CD TOPIC: MALARIA

September 19, 2012

melgenrenmegrap DR. FORTUNO

Definition:
 Disease caused by protozoan parasites called
Plasmodium.
 It is usually transmitted through the bite of an
infected female Anopheles mosquito.
 Malaria may also be transmitted through the
following:
 Transfusing blood that is positive for malaria parasites
 Sharing of IV needles (especially among IV drug
users)
 Trans -placental (transfer of malaria parasites from an
infected mother to her unborn child)
OVERVIEW OF MALARIA
 Most important parasitic disease in humans globally.
 Causes a heavy burden among tropical countries.
 Poses a threat to non – endemic countries.
 Poses a danger to international and local travellers.
LIFE CYCLE
EPIDEMIOLOGY
***Definitive Host – it is where the sexual stage takes place
Therefore, Mosquitoes – are the definitive host
What are the common species of malaria parasites in the
Phiilippines?
Plasmodium falciparum and Plasmodium vivax are the
common species of malaria parasites in the Philippines
where 70% of malaria cases are P. falciparum while 30% are
P. vivax cases.
*There are also P. malariae cases and contributes to about
< 1% of the total malaria cases.
• P. falciparum malaria, if not treated immediately, can
lead to severe malaria, such as cerebral malaria.
• P. vivax malaria does not lead to cerebral malaria but
it causes relapse if treatment was not completed.
Do all mosquitoes carry the malaria parasite?
 No, not all mosquitoes carry the malaria parasite.
 In the country, it is the adult female Anopheles
mosquito that can become infective and therefore
carries the malaria parasite after she bites a person
infected with malaria.
 The malaria parasite undergoes several
developmental stages inside the adult female
mosquito until such time that the mosquito becomes
infective with malaria parasites.
 This anopheles mosquito bites from dusk to dawn
(night biting) and it breeds in clear, slow flowing
streams that are found in mountainous/forested
areas or in brackish water where salt and fresh water
meet. This is usually found in coastal areas.
• Endemicity is defined as palpable spleen rates in
children 2 – 9 years old:
 < 10% - hypoendemic
 11-50% - mesoendemic
 51 – 75% - hyperendemic
 > 75% - holoendemic
• Africa and New Guinea
• PRINCIPAL DETERMINANTS ARE:
– Biting habits
– Density of the population
– Longevity of the anopheline mosquito
• The lifecycle that takes place inside
the mosquito is between 8 – 30
days.
• Low temperatures are not
conducive for sporogony to take
place.

• Stable transmission
– Constant year round transmission.
– By adulthood would have achieved full
immunity
• Unstable transmission
– Erratic transmission
– Usually in hypoendemic areas
– Full protective immunity is not acquired

Who are at risk in getting malaria?

