This is meant for MBBS undergraduate teaching

1. MALARIA
Dr.Benny PV
Professor & HOD
Department of Community Medicine

2. Malaria
Infection by parasite of the
genus Plasmodium, a protozoa
Transmitted to man by infected
female Anopheline mosquito

3. HISTORY
• Intermittent fever: High incidence during
rainy season, was first recognized by Romans
and Greeks
• They postulated that intermittent fevers
were due to ‘bad odour’ coming from
marshy areas and thus gave the name
‘malaria’ (‘mal’= bad + ‘air’)

4. Scientists
• In 1880, a French army surgeon, Charles
Louis Alphonse, first observed and
described the malarial parasite in red
blood cells
• In 1894, Sir Ronald Ross proved the
complete life cycle of plasmodium in
mosquitoes

5. History behind
anti-malarial
The indigenous people of Peru first used tincture
of Cinchona to control fever
In 1820, the active ingredient, Quinine, was first
extracted and named by 2 French chemists
It was the major drug till 1942.
In 1939, Paul Miller discovered the insecticidal
property of DDT
This opened a new avenue in control of malaria
worldwide
Artemisinins were discovered by Chinese
scientists in 1970s

6. BURDEN OF
DISEASE
• Globally in 2016:
• 216 million cases
• 4,45,000 deaths
• Population at risk - 3.5
billion (half of world’s
population)
• 91 countries had on-
going malaria
transmission
REGION CASES DEATHS
Sub-Saharan
Africa
90% 91%
SEAR 10% 7%

8. INDIA’S CONTRIBUTION TO
MALARIA IN SEAR

9. Epidemiology
Agent
Host &
Environment

10. Agent factors

11. Agent factors
• P. vivax
• P. falciparum
• P. malariae
• P. ovale
Agent
• Asexual cycle in humans & Sexual cycle in
mosquitoes
• Man – intermediate host, Mosquito –
definitive host
2 cycles of development

13. Hepatic phase
• In case of Pf, the intrahepatic
schizonts rupture almost
simultaneously & there is no
persistent tissue phase
• In Pv, Po, Pm they do not burst at
same time & some hepatic forms
persists and remain dormant in the
hepatocytes – “Relapses”

14. Reservoir of
infection
No animal reservoirs
A human reservoir is one who harbours the
sexual forms (gametocytes) of the parasite
Criteria for a man to serve as malaria carrier
• Person should have both the sexes of gametocytes in
the blood
• Gametocytes must be mature
• They must be viable
• Must be present in sufficient density to infect
mosquitoes (at least 12 per cubic mm of blood)

15. Period of
communicability
Relapses: vivax & ovale - upto 3 years, due to
liver schizonts
Recurrences in falciparum malaria: disappear
within 1-2 years
P.malariae: prolonged, low level, asymptomatic
parasitaemia
P.falciparum & P.malariae: chronic blood
infection (Erythrocytic schizogony persisting at
low level)

16. Host factors

17. Host factors
1. Age 6. Housing
2. Sex 7. Population mobility
3. Race 8. Occupation
4. Pregnancy 9. Human Habits
5. Socio- economic development 10. Immunity

18. Environmental
factors

19. Environmental
factors
Season: Maximum during July-November
Temperature: Affects life cycle of the parasite
inside vector; optimum range is 20-30 deg.C
Humidity: humidity of 60% is considered necessary
for mosquito to live its normal life span
Rainfall: Provides mosquito breeding places;
increases atmospheric humidity
Altitude: 2000-2500 metres, beyond which
anophelines are not found

20. Vector
45 species of Anopheles mosquitoes
in India
Six of them are vectors of important
• An. culicifacies-rural & peri-urban areas; highly
zoophilic
• An. stephensi- urban & industrial areas
• An. fluviatilis-hills & forest areas; highly
anthrophilic
• An. minimus-foothills of north eastern states
• An. dirus-forest vector in north east states
• An. epiroticus-Andaman and Nicobar islands

21. Vector factors
• Breeding habits-fresh water
collections
• Feeding habits-zoophilic / anthrophilic
• Resting habits- endophilic/exophilic
• Time of biting-nocturnal
• Density
• Life span

22. Mode of
transmission
Vector borne
Direct-blood transfusion; drug addicts
Congenital malaria
• It is the length of time between bite of infective
mosquito (inoculation of sporozoites) & the appearance
of clinical signs (fever)
• Pf - 10 days
• Pv - 12 days
• Po - 14 days
• Pm - 28 days
Incubation period

