2. INTRODUCTION
It is a protozoal disease caused by infection with
parasites of genus Plasmodium
It is transmitted to man by certain species of
infected female anopheles mosquito.
Its attack has three distinct stages-
-Hot Stage
-Cold Stage
3. PROBLEM STATEMENT
WORLD
2015 :- 214 million cases of malaria with 438000 deaths
Between 2000-2015 incidence of malaria decreased by
37% globally and mortality rate decreased by 60.
By 2015 Sub Saharan African region was home to 88% of
global malaria burden and 90% of malaria deaths.
4. INDIA
About 21.98% population lives in malaria high transmission areas.
About 67% in low transmission areas.
91% of malaria cases and 99% death is reported from North-
Eastern states, Chattisgarh, Jharkhand, Madhya Pradesh,
Odisha, Andhra Pradesh, Maharashtra, Gujarat, Rajasthan, West
Bengal and Karnataka.
From 2000-2015 case declined by 44% from 2.03 million to 1.13
million and death by 69% from 932 to 287 annually.
The Plasmodium falciparum percentage declined from 2000-2013 to
50% then rose to 65.6% in 2014 to 67.1% in 2015. Due to
increase P.falciparum detection by widespread use of R.D.T’s by
trained ASHA.
Seasonal transmission with increased intensity related to rains.
5. RISK GROUPS
1. Young children in stable transmissions
areas who have not yet developed
protective immunity against the most
severe form of disease.
2. Non immune pregnant women.
3. Semi immune pregnant women in areas of
high transmission in first and second
pregnancies. Malaria can cause
miscarriage, low birth weight, maternal
death.
6. 4. Semi immune HIV-infected
pregnant women in stable
transmission areas in all
pregnancies.
5. People with HIV/AIDS.
6. International travellers from non
endemic areas.
7. Immigrants and children from
non endemic areas.
7. 6 primary vectors of Malaria in India
An.culicifacies
An.stephensi
An.fluviatilis
An.minimus
An.dirus
An.epiroticus
8. Major Epidemiological types of Malaria in India
1.Tribal Malaria- 50% of p.falciparum cases are
infant, children and pregnant women are identified
as high risk groups followed by mobile tribal
people.
2. Rural Malaria- Irrigated areas of arid and semi
arid areas. An.culicifacies is the main vector and
P.vivax is periodic during lean period.
3. Urban Malaria- 15 major cities including 4
metropolitans account for 80% of malaria cases
covered under Urban Malaria Control Scheme.
9. 4. Malaria in Project Areas- Project areas are
those areas where construction and development
activities are taken up and temporary tropical
aggregative of labour takes place bringing on
different strains of malaria parasites and non-
immune population.
5. Border Malaria- High malaria transmission
alongwith International and State Border.
6. Forest Malaria- Forest and settlement in recently
deforested areas are known to harbour very efficient
malaria vectors.
7. Flood and Malaria- Rise in incidence of malaria
and flooding may flush out mosquito breeding. Later
creating mosquitogenic conditions.
10. EPIDEMIOLOGICAL
DETERMINANTS
AGENT FACTORS
Agent- Caused by 4 species-
P.vivax
P.falciparum
P.ovale
P.malariae
P.vivax has widest geographical distribution all over the world , In
India 50% cases are of P.falciparum and 2-8% are mixed, rest
due to P.vivax and malaria.
In india P.ovale is absent.
11. Parasite has two cycles
Human cycle- Asexual
Mosquito cycle- Sexual
12. Reservoir of Infection
No animal is reservoir of plasmodium is known
to exist.
Human reservoirs harbours sexual form of
parasites.
Children have more chances of being a
reservoir than adults.
13.
14. Host Factors-
Age- Affects all age groups. New born infants
are resistant to P.falciparum infection.
Sex- Males are more affected than females.
Race- Individual with sickle cell trait have a
milder illness with P.falciparum infection.
Person with RBCs Duffy negative are resistant to
P.vivax.
Pregnancy- Increases the risk of malaria in
pregnant women.
15. • Socio-economic developement- More in poor socio-economic
status.
Housing- ill ventilated and ill lighted house provide ideal place for
mosquitoes to rise.
Population Mobility- People migrating from one region, country or
from a part of a country to another.
Occupation- Common in agriculture practice.
Human Habits- Sleeping outdoors, Nomadism and people refusing to
accept spraying in the house.
16. ENVIRONMENTAL FACTORS
Season- Prevalence from July to November.
Temperature- Optimum temperature for development of malaria
parasite 20-30 degree Celsius.
Humidity- 60% is necessary for mosquito to live normal
lifespan.
Rainfall- Rainfall provides opportunities for breeding of mosquitoes and
give rise to epidemics.
