EMILIO AGUINALDO COLLEGE

1113-1117 San Marcelino Street,

Ermita, Manila

A Research On:

MALARIA

In Partial Fulfillment of Requirements of the Subject Nursing Care Management 104 for the Degree Bachelor of Science in Nursing

Submitted By: Nieva, Geraldine A. BSN IV, Section 1, Group C

01 OCTOBER 2010

MALARIA
A. INTRODUCTION
y The word malaria comes from 18th century Italian mala, meaning "bad" and aria, meaning "air". Most likely, the term was first used by Dr. Francisco Torti, Italy, when people thought the disease was caused by foul air in marshy areas. It was not until 1880 that scientists discovered that malaria was a parasitic disease which is transmitted by the anopheles mosquito. The mosquito infects the host with a one-cell parasite called plasmodium. Not long after they found out that Malaria is transmitted from human-to-human through the bite of the female mosquito, which needs blood for her eggs. Malaria is an infectious disease caused by the parasite called Plasmodia. There are four identified species of this parasite causing human malaria, namely, Plasmodium vivax, P. falciparum, P. ovale and P. malariae.. It is a disease that can be treated in just 48 hours, yet it can cause fatal complications if the diagnosis and treatment are delayed. It is re-emerging as the # 1 Infectious Killer and it is the Number 1 Priority Tropical Disease of the World Health Organization. Malaria is a major global health problem

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Malaria affects more than 2400 million people, over 40% of the world's population, in more than 100 countries in the tropics from South America to the Indian peninsula. The tropics provide ideal breeding and living conditions for the anopheles mosquito, and hence this distribution. Every year 300 million to 500 million people suffer from this disease (90% of them in subSaharan Africa, two thirds of the remaining cases occur in six countries- India, Brazil, Sri Lanka, Vietnam, Colombia and Solomon Islands). WHO forecasts a 16% growth in malaria cases annually. About 1.5 million to 3 million people die of malaria every year (85% of these occur in Africa), accounting for about 4-5% of all fatalities in the world. One child dies of malaria somewhere in Africa every 20 sec., and there is one malarial death every 12 sec somewhere in the world. Malaria kills in 1 year what AIDS killed in 15 years. In 15 years, if 5 million have died of AIDS, 50 million have died of malaria.

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Malaria ranks third among the major infectious diseases in causing deaths- after pneumococcal acute respiratory infections and tuberculosis. It is expected that by the turn of the century malaria would be the number one infectious killer disease in the world. It accounts for 2.6 percent of the total disease burden of the world. It is responsible for the loss of more than 35 million disability-adjusted life-years each year. Every year ~ 30000 visitors to endemic areas develop malaria and 1% of them may die. Estimated global annual cost (in 1995) for malaria: US$ 2 billion (direct and indirect costs, including loss of labour). Estimated worldwide expenditure on malaria research: US$ 58 million, one thousandth of the US$ 56 billion spent globally on health research annually. Estimated annual expenditure on malaria research, prevention and treatment: $ 84 million. Estimated worldwide expenditure per malaria fatality: $ 65; as compared to $ 3274 for HIV/AIDS and $ 789 for asthma. That is to say, one HIV/AIDS death is equal to about 50 malaria deaths! Malaria was nearly eradicated from most parts of the world by the early 60's, owing largely to concerted anti malarial campaigns world over under the guidance of the World Health Organization. The following are some of the reasons for the resurgence of malaria: Complacency and laxity in anti malarial campaigns; conflicts and wars; migrations; deteriorating health systems; poverty Drug Resistance Insecticide Resistance and ban on DDT Global Warming - increased breeding and life span of the insect vector Shrinking World - spread of malaria from endemic areas to all other parts of the world

Man made Parasite Vector Environment Jet Age

1. 3 Stages of Malaria A. Cold Stage chilling Manifestations ( 10-15 mins) B. Hot Stage characterized by fever, headache, abdominal pain, & vomiting usually last for (4-6hrs) C. Diaphoretic Stage excessive sweating / feeling of weakness due to the past stages

B. CAUSATIVE AGENT
2. Malaria most often is caused by the bite of a female Anopheles species mosquito that is infected with species of the protozoan genus Plasmodium. The 5 most common species affecting humans are as follows:
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P vivax: If this kind of infection goes untreated, it usually lasts for 2-3 months with diminishing frequency and intensity of paroxysms. Of patients infected with P vivax, 50% experience a relapse in a few weeks to 5 years after the initial illness. Splenic rupture may be associated with P vivaxinfection secondary to splenomegaly resulting from RBC sequestration. P vivax infects only immature RBCs, leading to limited parasitemia.

