1. Malaria & typhoid
© DR LEJU BENJAMIN MODI (MBChB)
FOR EFSS AUDIENCE (ON ZOOM/YOUTUBE)
AUGUST 12 – 13, 2023

2. Disclaimer
The material shared in this presentation is strictly for
health awareness and information purposes to the
audience, and must not be used for making self
diagnosis and/or prescriptions!
This presentation does not contribute to any CPD points.

3. Outline
 Malaria
 What it is/cause.
 Transmission/signs and symptoms/diagnosis
 Complications/Treatment/Prevention
 Typhoid
 What it is/cause.
 Transmission/signs and symptoms/diagnosis
 Complications/Treatment/Prevention

4. MALARIA
 Derived from Italian words “mal” = bad, “aria” = air ➔ malaria
 Caused by the parasite Plasmodium; of four main species
➢ P. falciparum (the most dangerous and common)
➢ P. vivax
➢ P. malariae
➢ P. ovale
➢ (P. knowlesi; Southeast Asia, common in monkeys)
 Spread by the vector, female Anopheles mosquito
 Possible transmission through blood transfusion, organ transplant (liver), and
placentally
 Life cycle in blood (and organs like liver) and in the mosquito’s salivary glands

5. Incubation Period
Parasite Species Incubation Period (days) characteristic
P. falciparum 9 – 14 Fulminant; fever recurs
36 – 48hrly
P. vivax and
ovale
12 – 18 Fever spikes every
48hrs; latency in liver
P. Malariae 18 – 40 Fever recurs 72hrly

6. Epidemiology of Malaria
WORLD MALARIA REPORT, 2022
(WHO)
• 247M cases, 619,000 deaths
world wide in 2021
• 234M (95%) cases in Africa, with
593000 (96%) deaths; ~ 80% in <
5years old
• South Sudan accounted for 1.2%
of cases (2,964,000) and 1.2%
deaths (7,428)
• 20 people die of malaria daily in
South Sudan

7. Signs and Symptoms
 Signs and symptoms occur in
repetitive cycles (paroxysmal)
 Broadly grouped into three
stages:
 Cold stage – chills and
shivering
 Hot stage – warm/high fever,
headache,
 Sweating stage – weakness
Fever 96%
Chills 96%
Headache 79%
Muscle Pain 60%
Palpable liver 33%
Palpable Spleen 28%
Nausea or vomiting 23%
Abdominal pain/diarrhea 6%

8. Diagnosis
History of illness, including travel to areas of endemicity
Physical examinations – fever, etc.
Laboratory tests:
Blood microscopy (gold standard; thin/thick films); 2+ is severe
Rapid test kits; less effective if low parasites in blood
Others (Complete Blood Count (CBC), clotting, sugar levels, LP,
etc.)
PCR (at reference labs)

9. Complications
 Low red blood cells (anemia)
 Cerebral malaria (decreased consciousness; convulsions)
 Organ enlargement (spleen, liver)
 Kidney failure
 Acute respiratory distress syndrome
 Fluid accumulation (lung, brain)
 Shock
 jaundice
 Miscarriage/preterm birth (in pregnancy; P. falciparum!)

11. Treatment
Pain/fever relief (paracetamol); tepid sponging
Artemisinin combination therapy (ACTs) – coartem, lumartem,
etc. (artemether/lumefantrine)
Quinine (preferable in pregnancy)
Fansidar (sulfadoxine-pyrimethamine)
Chloroquine; hydroxychloroquine
Atovaquone-proguanil
Other symptomatic treatment (transfusion, etc.)
If severe, injections then oral regimen

13. Prevention – 3 prong
Attack Parasite
in Human Body:
 Diagnose and
treat promptly
as above
Reduce contact between
humans and mosquitos/parasites:
 Repellants (lotion, mosq coil)
 Mosquito net (ITN)
 Use preventive anti-malarials –
doxycycline, mefloquine,
primaquine, etc.
 Close doors/windows; wear
long-sleeves/socks dusk to
dawn
 Mosquirix malaria vaccine
(WHO recommended 2021 for
high burden Africa countries)
Decrease mosquito
population:
 Bury stagnant
water.
 Insecticides
(Doom)