Altitude- Anopheles are not found above 2000-2500m altitude.
Man made Malaria- Burrow pits, garden pools, irrigation channels and
engineering projects like construction of dams, roads and bridges have
led to breeding of mosquitoes.
17. VECTORS OF MALARIA
Density- To be an effective vector species must be present in
adequate density in or near human habitation.
Lifespan- Mosquitoes must live for atleast 10-12 days after an
infected blood meal to become infected.
Choice of Host- Human blood meal by Anopheles is 2-80%.
Resting Habitats- After blood meal malaria rest indoor in the
walls for quite sometime, this is called endophily.
Breeding Habits- Some breed in brackish water, some in
wells, fountains and overhead tanks.
Time of Bite- Has nocturnal feeding habits between dusk and
dawn.
18. MODES OF TRANSMISSION
Vector Transmission- Bite of infected, female, anopheline
mosquitoes. A single infected vector may infect several
persons.
Direct Transmission- Can be transmitted through
Intravenous or intramuscular injection of blood/plasma.
Congential- Newborn from the infected mother may also
occur.
19. INCUBATION PERIOD
Not less than 10 days
The duration for P.falciparum is 9-14 days.
P.vivax duration is 8-17 days.
P.malariae duration is 18-40 days.
P.ovale duration 16-18 days.
20. CLINICAL FEATURES
Primary fever is marked by paroxysms which correspond to the
development of parasite in the RBCs.
Cold Stage- Lassitude, headache, nausea, chilly sensation followed in
an hour or so by rigors.
Temperature rises from 39-41 degree C.
Early stage skin feels cold and then later becomes hot.
Parasite are demonstrated in blood (15-60 mins)
Hot Stage- Person feels burning hot and cast off his cloths. Skin is hot
and dry to touch. Pulse and respiration is rapid.
Sweating Stage- Fever comes down with profuse sweating, skin is cool
and moist.
21. Measurement of malaria
Pre eradication era :
Spleen rate
Average enlarged spleen
Parasite rate
Parasite density index
Infant parasite rate
Proportional case rate
23. DIAGNOSIS
Microscopic-
Thin Film- To identify the species of the parasite present.
Thick Film- Used for finding the parasite.
Serology-
Malarial fluorescent Antibody Test becomes positive after two weeks
or after primary infection.
Rapid Diagnostic Test-
For detection of circulating parasite antigen with a simple dipstick
format.
Some are for P.falciparum only and others can detect other parasites
also.
24. APPROACHES AND STRATEGIES OF
MALARIA CONTROL
Initially the Malaria Control Programme was started in 1953 then it was integrated
for strategic action plan for malaria control in India 2012 -2017 with National
Vector Borne Disease Control Programme.
Strategies are -
Surveillance and Case Management-
Case detection
Early diagnosis and complete treatment
Sentinel surveillance
Integrated vector management-
Indoor residual spray
Insecticide tested bed nets
Anti-larval measures including source reduction.
25. Epidemic- Preparedness and early diagnosis
Supportive Interventions-
Capacity building
Behavioural and Communicable Changes (BCC)
Intersectorial Collaboration
Monitoring and Evaluation
26. AIMS OF EARLY DIAGNOSIS AND
TREATMENT OF MALARIA
Complete cure.
Prevention of progression of uncomplicated malaria
to severe disease.
Prevention of death.
Interruption of transmission chain.
Minimising risk of selection and spread of drug
resistant malaria parasite.
27. Treatment of Uncomplicated
Malaria
1. Treatment of P. Vivax Cases
Chloroquine 25 mg/kg divided over three days should be
given for relapse Primaquine 0.25mg/kg for 14 days should
be given
2.Treatment of P. Falciparum
Artemisinin Combination therapy :
Artesunate 3 days +Sulphadoxine -pyrimethamine 1 day
Accompanied by single dose of Primaquine 0.75 mg/kg
28. 3. Treatment of malaria in pregnancy
For P. Falciparum : ACT in 2 and 3
trimester
For P. Vivax : Chloroquine
Primaquine is contraindicated in it.
4. Mixed form
Quinine with Tetra / Doxycycline should be given
.
Reported to district /state malaria officer.
29. Chloroquine resistant P. Falciparum
1.ACT regimen (any one)
Artesunate 100mg BD for 3 days +mefloquine 750 mg 2 day and 500
mg 3 day.
Artemether 80mg + Lumefantrine 480 mg 3days
Artesunate 4mg/kg/day +amodiaquine 10mg/kg/day for 3-7days
Artesunate 2mg/kg OD + tetracycline 4mg/kgQID for 7 days
Artesunate 2mg/kg OD + doxycycline 3.5mg/kgOD 3-7 days
Artesunate 2mg/kgOD + clindamycin 10mg/kgBD 7 days
2. Alternative to ACT regime
Quinine sulphate 650 mg orally TDS for 3-7 days +clindamycin 600 BD
for 7 days
30. Diagnosis of Malaria
All fever cases diagnosed as malaria by either RDT or
microscopic.