P ovale: These infections are similar to P vivax infections, although they are usually less severe. P ovale infection often resolves without treatment. Similar to P vivax, P ovale infects only immature RBCs and parasitemia is usually less than that seen in P falciparum. P malariae: Those infected with this species of Plasmodium remain asymptomatic for a much longer period of time than those infected with P vivax or P ovale. Recrudescence is common in those infected with P malariae. It often is associated with a nephrotic syndrome, possibly resulting from deposition of antibody-antigen complex upon the glomeruli. P knowlesi: Autochthonous cases have been documented in Malaysian Borneo, Thailand, Myanmar, Singapore, and in the P hilippines, and other neighboring countries. It is thought that simian malaria cases probably also occur in Central America and South America. Patients infected with this, or other simian species, should be treated as seriously as those infected with falciparum malaria, as P knowlesi may cause fatal disease.2 P falciparum: The most malignant form of malaria is caused by this species. Infection with P falciparum is not limited to RBCs of a particular age and, hence, represents the highest level of parasitemia among the 5 Plasmodium species. This species also causes vascular obstruction due to its ability to adhere to endothelial cell walls. This property leads to most complications of P falciparum infection. P falciparum can cause cerebral malaria, pulmonary edema, rapidly developing anemia, and renal problems. Blackwater fever, is the darkening of the urine seen with severe RBC hemolysis resulting from high parasitemia, and is often a sign of impending renal failure and clinical decline.

Other less common routes of infection are through blood transfusion and maternal-fetal transmission. When P vivax and P ovale are transmitted via blood, no latent hypnozoite phase occurs and treatment with primaquine is not necessary, as it is the sporozoites that form hypnozoites in infected hepatocytes.

C. MODE OF TRANSMISSION
1. Principal mode of spread of malaria is by the bites of female anopheles mosquito. The female anopheles mosquito is the vector for human malaria. Some 60 species of this mosquito have been identified as vectors for malaria, and their distribution varies from country to country. When a mosquito bites an infected individual, it sucks the gametocytes, the sexual forms of the parasite, along with blood. These gametocytes continue the sexual phase of the cycle and the sporozoites fill the salivary glands of the infested mosquito. When this female mosquito bites the man for a blood meal, which it needs to nourish its eggs, it inoculates the sporozoites into human blood stream, thus spreading the infection. The female anopheles mosquito bites man between 5 PM and 7 AM, with maximum intensity at midnight.

2. Other modes of transmission: Rarely malaria can spread by the inoculation of blood from an infected person to a healthy person. In this type of malaria, asexual forms are directly inoculated into the blood and pre-erythrocytic development of the parasite in the liver does not occur. Therefore, this type of malaria has a shorter incubation period and relapses do not occur. o Blood transfusion (Transfusion malaria): This is fairly common in endemic areas. Following an attack of malaria, the donor may remain infective for years (1-3 years in P. falciparum, 3-4 years in P. vivax, and 15-50 years in P. malariae.) Most infections occur in cases of transfusion of blood stored for less than 5 days and it is rare in transfusions of blood stored for more than 2 weeks. Frozen plasma is not known to transmit malaria. The clinical features of transfusion malaria occur earlier and any patient who has received a transfusion three months prior to the febrile illness should be suspected to have malaria. Donor blood can be tested with indirect fluorescent antibody test or ELISA, and direct examination of the blood for the parasite may not be helpful. In endemic areas, it is safe to administer full course of chloroquine to all recipients of blood transfusion. In transfusion malaria, pre-erythrocytic schizogony does not occur and hence relapses due to dormant hepatic forms also does not occur. Therefore, treatment with primaquine for 5 (or14) days is not indicated. o Mother to the growing fetus (Congenital malaria): Intrauterine transmission of infection from mother to child is well documented. Placenta becomes heavily infested with the parasites. Congenital malaria is more common in first pregnancy, among non - immune populations. Needle stick injury: Accidental transmission can occur among drug addicts who share syringes and needles. (Therapeutic inoculation of malarial parasites, so as to induce fever, was a mode of treatment for neurosyphilis!)

Malaria Cycle

Ruptured blood cells release free parasites (gametocytes) into the host's bloodstream. The human host shows the classic malaria symptoms at this stage. The gametocytes are sucked up by a feeding mosquito and the cycle begins again.