23. Types of
malaria
• Urban
• Rural
• Tribal
• Malaria in project areas
• Border
Epidemiological
• Uncomplicated
• Severe
Clinical
• Benign Tertian (Pv)
• Malignant Tertian (Pf)
• Quartan malaria
• Ovale tertian
Periodicity

24. Clinical
features

25. Stages of malaria
• Cold Stage
• Hot Stage
• Sweating Stage

26. Complications of malaria
• Cerebral malaria
• Anemia
• Dehydration
• Acute renal failure
• Liver damage
• GI symptoms
• Black water fever

27. Features of
severe
malaria
• Impaired consciousness /
coma
• Repeated generalized
convulsions
• Renal failure ( S.creatinine
>3mg/dl )
• Jaundice ( S.bilirubin
>3mg/dl)
• Severe anaemia ( Hb <
5g/dl)
• Pulmonary oedema /
ARDS
• Hypoglycemia ( Plasma
glucose < 40mg/dl)
• Metabolic acidosis
• Circulatory collapse or
shock - “Algid
malaria”
• Abnormal bleeding /
DIC
• Haemoglobinuria
• Hyperthermia (
Temperature >104 F)
• Hyper-parasitaemia

28. Diagnosis

29. Diagnosis of
malaria

30. Microscopy
• Stained thick and thin blood
smears
• Helps to quantify the parasite
load
• Thick smear shows whether the
slide is positive for MP or not
• Thin smear shows the species
of the MP & the stages of
development in red cells

31. Rapid diagnostic test (RDT)
• RDTs are based on the detection of
circulating parasite antigens
• Several types of RDTs are available
• Cassettes, cards or dip sticks
• Some of them can only detect P.falciparum,
while others can detect other parasite
species also
• Bivalent RDTs (for detecting P.falciparum
and P.vivax )

32. Serological test
• Malarial fluorescent antibody test
• Positive two weeks or more after primary
infection
• Useful in Epidemiological studies

33. Treatment

34. Treatment
• Early diagnosis & treatment of malaria aims
at
• Complete cure
• Prevention of progression of
uncomplicated malaria to severe disease
• Prevention of deaths
• Interruption of transmission
• Minimizing risk of selection and spread of
drug resistant malaria parasite

35. Treatment of
P.vivax cases
• 10 mg/kg on day 1
• 10 mg/kg on day 2
• 5 mg/kg on day 3
Chloroquine: 25 mg/kg body
wt divided over 3 days
• Primaquine is contraindicated in infants, pregnant
women and individuals with G6PD deficiency
• It can lead to haemolysis in G6PD deficiency
Primaquine: 0.25 mg/kg
body wt daily for 14 days

36. Treatment of
P.vivax cases
14 days regimen of Primaquine should be
given under supervision
Patient should be advised to stop
primaquine immediately if he/she develops
any of the following symptoms and should
report to the doctor immediately
• Dark coloured urine
• Yellow conjunctiva
• Bluish discolouration of lips
• Abdominal pain
• Nausea, vomiting etc

37. Paediatric
dose

39. Treatment of uncomplicated P.falciparum cases
• In states other than NE states
• Artemisinin based Combination Therapy
(ACT-SP)
• Artesunate: 4 mg/kg body wt daily for 3
days +
• Sulfadoxine (25 mg/kg body wt) &
Pyrimethamine (1.25 mg/kg body weight)
on day 1 +
• Primaquine: 0.75 mg/kg body wt on day 2

40. Treatment of
uncomplicated
P.falciparum
cases
ACT is not to be given in 1st trimester of
pregnancy & for children weighing < 5 kg
“Different coloured Blister Packs” have been
introduced for treatment of uncomplicated
falciparum malaria in different age groups
This has made administration of treatment
by field level staff easy
Monotherapy of Artemisinin derivatives is
BANNED in India

41. In Children

42. In North-
Eastern
states
Co-formulated ACT-AL tablets given
according to age group
Artemether 20mg &
Lumefantrine 120mg (
twice daily for 3 days )
Primaquine : 0.75 mg/kg
body wt on day 2
Due to resistance to currently used ACT-SP,
effective combination of Artemether-
Lumefantrine (ACT-AL) has been
recommended

43. In Children

44. Treatment of
uncomplicated
P.falciparum
cases in
pregnancy
• Quinine salt 10mg/kg 3 times daily for 7
days
• Quinine may induce hypoglycaemia
• Pregnant women should not start taking
quinine on an empty stomach
1st Trimester
• Area-specific ACT as per dosage schedule
• i.e. ACT-AL in North Eastern states
• ACT-SP in other states
2nd & 3rd Trimester

45. Treatment of mixed infections
(P.vivax + P.falciparum) cases
• All mixed infections should be treated with
full course of age-specific ACT and
Primaquine 0.25 mg/kg body wt daily for
14 days
• In NE states: ACT-AL for 3 days +
Primaquine 0.25 mg per kg body wt daily
for 14 days
• In other states: ACT-SP for 3 days +
Primaquine 0.25 mg per kg body wt daily
for 14 days.