Treatment depend upon the diagnosis of malaria .
Malaria caused by different species have different treatment.
They are diagnosed by three way :
Microscopy
Monovalent RDT where microscopy is not present
Bivalent RDT where microscopy is not present
31. Treatment of malaria
1.Treatment for P. Vivax
1. Chloroquine : 25mg/kg body weight divided over 3 days
10 mg/kg on day 1
10 mg/kg on day 2
5mg/kg on day 3
2.Primaquine : 0.25mg/kg body weight for 14 days
Contraindicated in infants ,pregnant women and with
G6PD deficiency patients
Treatment for P. Falciparum : Diagnosis by RDT
Artesunate 50mg tablet for 3 days and Sulfadoxine - Pyrimethamine
Containing 500mg Sulfadoxine and 25 mg Pyrimethamine
32. Treatment of mixed infections : They should
be treated with ACT and Primaquine.
In North-Eastern State: Treat with : Age specific
ACT-AL for 3 days and Primaquine 0.25
mg/kg body weight day for 14 days.
In other state : ACT-SP for 3 days +Primaquine
0.25 mg/kg body weight for 14 days .
33. Recommendation :-
Avoid empty stomach
First dose should be given observation
If vomits occur within 15 min. then repeat the dose for blister
pack , if vomiting occurs again then severe case refer to
nearest PHC/CHC/Hospital.
34. Resistance To Anti-
Malarial Drug
It is the ability of a parasite strain to survive
and multiply despite the administration and
absorption of a drug given in doses equal to
or higher than those usually recommended
but within the limit of tolerance of patient.
35. • Acquired by genetic metabolism
Parasite acquired resistance by :
Due to insufficient amount of drug due to low
dose prescription
Lesser amount of drug dispensed
Incomplete treatment taken by patient
Drug vomited out
Low absorption due to diarrhoea , poorly stored
drug and poor quality of drug.
36. Treatment Failure
Some patient may not respond to treatment which may be
due to acquiring resistance or treatment failure ,specially in
P. Falciparum
Early treatment failure : development of danger sign or
severe malaria on day 1,2,3 in the presence of parasitaemia
Late clinical features : development of danger sign or severe
malaria in of parasitaemia on any day between 4-28.
Late parasitological failure : presence of parasitaemia any
day between 7-28 with axillary temp. >37.5 degree C.
37. Clinical features in severe malaria
Impaired consciousness
Renal failure
Repeated generalised convulsion
Jaundice
Severe anemia
Hypoglycaemia
Metabolic acidosis
Shock
Abnormal bleeding
Hyperthermia
Hyperparasitaemia
38. Treatment of severe malaria case
Initial parental treatment for 48 hours :
Quinine : 20 mg salt/kg body weight through I.V or I.M
Followed by maintenance dose of 10 mg /kg 8 hourly , infusion rate does
not exceed 5mg/kg per hour.
OR
Artesunate : 2.4 mg/kg I.V or I.M, then at 12 h and 24 h, then once a day.
OR
Artemether :3.2 mg/kg body weight given I.M. then 1.6 mg/kg per day.
OR
Arteether : 150 mg daily IM for 3 days.
39. Follow up treatment :
Quinine 10mg/kg 3 times a day with doxycycline 100mg once a day or
clindamycin in pregnant women and children under 8 years of age
to complete 7 days of treatment .
Full oral course of area -specific ACT:
In North Eastern states : age specific ACT-AL for 3 days
+Primaquine single dose on 2 day.
In other states : Treat with : ACT-SP for 3 days +Primaquine
single dose on 2 day.
40. Chemoprophylaxis
Chemoprophylaxis of malaria has, with the development of drug
resistance, become unreliable.
For traveller from non endemic areas and as a short term measure for
soldiers ,police and labour forces serving in highly endemic areas.
Short term chemoprophylaxis (<6 weeks ):
Dosing schedule for children on body weight
Antimalarial to be taken daily
Weekly chloroquine should be started 1 week before arrival
Weekly primaquine should be started 2-3 week before departure
All drug taken with unfailing regularities should be continued 4week after
the last possible day of exposure.
41. Long term prophylaxis (>6weeks)
300 mg of chloroquine weekly for 5 yrs , require
prophylaxis for retinal change twice a year.
Mefloquine is also safe and well tolerated with no
accumulation on long term intake .
Drug regimens for prophylaxis of malaria
Chloroquine 100 -150 mg
Proguanil 100 mg
Mefloquine 250 mg
Doxycycline 100 mg
