MALARIA-IN MALARIA-IN BELGAUM-2008BELGAUM-2008

Dr.J.Nuchin. Dr.J.Nuchin. M.D.,M.B.AM.D.,M.B.A..Epidemiologist Epidemiologist

BelgaumBelgaum

MALARIAMALARIA

By the end of session, you would By the end of session, you would be expected to be able to be expected to be able to describe:describe:

Problem statement Life cycle of parasiteType of vectorClinical features8 important CFs of severe

complicated malariaTreatment Diagnosis

Introduction…Introduction… A protozoan disease caused by a parasite A protozoan disease caused by a parasite

plasmodiumplasmodium A major parasitic cause of death in manA major parasitic cause of death in man One of the oldest recorded diseasesOne of the oldest recorded diseases Malaria was well known to the Ancient Greeks Malaria was well known to the Ancient Greeks

and Romans. and Romans. The Romans thought the disease was caused by The Romans thought the disease was caused by

bad air (bad air (mal-ariamal-aria) from swamps, which they ) from swamps, which they drained to prevent the disease.drained to prevent the disease.

A tropical disease-considered as ‘king of A tropical disease-considered as ‘king of tropical diseases’tropical diseases’

Problem statementProblem statement-World-World

Has been a scourge of Has been a scourge of mankind for the centuriesmankind for the centuries

Total death toll due to Total death toll due to malaria is more than that malaria is more than that due to any other diseases due to any other diseases or even warsor even wars

Endemic in 91 countries Endemic in 91 countries covering about 40% of covering about 40% of global populationglobal population

Burden – 300-500 million Burden – 300-500 million cases and 2-3 million deathscases and 2-3 million deaths

African countries contribute African countries contribute 90% of the total burden90% of the total burden

Malaria in AfricaMalaria in Africa• Kills a child every 10 Kills a child every 10

to 15 seconds or to 15 seconds or 8000 children per 8000 children per dayday

• 90 percent of global 90 percent of global incidence of malaria incidence of malaria occurs in Africaoccurs in Africa

• Nine of 10 deaths Nine of 10 deaths globally are among globally are among sub-Saharan children sub-Saharan children under age 5under age 5

Indian scenarioIndian scenario

Has always been a home ground for Has always been a home ground for malariamalaria

Before 1947 (preDDT era)- malaria was a Before 1947 (preDDT era)- malaria was a major cause of deathmajor cause of death

In 1908, an outbreak in UP and Punjab In 1908, an outbreak in UP and Punjab killed more than 3 lakh people in just a killed more than 3 lakh people in just a span of 2 monthsspan of 2 months

In 1947, India had about 75 million cases In 1947, India had about 75 million cases and >50% of total deaths were due to and >50% of total deaths were due to Malaria alone Malaria alone

Contnd…Contnd…

• All the aspects of life All the aspects of life were affected directly were affected directly or indirectlyor indirectly

• Industrial and Industrial and agricultural production agricultural production was very lowwas very low

• At present, 2-2.5 At present, 2-2.5 million cases are being million cases are being reported with 1000 reported with 1000 deaths every yeardeaths every year

Current situation analysis of Current situation analysis of malaria in Indiamalaria in India• 1 Billion population at risk of malaria• 10 Million population under sp treatment• 2 Million cases reported • 800-1000 malaria deaths reported • 6 Major vectors-resistant, exophilic and or endophilic

behavior• New malaria ecotypes identified• Spraying produces transient control• Widespread mono-drug resistance, multi-drug

resistance in p. falciparum • Inadequate resources• 1 billion us dollars loss due to malaria

Major malaria ecotypes found in India

• Rural malariaRural malaria

• Urban malariaUrban malaria

• Forest malariaForest malaria

• Irrigation malariaIrrigation malaria

• Project malariaProject malaria

• Migration malariaMigration malaria

• Border malariaBorder malaria

Factors responsible for the Factors responsible for the increase in VBDsincrease in VBDs

Poverty and rapid population growthPoverty and rapid population growthIrrigationIrrigationUrbanization and improper sanitationUrbanization and improper sanitationIndustrializationIndustrializationMigration and rapid population movementMigration and rapid population movementNatural disastersNatural disastersResistanceResistanceGlobal warmingGlobal warmingPolitical instabilityPolitical instabilityInadequate health infrastructureInadequate health infrastructure

1.1 billion people live on less than $1 a day.