14. Comments/Questions?
Health break

15. Typhoid (Enteric) Fever
 Mainly caused by the bacterium, Salmonella typhi. Other species,
S. paratyphi A, B, & C are relatively infrequent
 Humans the only host – may be a case (infectious as long as
bacterium appears in stools/urine) or a carrier (who may be
temporary or incubatory, excreting bacteria for 6 – 8 weeks; or
chronic carrier, excreting for over a year)
 Main/primary source of infection = feces (and urine) of cases;
secondary source = contaminated water, food, fingers, flies
 Incubation period = 10 – 14 days, but may be as short as 3 days or
as long as 21 days, depending on dose of bacteria

16. Mode of transmission
• Faeco-oral or uro-oral
• Worsened by human
activities:
• Open area
defecation/urination
• Contamination of
drinking water
supplies/food
• Vegetables/crops
grown in sewage water
• Low personal hygiene
Faeces and
urine from
cases or
carriers
Water
Soil
Flies
Fingers
Foods raw
or half-
cooked
Mouth of
well persons

17. Signs and symptoms
First week:
 Characteristic “step-
ladder”, fever over 4
– 5 days; mostly
afternoon hrs
 Headache, vague
abdominal pain;
constipation
 Weakness; muscle
pains; relative
decrease in heart
rate
Second week:
 Mild organ
(liver, spleen)
enlargement –
in majority
patients
 Skin rash (rose
spots) may
appear;
diarrhea
Third week:
 Patient appears in
the “typhoid
stage” – prolonged
apathy, toxemia,
disorientation/com
a, apparent
diarrhea
 If untreated, 5 –
10% risk of intestinal
perforation and
bleeding

19. Diagnosis
Widal test – tests for antibodies to antigens of the bacterium
Unreliable as some of the antibodies not specific to S. typhi (cross-
reactivity); other antibodies rise late in the illness; false positive/false
negative results
Cultures – gold standard, different as illnesses progresses
1st week – blood culture – useful since high bacterial load in blood
early in infection
3rd week – stool culture
4th week – urine culture

20. Complications
General – toxemia, shock
Digestive system – intestinal bleeding/perforation (3rd or 4th
week)
Nervous system – deranged, coma, meningitis
Miscellaneous – organ injury – heart, liver, kidneys, lungs,
bone infection (if sickle cell)

21. Treatment
Antibiotics – oral fluoroquinolones (e.g., ciprofloxacin);
chloramphenicol; amoxicillin; ampicillin;
If resistance to fluoroquinolones – azithromycin; 3rd
generation cephalosporins (e.g., ceftriaxone)
Chronic carrier state – prolonged (4 weeks) fluoroquinolone;
gall bladder removal in some patients
Supportive treatment – pain/fever medications, adequate
hydration, appropriate nutrition

22. Prevention of Enteric Fever
Control of sanitation
• Protection and
purification of drinking
water supplies
• Promotion of food
hygiene (wash fruits!)
• Improvement of basic
sanitation

23. Immunization/Vaccination
of
• Those living in endemic
areas
• At risk, e.g., school children,
hospital staff
• Household members
• Food handlers (restaurants)
Two types of vaccines
• The injectable typhoid
vaccine (TYPHIM – Vi)
• The live oral vaccine
(TYPHORAL)

24. Vaccination
Injectable Typhim Vi TYPHORAL
• Single dose injectable vaccine;
• Subcutaneous or intramuscular
• For children 2years and over
• One capsule taken by mouth with
water/milk on 1st, 3rd, and 5th, days;
no antibiotic to be taken at this
time (live attenuated vaccine)
• For 6 years old and over
• Booster dose after 3 years

25. Summary
 Malaria (caused by a parasite, Plasmodium), is not always associated
with typhoid (caused by a bacterium, Salmonella typhi); double
diagnosis often incorrect
 A true typhoid infection has a characteristic presentation a clinician
should be able to discern and make the correct diagnosis
 Best test for typhoid is culture; Widal test is unreliable
 First line treatment for typhoid is oral fluoroquinolones; use of
ceftriaxone should be minimized to prevent antibiotic resistance
 Personal and environmental hygiene can prevent typhoid, practice it!
 Vaccination facilities and cost in Juba? Let’s all find out!

26. Thank you for listening
Questions/Comments?