The document summarizes information about malaria, including: - Malaria is caused by a parasite transmitted through mosquito bites and causes symptoms like fever and headache. It disproportionately impacts sub-Saharan Africa. - The parasite's lifecycle involves stages in the liver and blood cells. Diagnosis involves examining blood smears under a microscope. Complications can include cerebral malaria, organ failure, and low blood sugar. - Bangladesh reports around 50,000 confirmed malaria cases annually, mostly Plasmodium falciparum. Distribution of insecticide-treated bed nets and antimalarial drugs has reduced cases and deaths in recent years.

1. 2011
Project paper on
Malaria
Department of Public Health
Submitted by :
Imran Ahmed
[Type the company name]
1/1/2011

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.
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3. Introduction:
Malaria is a mosquito-borne infectious disease of humans and other animals caused by eukaryotic
protists of the genus Plasmodium. The disease results from the multiplication of Plasmodium parasites
within red blood cells, causing symptoms that typically include fever and headache, in severe cases
progressing to coma or death. It is widespread in tropical and subtropical regions, including much of
Sub-Saharan Africa, Asia, and the Americas.
Five species of Plasmodium can infect and be transmitted by humans. Severe disease is largely caused by
Plasmodium falciparum while the disease caused by Plasmodium vivax, Plasmodium ovale, and
Plasmodium malariae is generally a milder disease that is rarely fatal. Plasmodium knowlesi is a
zoonosis that causes malaria in macaques but can also infect humans.
Malaria transmission can be reduced by preventing mosquito bites by distribution of mosquito nets and
insect repellents, or by mosquito-control measures such as spraying insecticides and draining standing
water (where mosquitoes breed). The challenge of producing a widely available vaccine that provides a
high 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 or
intramuscular quinine or, since the mid-2000s, the artemisinin derivative artesunate, which is superior
to quinine in both children and adults. Resistance has developed to several antimalarial drugs, most
notably chloroquine.
There were an estimated 225 million cases of malaria worldwide in 2009. An estimated 781,000 people
died from malaria in 2009 according to the World Health Organization's 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 most
severe 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 major
hindrance to economic development.
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4. Life Cycle:
A female Anopheles mosquito carrying malaria-causing parasites feeds on a human and injects the
parasites in the form of sporozoites into the bloodstream. The sporozoites travel to the liver and invade
liver cells.
Over 5-16 days, the sporozoites grow, divide, and
produce tens of thousands of haploid forms, called
merozoites, per liver cell. Some malaria parasite
species remain dormant for extended periods in the
liver, causing relapses weeks or months later.
The merozoites exit the liver cells and re-enter the
bloodstream, beginning a cycle of invasion of red
blood cells, asexual replication, and release of newly
formed merozoites from the red blood cells
repeatedly over 1-3 days. This multiplication can
result in thousands of parasite-infected cells in the
host bloodstream, leading to illness and
complications of malaria that can last for months if
not treated.
Some of the merozoite-infected blood cells leave the
cycle of asexual multiplication. Instead of replicating,
the merozoites in these cells develop into sexual
forms 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 infected
human blood cells burst, releasing the gametocytes, which develop further into mature sex cells called
gametes. Male and female gametes fuse to form diploid zygotes, which develop into actively moving
ookinetes that burrow into the mosquito midgut wall and form oocysts.
Growth and division of each oocyst produces thousands of active haploid forms called sporozoites. After
8-15 days, the oocyst bursts, releasing sporozoites into the body cavity of the mosquito, from which
they travel to and invade the mosquito salivary glands. The cycle of human infection re-starts when the
mosquito takes a blood meal, injecting the sporozoites from its salivary glands into the human
bloodstream
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5. Causes, incidents, and risk factors:
Malaria is caused by a parasite that is passed from one human to another by the bite of
infected Anopheles mosquitoes. After infection, the parasites (called sporozoites) travel
through the bloodstream to the liver, where they mature and release another form, the
merozoites. 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 after
infection, though they can appear as early as 8 days or as long as a year after infection. The
symptoms occur in cycles of 48 to 72 hours.