2.7 billion people live on less than $2 a day.

IRRIGATION IN INDIAIRRIGATION IN INDIA

22.626.25

29.12 30.5737.1

41.21

52.0256.81

91.02

78.12

0

20

40

60

80

100

Pre 1st 1951-56

IInd1956-61

IIIrd1961-66

Annual1966-69

IVth 1969-74

Vth 1974-78

Annual1978-80

VIth1985-90

VIIth1990-95

Mil

lion

Hec

tare

s

KarnatakaKarnataka A major CMD in the state.A major CMD in the state. 7 districts namely DK,K,R,G,T and 7 districts namely DK,K,R,G,T and

Belgaum together contributed >65% of Belgaum together contributed >65% of the total burden in the state in 2006the total burden in the state in 2006

The P.f cases are being increased.The P.f cases are being increased. Double resistance has been recordedDouble resistance has been recorded

Karnataka in 2006- 62864 cases

Dakshina kannada

21%

Kolar13%

Raichur12%Gulbarga

8%

Tumkur7%

Belgaum7%

Others32%

Geographically the district has Geographically the district has been divided into 3 partsbeen divided into 3 parts1)1) Hilly region- Hilly region-

Khanapur Khanapur

2)2) (South) Semi (South) Semi Malnad – Malnad – Savdatti, Hukkeri, Savdatti, Hukkeri, Bailhongal and Bailhongal and Belgaum Belgaum

3)3) (North) Tropical (North) Tropical Region- Athani, Region- Athani, Raibagh, Gokak, Raibagh, Gokak, Ramdurga and Ramdurga and Chikkodi TaluksChikkodi Taluks

Belgaum districtBelgaum district• Taluks-10Taluks-10• GHs-9GHs-9• CHCs-16CHCs-16• PHCs-140PHCs-140• SCs-660SCs-660• M.O.s-165, HWs-745,LTs-121M.O.s-165, HWs-745,LTs-121• Villages-1160Villages-1160• Rural population-3201814 (2001 census)Rural population-3201814 (2001 census)• Urban population-1012691Urban population-1012691• Total population-4214505Total population-4214505• Density-314 per sq mtrDensity-314 per sq mtr

• The average rain fall in the district is The average rain fall in the district is 808mm every year.808mm every year.

• Krishna, Malaprabha and Ghata prabha Krishna, Malaprabha and Ghata prabha being the major rivers in the districts, it also being the major rivers in the districts, it also has five small rivers namely Markhandeya, has five small rivers namely Markhandeya, Hiranyakeshi, Mahadaayi, Vedaganga and Hiranyakeshi, Mahadaayi, Vedaganga and Dudhaganga. Navilu Tirtha dam is built for Dudhaganga. Navilu Tirtha dam is built for Malaprabha river in Savadatti taluka and Malaprabha river in Savadatti taluka and Hidkal dam for Ghataprabha river in Hukkeri Hidkal dam for Ghataprabha river in Hukkeri taluka. These two huge dams provide taluka. These two huge dams provide irrigation facilities through canals for the 8 irrigation facilities through canals for the 8 taluks of the district taluks of the district

• With many historical places to its With many historical places to its credit and plenty of Jatraas, the credit and plenty of Jatraas, the district attracts travelers from the district attracts travelers from the near by districts and neighboring near by districts and neighboring states all through the yearstates all through the year

22263908

41492859

1674869

352989

26894343

63342102

601692

400574

1490633

8791576

206612511987

198819891990199119921993199419951996199719981999200020012002200320042005200620072008

