base/kg (6.5 mg salt/kg) po per dose
Primaquine phosphate
30 mg base po qd x 14 days
Primaquine phosphate
0.5 mg base/kg po qd x 14 days
Tafenoquine (Krintafel)
300 mg po x 1 dose
Tafenoquine (Krintafel)
300 mg po x 1 dose, only for patients ≥16 years old
(continued)...
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15. Uncomplicated malaria: Plasmodium falciparum or unknown species
Drug Susceptibility Recommended Regimen
Chloroquine resistant or unknown resistance
(All malariaendemic regions except those in Central
America west of Panama Canal, Haiti, and Dominican
Republic)
Four treatment options are available:
A. Artemether-lumefantrine (Coartem)
B. Atovaquone-proguanil (Malarone)
C. Quinine sulfate plus doxycycline , tetracycline , or
clindamycin
D. Mefloquine
Chloroquine sensitive
(All malariaendemic regions except those in Central
America west of Panama Canal, Haiti, and Dominican
Republic)
Chloroquine phosphate (Arale and generics),
or
Hydroxychloroquine (Plaquenil and generics)
NOTE: refer TABLE 1 for dosing.
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16. Uncomplicated malaria: P. vivax or P. ovale
Drug Susceptibility
(Based on where
acquired)
Recommended Regimen
Acute treatment Antirelapse treatment
Chloroquine sensitive
(All malaria endemic
regions except Papua
New Guinea and
Indonesia)
Chloroquine phosphate (Aralen and
generics)
Or
Hydroxychloroquine (Plaquenil and
generics)
Primaquine phosphate
Or
Tafenoquine (Krintafel)
Chloroquine resistant
(Papua New Guinea
and Indonesia)
Four treatment options are available:
A. Artemether-lumefantrine (Coartem)
B. Atovaquone-proguanil (Malarone)
C. Quinine sulfate plus doxycycline ,
tetracycline , or clindamycin
D. Mefloquine
Primaquine phosphate
NOTE: refer TABLE 1 for dosing.
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17. 17
Uncomplicated malaria: P. malariae or P. knowlesi
Drug Susceptibility
(Based on where
acquired)
Recommended Regimens
Chloroquine sensitive
(All malariaendemic
regions, no known
resistance)
Chloroquine phosphate (Aralen and generics)
or
Hydroxychloroquine (Plaquenil and generics)
PLUS
Anyone of the following:
A. Artemether-lumefantrine (Coartem)
B. Atovaquone-proguanil (Malarone)
C. Quinine sulfate plus doxycycline , tetracycline , or
clindamycin
D. Mefloquine
NOTE: refer TABLE 1 for dosing.

18. Uncomplicated malaria: Pregnant women
Species and Drug Susceptibility
(Based on where acquired)
Recommended Regimens
Chloroquine resistant
P. falciparum
(All malariaendemic regions except
Central America west of Panama
Canal, Haiti, and Dominican
Republic)
P. vivax or P. ovale
(Papua New Guinea and Indonesia)
Preferred for 2nd and 3rd trimesters: Artemether-lumefantrine (Coartem)
(1 tab: 20 mg artemether and 120 mg lumefantrine)
Adults: 4 tabs po per dose
Three-day course:
Day 1: Initial dose and second dose 8 h later
Days 2 and 3: 1 dose BID
All trimesters: Quinine sulfate plus clindamycin
Quinine sulfate: 542 mg base (650 mg salt) po TID x 3 or 7 days
Clindamycin: 20 mg/kg/day po divided TID x 7 days
If no other options, all trimesters:
Mefloquine Dose 1: 684 mg base (750 mg salt) po
Dose 2 at 6 to 12 h: 456 mg base (500 mg salt) po
AND if P. vivax or P.ovale:
Chloroquine 500 mg salt (300 mg base) weekly until delivery, then consider antirelapse treatment
Antirelapse treatment with either primaquine or tafenoquine contraindicated during pregnancy
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19. Species and Drug Susceptibility
(Based on where acquired)
Recommended Regimens
Chloroquine sensitive
P. falciparum
(Central America west of Panama
Canal, Haiti, and Dominican
Republic)
P. vivax or P. ovale
(All malaria-endemic regions except
Papua New Guinea and Indonesia)
P. malariae or P. knowlesi
A. Chloroquine phosphate (Aralen and generics)
● Dose 1: 600 mg base (1,000 mg salt) po
● Doses 2 to 4 (3 additional doses) at 6, 24 and 48 h: 300 mg base
(500 mg salt) po per dose; or
Hydroxychloroquine (Plaquenil and generics)
● Dose 1: 620 mg base (800 mg salt) po
● Doses 2 to 4 (3 additional doses) at 6, 24 and 48 h: 310 mg base
(400 mg salt) po per dose
Options above for chloroquine-resistant malaria parasites
AND if P. vivax or P.ovale:
Chloroquine 500 mg salt (300 mg base) weekly until delivery, then
consider antirelapse treatment
Antirelapse treatment with either primaquine or tafenoquine
contraindicated during pregnancy
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(continued)...