Most symptoms are caused by:
1. The release of merozoites into the bloodstream
2. Anemia resulting from the destruction of the red blood cells
3. Large amounts of free hemoglobin being released into circulation after red blood cells break
open
Malaria can also be transmitted from a mother to her unborn baby (congenitally) and by blood
transfusions. Malaria can be carried by mosquitoes in temperate climates, but the parasite
disappears over the winter.
The disease is a major health problem in much of the tropics and subtropics. The CDC estimates
that there are 300-500 million cases of malaria each year, and more than 1 million people die
from 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 to
insecticides. In addition, the parasites have developed resistance to some antibiotics. These
conditions have led to difficulty in controlling both the rate of infection and spread of this
disease.
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, falciparum
malaria, affects more red blood cells than the other types and is much more serious. It can be
fatal within a few hours of the first symptoms.
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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.
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7. Diagnosis and tests:
In order to make a malaria diagnosis, the healthcare provider may ask a number of questions
concerning:
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 symptoms
of malaria. He or she may also order certain tests to help in diagnosing malaria or another
condition.
The doctor may suspect malaria based on the patient's symptoms, and the physical findings
at examination; however, to make a definitive diagnosis of malaria, laboratory tests must
demonstrate the malaria parasites, or their components.
The best test available to diagnose malaria is called a blood
smear. In this test, malaria parasites can be identified by
examining a drop of the patient's blood under the microscope,
spread out as a "blood smear" on a microscope slide. Prior to
examination, the specimen (blood) is stained to give to the
parasites a distinctive appearance.
There are other blood tests available that may be used along
with a blood smear to confirm a malaria diagnosis. Figure 5: Blood smear test
A malaria diagnosis can be difficult to make, especially in areas where malaria is not very
common. A number of other conditions share similar symptoms with malaria. Some of these
conditions the healthcare provider will consider before diagnosing malaria include:
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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 that's common in tropical parts of Africa. The
Centers for Disease Control and Prevention estimate that 90 percent of all malaria deaths occur
in 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 (cerebral
malaria), swelling of your brain or brain damage may occur.
Breathing problems. Accumulated fluid in your lungs (pulmonary edema) can make it difficult
to breathe.
Organ failure. Malaria can cause your kidneys or liver to fail, or your spleen to rupture. Any of
these 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 result
in coma or death.
Recurrence may occur
Some varieties of the malaria parasite, which typically cause milder forms of the disease, can
persist for years and cause relapses.
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9. Table 1: Indicators of severe malaria and poor prognosis [1,3-5]
Manifestation Features
Initial 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 convulsion
2. Severe anemia Hematocrit <15% or hemoglobin < 50 g/l in the presence of
parasite count >10000/µl
3. 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 repletion
4. Metabolic (Lactic) Metabolic acidosis is defined by an arterial blood pH of <7.35
Acidosis/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 of
respiratory 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 pressure
6. 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 >100C
8. Abnormal bleeding and/or Spontaneous bleeding from the gums, nose, gastrointestinal
disseminated intavascular tract, retinal haemorrhages and/or laboratory evidence of
coagulation disseminated intravascular coagulation.
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10. 9. Repeated generalised ≥3 generalized seizures within 24 hours
convulsions
10. 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 arousable
12. Prostration Extreme weakness, needs support
13. Hyperparasitemia 5% parasitized erythrocytes or > 250 000 parasites/µl (in
nonimmune individuals)
14. Hyperpyrexia Core body temperature above 400C
15. Jaundice Serum bilirubin of more than 43m mol/l (2.5 mg/dl).
(Hyperbilirubinemia)
Other
16. Fluid and electrolyte Dehydration, postural hypotension, clinical evidence of
disturbances [5] hypovolemia
17. Vomiting of oral drugs Patients with persistent vomiting may have to be admitted for
parenteral therapy.
18. Complicating or associated Aspiration bronchopneumonia, septicemia, urinary tract
infections infection etc.
19. Other indicators of poor Leukocyte count >12,000/cumm; high CSF lactate (>6
prognosis [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
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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 the
total population are at risk of malaria Majority of malaria cases are reported from 13 out of
the total 64 districts in the country. About 4 million populations living in 34 upazillas of eight
of the thirteen districts live in the epidemic-prone border areas. Focal outbreaks occur every
year, and the response to control the epidemic is inadequate. Malaria cases are grossly
under-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 funds
enhanced surveillance and case finding activities including vector control through bednets and
treatment through ACTs
resulted in a increase in lab
confirmed cases and significant
decrease in malaria deaths
. Country did not reaport any
probable malaria case in 2009.