Trend of Malaria in the District- 1987-2008

Trend of Malaria in the District-1987-2008

0

1000

2000

3000

4000

5000

6000

7000

Talukwise Malaria incidence-2008

Gokak59%

Savdatti18%

Ramdurg13%

Bailhonngal4% Belgaum

4%

Talukwise malaria incidence-2007

Gokak68%

Ramdurg13%

Soundatti10%

Bailhongal5%

Malaria incidence-2006 month wise-Total Cases- 4149

160

9380

246

678

589

551

386363

237

392374

1

Jan to Dec

Mal

aria

cas

es

Monthwise Malaria incidence-2007

210

154181

299

421 429

305279

250

401 419

560

Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec

Monthwise incidence-2004 to 2007

643408 373

776

1498 1483

1072960

836

1358 1334

1849

0

500

1000

1500

2000

January to December

Monthwise Malaria incidence-2007

210

154181

299

421 429

305279

250

401 419

560

Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec

Monthwise Malaria incidence-2008

208183 175

242

332355

208

127 139124

7657

Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec

Trend of Pf incidence rate in the district

45.2

39.5

30.1

28.0

21

2004

2005

2006

2007

2008

Series1 45.239.530.128.021

20042005200620072008

PHCs which reported malaria in 2008PHCs which reported malaria in 2008

• Belgaum taluk-Belgaum taluk- Except Sulebhavi and YallurExcept Sulebhavi and Yallur

• BailhongalBailhongal-Except-Except DodwadDodwad

• ChikkodiChikkodi- - Jainapur and Soundalaga have and Jainapur and Soundalaga have and others notothers not

• GokakGokak--Except Melavanki andExcept Melavanki and ThukkanattiThukkanatti

• Hukkeri-Hukkeri-Ammanagi, Daddi, Hulloli, Kot & Ammanagi, Daddi, Hulloli, Kot & Paschapur have reportedPaschapur have reported

• Khanapur-Khanapur- Except Halashi &Itagi Except Halashi &Itagi

• Ramdurg-Ramdurg- Except Katakol & Ramdurga GH Except Katakol & Ramdurga GH

• Soudatti-Soudatti- Except Sutagatti,Muragod, Except Sutagatti,Muragod, Madlur,Imanhongal,Hirekumbi and AsundiMadlur,Imanhongal,Hirekumbi and Asundi

• Athani and Raibagh-Athani and Raibagh- No cases No cases

What’s the Good News?What’s the Good News?

•Every one of these deaths is Every one of these deaths is preventable!!!preventable!!!

• Just a 3 day course of treatment can cure Just a 3 day course of treatment can cure the diseasethe disease

• No stigma associated with malariaNo stigma associated with malaria

• No morality debatesNo morality debates

• No “Save the Mosquito” groupsNo “Save the Mosquito” groups

Endemicity and immunity to Endemicity and immunity to malariamalaria

Endemicity Malaria is said to be endemic when there is a

constant incidence of cases over a period of many successive years.

Endemic malaria may be present in various degrees. There are four grades A. Hypoendemicity – There is a little transmission

and the disease has little effect on the population. B. Mesoendemicity - varying intensity of

transmission; typically found in the small, rural communities of the sub-tropics.

C. Hyperendemicity - intense but seasonal transmission; immunity is insufficient to prevent the effects of malaria on all age groups.

contnd…contnd…

D. HoloendemicityD. Holoendemicity - - intense transmission intense transmission occurs throughout the year.occurs throughout the year. - As people are continuously exposed to - As people are continuously exposed to malaria parasites, they gradually develop malaria parasites, they gradually develop immunity to the disease.immunity to the disease.

- In these areas, severe malaria is mainly a - In these areas, severe malaria is mainly a disease of children from the first few months of disease of children from the first few months of life to age 5 years. life to age 5 years.

- Pregnant women are also highly susceptible- Pregnant women are also highly susceptible Although seasonal variations in transmission may occur Although seasonal variations in transmission may occur

in holoendemic areas, malaria transmission occurs all in holoendemic areas, malaria transmission occurs all year round. Therefore, people acquire natural immunity year round. Therefore, people acquire natural immunity and epidemics are unlikely.and epidemics are unlikely.

Contnd…Contnd…

Depending on the intensity of transmission, malaria can be stable or unstable, reflecting different epidemic scenarios.

Stable malaria: Sustained incidence over several years. Seasonal fluctuations in transmission may occur but epidemics are unlikely.

Unstable malaria: Marked variations in the

incidence of malaria over time. Population does not develop immunity and people of all ages are susceptible to severe disease when transmission increases.