47. Treatment of
severe malaria
cases
It’s an emergency and treatment
should be given as per severity
Should do RDT and take blood smear
first
Immediately give a parenteral dose of
artemisinin derivative (or) quinine in
suspected cerebral malaria cases
The parenteral treatment in severe malaria
cases should be given for minimum of 24
hours once started

50. Prevention and control
Malaria

51. Malaria
control

52. Strategic
action plan of
malaria
control in
India
• Case detection ( active & passive )
• Early diagnosis and complete treatment
• Sentinel surveillance
Surveillance and case management
• Indoor residual spray (IRS)
• Insecticidal treated nets (ITN)
• Long lasting insecticidal nets (LLIN)
Integrated vector management
Anti larval measures
Epidemic preparedness and early
response

53. Strategic action plan of
malaria control in India
• Supportive interventions
• Capacity building
• Behavioural change communication
• Intersectoral collaboration
• Monitoring & Evaluation
• Operational research & applied field
research

54. Malaria indices
• Annual Parasite Incidence (API)
• Annual Blood Examination Rate
(ABER)
• Annual falciparum incidence
• Slide positivity rate
• Slide falciparum rate

55. Vector
indices
• Human Blood Index
• Sporozoite Rate
• Mosquito Density
• Man biting Rate
• Inoculation Rate

56. Surveillance
• Malaria is under regular surveillance under IDSP
• Active case detection(ACD)
• Carried out by MPWs/ ASHAs through fortnightly house visits
• Under NVBDCP, Pf specific RDT kits have been deployed in Pf predominant
areas where microscopy results are not available in 24 hrs
• Since 2012, bivalent RDTs have been introduced
• Passive case detection
• All fever cases attending PHCs/hospitals should be screened for malaria

57. SHORT TERM
CHEMOPROPHYLAXIS
( UPTO 6 WEEKS )
CHEMOPROPHYLAXIS FOR
LONGER STAY
( MORE THAN 6 WEEKS )
Doxycycline Mefloquine
100 mg once daily & 1.5 mg/kg once daily for
children
250 mg weekly for adults
Should be started 2 days before travel &
continued for 4 weeks after leaving the area
Should be administered 2 weeks before & 4
weeks after exposure
Contraindicated in pregnant women &
children < 8 yrs
Contraindicated in individuals with history of
convulsions, neuropsychiatric problems &
cardiac conditions

58. Vector control
ANTI – ADULT
MEASURES
ANTI – LARVAL
MEASURES
PERSONAL
PROTECTION
Residual sprays Environmental
Control
Mosquito nets
Space Sprays Chemical control Repellents
Biological control

59. Anti-adult
measures
• DDT, Malathion,
Fenitrothion
Residual
spraying
• Pyrethrum, Residual
insecticides
Space
sprays
Genetic
control

60. Spraying

61. Anti-larval measures
• Environmental control
• Source reduction
• Chemical control
• Mineral oils, Paris green, Synthetic
insecticides
• Biological control
• Gambusia affinis, Lebister
reticulatus

62. Protection against mosquito
bite
• Mosquito net
• Insecticidal treated nets (ITN)
• Long lasting insecticidal nets (LLIN)
• Screening
• Repellents
• Diethyltoluamide

64. Chemoprophylaxis

65. Chemoprophylaxis
• Chemoprophylaxis should be administered
only in selective groups in high P.falciparum
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
travellers for longer stay

66. Malaria vaccine
• Completed phase 3 trials
• RTS, S/ASO1- P.falciparum
circumsporozoite
• R+T segments of circumsporozoite protein
+ S (HbSAg)= RT (S+ S)
• Adjuvant- ASO1
• 1 vial= 1 mL (2 patients)

67. Malaria vaccine
• 0.5 mL IM
• WHO recommends 4 doses
• 1st dose at 5 months
• Repeat at 6th and 7th
months
• 4th dose at 18 months
after 3rd dose

68. THANK YOU