Programme is promoting LLINs
& ITNs amongst the community
as a vector control measure in
these areas which has increased
tremendously in last few years. Figure 6: : Trends of confirmed malaria cases in Bangladesh, 1970-2009
Total 2.57 million bednets (LLINS
+ ITNs) were distributed and 6.42 million people are covered by it. However, it’s coverage in
high endemic districts ranges between 40% to 63%.
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12. Figure 7: Distribution of ACT and Number of malaria deaths in Bangladesh, 2005-2009
Figure 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
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13. Pogramme Goals and Targets:
To reduce malaria morbidity and mortality until the disease is no longer a public health
problem 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
control
Control 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 priority
Best 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
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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 border
Partners and donors
WHO
World Bank
Global fund
BRAC and 14 member NGO Consortium
4 Local NGOs in Chittagong Hill Tract (CHT)
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15. Treatments:
Preventing malaria - four steps
There 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 travelling
to rural areas is generally more risky than staying in urban hotels. In some countries the risk
varies 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 therefore
evenings 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 to
three hours for 20%, up to six hours for 30% and up to 12 hours for 50% DEET. There is no
further increase in duration of protection beyond a concentration of 50%. When both
sunscreen 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 be
used, in a concentration of up to 50%, if anyone is pregnant. It is also safe to use if you are
breast-feeding.
If we sleep outdoors or in an unscreened room, we should use mosquito nets impregnated with
an insecticide (such as pyrethroid). The net should be long enough to fall to the floor all round
your bed and be tucked under the mattress. We should check the net regularly for holes. Nets
need to be re-impregnated with insecticide every six to twelve months (depending on how
frequently the net is washed) to remain effective. Long-lasting nets, in which the pyrethroid is
incorporated 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, long
trousers 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 being
bitten through our clothes.
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16. Sleeping in an air-conditioned room reduces the likelihood of mosquito bites, due to the room
temperature being lowered. Doors, windows and other possible mosquito entry routes to
sleeping accommodation should be screened with fine mesh netting. we should spray the room
before dusk with an insecticide (usually a pyrethroid) to kill any mosquitoes that may have
come into the room during the day. If electricity is available, we should use an electrically
heated device to vaporize a tablet containing a synthetic pyrethroid in the room during the
night. 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 are
therefore not recommended. Likewise, there is no scientific proof that homoeopathic remedies
are 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 the
country you visit. This is because the type of parasite varies between different parts of the
world. 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, being
fake. It is therefore recommended that we obtain our antimalarial treatment from our doctor's
surgery, a pharmacist or a travel clinic. Medications to protect against malaria are not funded
by 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 also
depend on any health problems we have, any medication you are currently taking, the length of
our 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 we
took for your last trip will be advised for your next trip, even to the same country. There is a
changing 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 each
country.
We must take the medication exactly as advised. This usually involves starting the medication
up to a week or more before you go on your trip. This allows the level of medicine in our body
to become effective. It also gives time to check for any side-effects before travelling. It is also
essential that we continue taking the medication for the correct time advised after returning to
our home (often for four weeks). The most common reason for malaria to develop in travellers
is because the antimalarial medication is not taken correctly. For example, some doses may be
missed or forgotten, or the tablets may be stopped too soon after returning from the journey.
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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 or
more to develop after you have been bitten by a mosquito. Occasionally, it takes a year for
symptoms to develop.
This means that we should suspect malaria in anyone with a feverish illness who has travelled
to 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.
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18. References:
http://www.mayoclinic.com/health/malaria/DS00475/DSECTION=complications
http://malaria.emedtv.com/malaria/malaria-diagnosis-p2.html
http://www.malariasite.com/malaria/Complications2.htm
http://en.wikipedia.org/wiki/Malaria
http://www.patient.co.uk/health/Malaria-Prevention.htm
http://www.google.com/imghp?hl=en&tab=wi
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