Agent –Parasite-PlasmodiumAgent –Parasite-Plasmodium• Unicellular Unicellular

• 140 types are there of which only 4 can 140 types are there of which only 4 can infect man(P.vivax, falciparum, ovale and infect man(P.vivax, falciparum, ovale and malariae)malariae)

• Malaria also affects other animals like Malaria also affects other animals like primates, rodents, birds, bats and even primates, rodents, birds, bats and even cold blooded animals like lizards cold blooded animals like lizards

• Some parasites infecting primates can Some parasites infecting primates can also infect man- eg,-P.knowelesi, also infect man- eg,-P.knowelesi, P.brasilianum and P.cyanomalgi P.brasilianum and P.cyanomalgi

Figure 11.30

Plasmodium Sporozoite

Different speciesDifferent speciesP.vivaxP.vivax- all - all over world-over world-less common less common in Africa in Africa

60-70%60-70% BTMBTM MildMild

Anaemia, Anaemia, splenic rupture splenic rupture rarelyrarely

P.falciparumP.falciparum--tropics and tropics and sub-tropicssub-tropics

25-35%25-35% MTMMTM High degree High degree parasitaemia, parasitaemia, all deathsall deaths

P.malariaeP.malariae <1%<1% BQMBQM NSNS

P.ovaleP.ovale-very -very rarerare

NFNF BTMBTM OMOM

Mode of transmissionMode of transmission

1.1. By bite of female anopheles mosquitoesBy bite of female anopheles mosquitoes

2.2. By blood- Blood transfusion and By blood- Blood transfusion and contaminated syringes and needlescontaminated syringes and needles

3.3. Mother to foetus. Mother to foetus.

Congenital malariaCongenital malaria

• Occurs in 5% of the babies borne to mothers Occurs in 5% of the babies borne to mothers who were MP positive during pregnancywho were MP positive during pregnancy

• Transplacental infection– Can occur in all 4 species– Commonly seen P.v. and P.f. in endemic areas– P.m. infections in nonendemic areas due to long

persistence of species

• Neonate can be diagnosed with parasitemia within 7 days of birth

• Fever, irritability, feeding problems, anemia, hepatosplenomegaly, and jaundice

Life cycle of plasmodiaLife cycle of plasmodia

• The parasite 2 cycles of development- the The parasite 2 cycles of development- the Human cycle Human cycle (asexual cycle)(asexual cycle) and and Mosquito cycle Mosquito cycle (sexual cycle)(sexual cycle)

• Man is the Man is the intermediate hostintermediate host harbouring harbouring the larval stagesthe larval stages

• Mosquito is the Mosquito is the definitive hostdefinitive host harbouring harbouring the adult stagesthe adult stages

Asexual cycle or Human cycleAsexual cycle or Human cycle• Begins with the injection of Begins with the injection of

sporozoites following the sporozoites following the bite of infected mosquitobite of infected mosquito

• Three phases are Three phases are observedobserved

Phase 1-Hepatic phase (pre or exo erythrocytic or tissue)-

Sporozoites disappear from the circulation within 45-60 mins

Many of them are destroyed by phagocytes and some reach the liver cells

After 1-2 weeks of development ( depending upon the species) they become hepatic schizoints

Hepatic schizointHepatic schizoint

Hepatic schizointHepatic schizoint

Pre-erythrocytic schizonts

Contnd…Contnd…These These

hepatic hepatic schizoints schizoints eventually eventually rupture, rupture, releasing releasing showers of showers of merozoites merozoites which attack which attack RBCsRBCs

The number The number of merozoites of merozoites released vary released vary according to according to the type of the type of parasiteparasite

In case of P.f, as many as 40,000 and In case of P.f, as many as 40,000 and in others 2000-15,000 merozoites in others 2000-15,000 merozoites are released are released

In case of P.f, the intrahepatic In case of P.f, the intrahepatic schizoints rupture almost schizoints rupture almost simultaneously and there is no simultaneously and there is no persistent tissue- no secondary exo persistent tissue- no secondary exo erythrocytic stageerythrocytic stage

Contnd…Contnd…

On the contrary, the intrahepatic On the contrary, the intrahepatic schizoints of other plasmodia do not burst schizoints of other plasmodia do not burst all at the same time.all at the same time.

Some intrahepatic schizoints persist and Some intrahepatic schizoints persist and remain dormant (hypnozoites) for remain dormant (hypnozoites) for considerable periods and later they cause considerable periods and later they cause relapsesrelapses

Once the parasites enter RBCs, they do Once the parasites enter RBCs, they do not reinvade the hepatic cellsnot reinvade the hepatic cells

Phase 2- Erythrocytic phase (erythrocytic schizogony)

Many of the merozoites are quickly destroyed and significant number of merozoites bind and enter the RBCs

Then they pass through the stages of trophozoites and schizoints

Each parasite spends Each parasite spends two days in a red two days in a red blood cell consuming blood cell consuming the hemoglobin and the hemoglobin and reproducing.reproducing.