D. INCUBATION PERIOD
The period between the mosquito bite and the onset of the malarial illness is usually one to three weeks (seven to 21 days). This initial time period is highly variable as reports suggest that the range of incubation periods may range from four days to one year. The usual incubation period may be increased when a person has taken an inadequate course of malaria prevention medications. Certain types of malaria (P. vivax and P. ovale) parasites can also take much longer, as long as eight to 10 months, to cause symptoms. These parasites remain dormant (inactive or hibernating) in the liver cells during this time. Unfortunately, some of these dormant parasites can remain even after a patient recovers from malaria, so the patient can get sick again. This situation is termed relapsing malaria. y y y 12 days for P. Falciparum 14 days for P. vivaxand ovale 30 days for P. malariae

E. PERIOD OF COMMUNICABILITY
Infective as long as gametocytes & asexual forms remain in the blood.

F. SIGNS AND SYMPTOMS

The symptoms characteristic of malaria include flu-like illness 8-30 days after infection with fever, chills, muscle aches, and headache. Some patients develop nausea, vomiting, cough, and diarrhea. Cycles of chills, fever, and sweating that repeat every one, two, or three days are typical. There can sometimes be vomiting, diarrhea, coughing, and yellowing (jaundice) of the skin and whites of the eyes due to destruction of red blood cells and liver cells. People with severe P. falciparum malaria can develop bleeding problems, shock, liver or kidney failure, central nervous system problems, coma, and can die from the infection or its complications. Cerebral malaria (coma, or altered mental status or seizures) can occur with severe P. falciparum infection. It is lethal if not treated quickly; even with treatment, about 15%-20% die.

G. DIAGNOSIS
Malaria is a very simple disease to diagnose and treat; yet it claims more lives than any other infectious disease in the world. It is therefore very essential that every case of malaria be assessed thoroughly. Clinical examination: General: Functional status, prostration, breathlessness, level of consciousness, hydration, toxicity, puffiness of face and lids, etc. Vital signs: Pulse rate, blood pressure (hypotension), temperature (hyperpyrexia), respiratory rate (tachypnoea, acidotic breathing). Other signs: Pallor, Jaundice, Cyanosis, Edema, etc. Abdomen: Liver, spleen, bowel sounds - Tender hepato/ splenomegaly is more common in acute malaria. Respiratory system: Basal crackles, wheezes; sometimes, associated pneumonia and its bronchial breath sounds. C.N.S.: Level of sensorium, convulsions, neck stiffness, ocular fundii, any focal deficits. Investigations: Hemoglobin: Anemia is common in malaria. Rapid reduction in level of hemoglobin is seen in falciparum malaria and less than 7 g/ dl should be a warning. Total leukocyte count: It can vary from low to high, and neutrophilic leukocytosis is common in severe malaria with or without associated bacterial infection. Leukopenia is seen in severe malaria with septicemia, and chronic hypersplenism. Platelet count: Thrombocytopenia is common in P. falciparum and P. vivax malaria, but it does not correlate with the severity of the infection. Parasite count: This is a simple yet very important and useful method of assessing the severity of infection in falciparum malaria. It should be done routinely in all cases of falciparum malaria.

How to do a parasite count? Thick film: The density of malarial parasites can be read against the leukocytes and an approximate parasite count can be calculated. a. Count the number of asexual forms of the parasite ( rings, trophozoites and schizonts) against 100 leukocytes and multiply by 75, this gives an approximate total per micro liter (mm3). b. The average leukocyte count per microscopic field is about ten. Therefore, multiply the average number of parasites per field by 750, this also gives an approximate total per micro liter. Thin film: Count the number of parasites within 1000 red blood cells and divide this by 10. This gives the percentage of parasitemia. A parasite count of 100000 or more per mm3 (or 5% and more) is considered as severe infection. Blood Glucose: Hypoglycemia is a common problem encountered in malaria and may remain undetected because the symptoms and signs of hypoglycemia viz. sweating, tachycardia etc., are even otherwise seen in malaria. It is very important to monitor the blood glucose levels once at least 6 hours in falciparum malaria, particularly if the patient is pregnant or is receiving quinine. Other investigations: Moderate elevation in blood urea and creatinine are common. Significant increase is suggestive of renal impairment. Hyperbilirubinemia is common in malaria, particularly due to hemolysis. Some patients with falciparum malaria may have very high levels of conjugated bilirubin due to associated hepatocyte dysfunction. Serum albumin levels may be reduced, some times markedly. Serum aminotransferases, 5' - nucleotidase and lactic dehydrogenase are elevated. Prothrombin time and partial thromboplastin time are elevated in 20% of patients with cerebral malaria. Some may have features of disseminated intravascular coagulation. Hyponatremia is common and needs careful management. Lactic acidosis is seen in severely ill patients, especially in patients with hypoglycemia and renal dysfunction. It can be suspected if there is a wide anion gap. Urine examination may show albuminuria, microscopic hematuria, hemoglobinuria and red cell casts. With massive intravascular hemolysis, urine may be black in colour.