 Children
 Pregnant women
 Indigenous peoples
 Forest workers, miners, soldiers
  Persons who are not from a malaria endemic area
but travel to this area
Can a person get malaria by drinking water in the streams
with mosquito eggs?
 No. The malaria parasite has to undergo development
inside the adult female mosquito; therefore one
cannot get malaria from drinking water that has
mosquito eggs in it.
BASIS FOR CHEMOPROPHYLAXIS
• Each species has a specific incubation period.
• P. falciparum infection typically develops within a
month of exposure. Rare cases have been reported
up to a year later.
• Hypnozoite form – P. vivax and P. ovale.
– Parasite stays in the liver for months before
inducing initial infection.
RBC CHANGES
• Once inside the cell, it consumes and degrades
intracellular proteins (hemoglobin).
• Alteration in RBC properties more irregular in shape
and less deformable.
• P. falciparum – causes appearances of knobs on the
cell surface.
– Mediates attachment to the capillary and
venular endothelium (cytoadherence).
P. FALCIPARUM
• Causes severe malaria.
• Creates a high level of parasitemia and sequestration
causing end organ damage.
• Sequestration is a specific property.
• Usually seen in the smears are younger forms before
sequestration takes place.
SEQUESTRATION
• Contribute to mental changes and coma.
• End organs affected are:
– CNS, lungs and kidneys.
OTHER THINGS NOTED IN P. FALCIPARUM INFECTION:
• Hypoglycemia
• Lactic acidosis
• Severe anemia
• Multi - organ dysfunction secondary to hypoxia.
• Usually occurs in travelers without immunity or young
children living in endemic areas.
TYPICAL MANIFESTATIONS IN DIAGNOSING MALARIA:
• Cerebral malaria – almost always due to P. falciparum
infections.
– Coma lasts more than 30 minutes.
• Severe anemia – usually associated with P. falciparum
infections.
• May be secondary to RBC infection and a loss of
infected RBC.
• Uninfected RBCs are inappropriately cleared and
bone marrow suppression may also be involved.
RENAL FAILURE
• Infected RBCs adhere to the microvasculature in the
renal cortex.
• Oliguric renal failure.
• Usually reversible.
• P. malariae can cause the nephrotic syndrome
RESPIRATORY SYMPTOMS
• Metabolic acidosis leading to respiratory distress.
• Can develop pulmonary edema.
 ROSETTE FORMATION – infected RBCs may adhere to
uninfected RBC.
 AGGLUTINATION – infected RBCs adhere to other
parasitized RBCs.
A combination of all these results in…
 Interfere with microcirculatory circulation and
metabolism especially in the brain.
INNATE IMMUNITY
• Depends on the host’s immunity.
• P. falciparum usually results in death.
PROTECTIVE GENETIC FACTORS:
• Sickle cell disease
• Hemoglobinopathies
• Polymorphisms in the host’s Tumor Necrosis Factor
(TNF).
HISTORY TAKING
• Get a history of recent travel in those patients with
high grade fever.
• Most patients will present with fever and headache.
– There is no neck stiffness or photophobia
resembling meningitis.
P. VIVAX AND P. OVALE
• Patient may relapse after long periods because of the
hypnozoite stage in the liver.
• Can remain dormant for months to years before
entering the blood stream to produce symptoms.
• Causes the benign form of tertian fever.
– (P. malariae causes the quartan fever.)
PHYSICAL EXAMINATION
Most patients will have splenomegaly.
Statistics
• P. falciparum and P. vivax – responsible for most new
infections.
DEMONSTRATION OF THE PARASITE
• Must identify the asexual forms in the peripheral
blood smear.
• Negative smears do not rule out malaria if there is a
high degree of suspicion. Repeat.
• Use the Giemsa stains at pH – 7.2
• Thick blood smear provides better sensitivity.
• Thin blood smear provides better specificity and
allows better identification of the species involved.
• Not so diagnostic in P. falciparum infections since
sequestration removes the RBCs out of the peripheral
circulation especially in the late stages.
MALARIA SUSPECT:
• Patients with malaria like illness
• With thrombocytopenia
• Relative lymphopenia
• Atypical lymphocytes
• Elevated LDH
 CHEMOPROPHYLAXIS
Thick and thin smears done 12 – 24 hours apart during Doxycycline 100 mg daily for 2 – 3 days before going to an
the spike of the fever. endemic area, continue while in the endemic area and
continue for 4 more weeks after leaving the endemic
THICK SMEARS THIN SMEARS
Primaquine
• More sensitive than  Less sensitive.  Prevents drug resistant falciparum and vivax
thin smears.  Facilitate speciation
• Cant speciate.  Qualitative test
malaria in adults.
• Parasitemia can be  Contraindicated in pregnant patients or new born
calculated based on the babies.
number of infected
 (x) G6PD deficiency  hemolysis  death
RBC.
• Quantitative test Personal protection
1. Reduce the frequency of mosquito bites.
2. Avoid the mosquito’s peak feeding hours.
ALTERNATIVE TESTS
3. DEET and picaridin
• Quantitative buffy coat – as sensitive as a thick smear
but must still do a thin smear. 4. Insecticide impregnated mosquito nets.
• Histidine rich protein - 2 ( the only approved rapid test
in the US. Malaria situation in the Philippines
 Malaria is a rural disease
TREATMENT
 One of the important mosquito-borne diseases
• P. falciparum – resistant to chloroquine.
• P. vivax – not so resistant to chloroquine. affecting far-flung barangays of the country
• P. ovale and P. malariae – sensitive to chloroquine.  Out of the 79 provinces nationwide, 57 are
• Primaquine - needed to treat the hypnozoites (liver malaria endemic
phase).
Malaria Control Program
ARTESUNATE Vision: malaria-free Philippines by 2020.
• IV anti – malarial now used in the US for severe
complicated malaria. Malaria Endemic Areas
• Reduced mortality among children in African Strategies:
countries compared with quinine.
• Patients have less symptoms of coma, seizures, post – 1) Early diagnosis and prompt treatment;
treatment hypoglycemia.
2) Vector control – insecticide-treated mosquito net as
• Water soluble derivative from artemisinin.
• Drug of choice for severe falciparum malaria. main vector control strategy, complemented by indoor
residual spraying;
Recommendations for malaria treatment: 3) early management and disease surveillance;
• P. falciparum malaria: 4) monitoring and evaluation
• Quinine plus doxycycline or clindamycin or
pyrimethamine – sulfadoxine. Current Treatment Policy in the Philippines
• Alternative treatment:
Uncomplicated Plasmodium falciparum:
• Artemether – lumefantrine, or
mefloquine  Combination therapy of chloroquine and
ARTEMISININ sulfadoxine/pyrimethamine as the 1st line
• Approved in 2009. treatment of uncomplicated P. falciparum.
• Can not be used as monotherapy because of a high  Artemisinin-based combination (Coartem®) is
rate of resistance. the 2nd line treatment of uncomplicated P.
– Due to only a temporary stop in the growth falciparum and is used if 1st line drugs are not
of ring stage parasites (dormant forms) after available or if there is treatment failure from 1st
exposure to artemisinin. line drugs.
> Primaqine is given on the 4th day of treatment
CHLOROQUINE PHOSPHATE
• Can be used for prophylaxis and treatment.
Treatment of severe P. falciparum
• Drug of choice for chloroquine sensitive malaria.
• Aralen (brand name)  Combination therapy of quinine ampule/tablet plus
any of the following antibiotics:
QUININE 1. Tetracycline,
• No role in prophylaxis
• Used with second agent in drug – resistant falciparum 2. Doxycycline or
infections. 3. Clindamycin.
FANSIDAR
• Pyrimethamine –sulfadoxine. Plasmodium vivax treatment with Chloroquine for 3
• Can also be used for treatment. days and Primaquine for 14 days
• Not anymore considered as a first line drug for
prophylaxis because of adverse drug reactions.
----END OF LECTURE----