20. Species and Drug Susceptibility
(Based on where acquired)
Recommended Regimen
All species, drug susceptibility not
relevant for acute treatment of
severe malaria
If P. vivax or P. ovale infections, in
addition to acute treatment listed
here, antirelapse treatment needed
IV artesunate:
1 dose=2.4 mg/kg
IV doses (3 in total) at 0, 12 and 24 hours
PLUS reassessment and follow-on treatment (in next slide..)
If IV artesunate not readily available, give oral antimalarials while obtaining IV
artesunate. When IV artesunate arrives, discontinue oral antimalarial and initiate IV
treatment. Interim treatment options (Table 1 for dosing):
• Artemether-lumefantrine (Coartem) (preferred); or
• Atovaquone-proguanil (Malarone); or
• Quinine sulfate; or
• Mefloquine (only if no other options available)
If oral therapy not tolerated, consider administration via nasogastric (NG) tube or
after an antiemetic.
TREATMENT OF SEVERE MALARIA
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21. Reassessment and follow-on treatment:
Reassess parasite density at least 4 hours after the third dose
Parasite density ≤1% and patient able to tolerate oral medications:
Give a complete follow-on oral regimen. Options include:
• Artemether-lumefantrine (Coartem) (preferred), or
• Atovaquone-proguanil (Malarone), or
• Quinine plus doxycycline or, in children <8 years old and pregnant women, clindamycin, or
• Mefloquine (only if no other options available)
Parasite density >1%:
Continue IV artesunate, same dose, QD up to 6 more days until parasite density ≤1%. When parasite density ≤1%, give
complete follow-on oral regimen as listed above.
Parasite density ≤1% but patient unable to take oral medication:
Continue IV artesunate, same dose, QD up to 6 more days until patient able to take oral therapy.
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22. CHEMOPROPHYLAXIS
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Considerations when choosing a drug for malaria prophylaxis:
• Recommendations for drugs to prevent malaria differ by country of travel and can be found in
Malaria Information by Country (source: CDC).
• No antimalarial drug is 100% protective and must be combined with the use of personal
protective measures, (i.e., insect repellent, long sleeves, long pants, sleeping in a mosquito-free
setting or using an insecticide-treated bednet).
• For all medicines, also consider the possibility of drug-drug interactions with other medicines that
the person might be taking as well as other medical contraindications, such as drug allergies.

23. 23
(continued)...
• DOSING FOR CHEMOPROPHYLAXIS:
Atovaquone/Proguanil (Malarone)
Adults: 1 adult tablet daily.
Children: 5-8 kg: ½ pediatric tablet daily. 8-
10 kg: ½ pediatric tablet daily. 10-20 kg: 1
pediatric tablet daily. 20-30 kg: 2 pediatric
tablets daily.30-40 kg 3 pediatric tablets
daily. 40 kg and over: 1 adult tablet daily.
Begin 1-2 days before travel, daily during
travel, and for 7 days after leaving.
Chloroquine
Adults: 300 mg base (500 mg salt),
once/week.
Children: 5 mg/kg base (8.3 mg/kg salt)
(maximum is adult dose), once/week.
Begin 1-2 weeks before travel,
once/week during travel, and for 4
weeks after leaving.
Doxycycline
Adults: 100 mg daily.
Children: ≥8 years old: 2.2 mg/kg (maximum is
adult dose) daily.
Begin 1-2 days before travel, daily during
travel, and for 4 weeks after leaving.
Mefloquine
Adults: 228 mg base (250 mg salt), weekly.
Children: ≤9 kg: 4.6 mg/kg base (5 mg/kg
salt), weekly. 10-19 kg: ¼ tablet weekly. 20-
30 kg: ½ tablet weekly. 31-45 kg: ¾ tablet
weekly. >45 kg: 1 tablet weekly.
Begin 1-2 weeks before travel, weekly
during travel, and for 4 weeks after leaving.
Primaquine
Adults: 30 mg base, daily
Children: 0.5 mg/kg base up to adult
dose daily
Begin 1-2 days prior to travel, daily
during travel, and for 7 days after
leaving
Tafenoquine (Arakoda)
Adults only: 200 mg per dose.
Begin daily for 3 days prior to travel, weekly
during travel, and for 1 week after leaving.

24. PREVENTION AND CONTROL
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 Insecticide-Treated Bed Nets (INTs)
- only two insecticides classes are approved for use
on INTs (pyrroles & pyrethroids).
 Indoor Residual Spraying (IRS) with DDT.
 Source reduction: Draining swamps or by ditching
marshy areas to remove standing water.
 Biological control
- fungi (E.g., Laegenidium giganteum)
- mermithid nematodes (E.g., Romanomermis
culicivorax)
- mosquito fish (Gambusia affinis)
 Fogging or area spraying.
 Wearing of light-colored clothes, long pants, & long-
sleeved shirts.
 Chemical Larviciding
- Oils applied to the water surface
- Toxins from the bacterium Bacillus
thuringiensis var. israelensis (Bti)
- Insect growth regulators such as methroprene.
INTs
IRS
Fogging
Source reduction

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26. REFERENCE
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27. THANK YOU
K.APARNA
A presentation on MALARIA
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