H. TREATMENT
Three main factors determine treatments: the infecting species of Plasmodium parasite, the clinical situation of the patient (for example, adult, child, or pregnant female with either mild or severe malaria), and the drug susceptibility of the infecting parasites. Drug susceptibility is determined by the geographic area where the infection was acquired. Different areas of the world have malaria types that are resistant to certain medications. The correct drugs for each type of malaria must be prescribed by a doctor who is familiar with malaria treatment protocols. Since people infected with P. falciparum malaria can die (often because of delayed treatment), immediate treatment for P. falciparum malaria is necessary. Mild malaria can be treated with oral medication; severe malaria (one or more symptoms of either impaired consciousness/coma, severe anemia, renal failure,pulmonary edema, acute respiratory

distress syndrome, shock, disseminated intravascular coagulation, spontaneous bleeding, acidosis, hemoglobinuria[hemoglobin in the urine], jaundice, repeated generalized convulsions, and/orparasitemia [parasites in the blood] of > 5%) requires intravenous (IV) drug treatment and fluids. Drug treatment of malaria is not always easy. Chloroquine phosphate is the drug of choice for all malarial parasites except for chloroquine-resistant Plasmodium strains. Although almost all strains of P. malariae are susceptible to chloroquine, P. falciparum,P. vivax and even some P. ovale strains have been reported as resistant to chloroquine. Unfortunately, resistance is usually noted by drugtreatment failure in the individual patient. There are, however, multiple drug-treatment protocols for treatment of drug resistant Plasmodium strains (for example, quinine sulfate plus doxycycline [Vibramycin, Oracea, Adoxa, Atridox] or tetracycline [Achromycin], or clindamycin [Cleocin], oratovaquone-proguanil [Malarone]). There are specialized labs that can test the patient's parasites for resistance, but this is not done frequently. Consequently, treatment is usually based on the majority of Plasmodium species diagnosed and its general drug-resistance pattern for the country or world region where the patient became infested. For example, P. falciparum acquired in the Middle East countries is usually susceptible to chloroquine, but if acquired in sub-Sahara African countries, is usually resistant to chloroquine.

I. NURSING RESPONSIBILITIES
For cold stage: provide warmth to patient -add clothing -warm drinks -hot water bags -socks For hot stage: to lower body temperature -TSB -light, loose clothing -antipyretics For diaphoretic stage: -keep pt. comfortable with dry, warm clothes, replace fluid loss -monitor V/S -high calorie diet, vitamins and minerals -fluid and electrolytes balance

J. NURSING PROBLEM
y y y y y y dehydration, oliguria, anemia, cerebral malaria anxiety related to disease process imbalance nutrition less than body requirements sleep pattern disturbance acute pain hyperthermia

K. HEALTH TEACHING
Precaution / Prevention y y y

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Avoid exposure to mosquitoes during the early morning and early evening hours between the hours of dusk and dawn (the hours of greatest mosquito activity). Wear appropriate clothing (long-sleeved shirts and long pants, for examples) especially when you are outdoors. Apply insect repellent to the exposed skin. The CDC recommended insect repellent should contains up to 50% DEET (N,N-diethyl-m-toluamide), which is the most effective mosquito repellent for adults and children over 2 months of age. Spray mosquito repellents on clothing to prevent mosquitoes from biting through thin clothing. Use a permethrin-coated (or similar repellant) mosquito net over your all beds. Have screens over cover windows and doors. Take anti-malaria drugs -- When traveling to an area known to have malaria, discuss your travel plans with a doctor well before departure. Medicines to prevent malaria are usually prescribed for persons traveling to areas where malaria is common. Travelers from different countries might receive different recommendations because of differences in the availability of medicines. Travelers visiting only cities or rural areas where there is no risk of malaria might not need preventive drugs. An exact itinerary is needed to decide on the right degree of protection. To be sure that your anti-malaria drug helps protect you against malaria, you must follow the recommended doses and schedules exactly:
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Take pills on the same day each week, or, for pills to be taken daily, at the same time each day. Take pills after meals. Take the recommended doses 1 to 2 weeks before travel, throughout the trip, and for 4 weeks after leaving the area with malaria. Do not stop taking the pills after arriving home. Complete the full dosage.

Travelers should understand that they can get malaria even if they use anti-malaria drugs. Pregnant women and young children need special instructions because of the potential effects of malaria illness and the danger in using some drugs for malaria prevention and treatment. Seek medical help in case of illness -- Symptoms of malaria can be mild. Travelers should suspect malaria if they experience an unexplained fever while in or after returning from an area where malaria is common. Persons with suspected malaria should get medical help right away.

References: http://www.medicalnewstoday.com/articles/150670.php http://www.malariasite.com/malaria http://www.dhpe.org/infect/Malaria.html