Erythrocytic Schizogony

• nuclear division = begin schizont stage

• 6-40 nuclei• budding merozoites =

segmenter• erythrocyte rupture

releases merozoites

gametocytes

erythrocytic schizogony• 48 hr in Pf, Pv, Po• 72 hr in Pm

Erythrocytic forms (signet)Erythrocytic forms (signet)

Young ring form trophozoites

RBCs rupture releasing merozoites which infect the fresh RBCs

16 new parasites burst out to infect other red blood cells from each merozoite

The sporozoites first invade liver cells and asexually reproduce to produce huge numbers of merozoites which spread to red blood cells where more merozoites are produced through more asexual reproduction.

Contnd…Contnd…

Duration of erythrocytic phase is constant for species to species

It is 48 hrs in case of P.v, P.f and P.o It is 48 hrs in case of P.v, P.f and P.o whereas 72 hrs in P.mwhereas 72 hrs in P.m

The cycle may be repeated many times The cycle may be repeated many times and may end with complications or be and may end with complications or be slowed down by immunity of the hostslowed down by immunity of the host

Contnd…Contnd…

Phase 3- Gametogony Some of the

erythrocytic forms do not divide but become male (smaller) and female (longer) gametocytes

These are infective to mosquitoes

Characteristics of different Characteristics of different speciesspecies

SpeciesSpecies Duration Duration of tissue of tissue phase phase (days)(days)

IncubatioIncubation period n period (days)(days)

Number of

merozoites / cell

Red cells Red cells invadedinvaded

P. falciparum

5.5 – 75.5 – 7 8 - 118 - 11 40,000 cells of all cells of all agesages

P. vivax 6-86-8 10 - 1710 - 17 10,000 reticulocytreticulocyteses

P. ovale 99 10 – 1710 – 17 15,000 reticulocytreticulocyteses

P. malariae

12-1612-16 18 - 4018 - 40 2,000 mature mature

cellscells

Sexual or mosquito cycleSexual or mosquito cycle

These infective gametocytes These infective gametocytes are ingested by the are ingested by the anopheles mosquitoesanopheles mosquitoes

Then develop and undergo Then develop and undergo stages of fertilisation- zygote, stages of fertilisation- zygote, ookinate, oocyst and ookinate, oocyst and sporozoitessporozoites

Sporozoites enter the salivary Sporozoites enter the salivary gland from the gut and are gland from the gut and are infective to maninfective to man

Once in the mosquito, Once in the mosquito, PlasmodiumPlasmodium needs about 8- needs about 8-10 days to produce 10 days to produce sporozoites that are ready to sporozoites that are ready to be injected into a human.be injected into a human.

Plasmodia in AnophelesPlasmodia in Anopheles

Liver stage

Sporozoites

Mosquito Salivary Gland

Malaria Life Cycle

Gametocytes

Oocyst

Red Blood Red Blood Cell CycleCell Cycle

Zygote

Life CycleLife Cycle

Sporozoite Liver Schizont

Oocyst

Ookinete

Trophozoite

Merozoite

Gametocytes

RBC

Types of InfectionsTypes of Infections

• RecrudescenceRecrudescence– exacerbation of persistent undetectable parasitemia, exacerbation of persistent undetectable parasitemia,

due to survival of erythrocytic forms, no exo-due to survival of erythrocytic forms, no exo-erythrocytic cycle (erythrocytic cycle (P.f., P.m.P.f., P.m.))

• RelapseRelapse– reactivation of hypnozoites forms of parasite in liver, reactivation of hypnozoites forms of parasite in liver,

separate from previous infection with same species separate from previous infection with same species ((P.v. and P.o.P.v. and P.o.) )

– P.v and P.o continue to relapse for 2-3 years and P.m P.v and P.o continue to relapse for 2-3 years and P.m may persist for as long as 45 yearsmay persist for as long as 45 years

• Recurrence or reinfection Recurrence or reinfection – exo-erythrocytic forms infect erythrocytes, separate exo-erythrocytic forms infect erythrocytes, separate

from previous infection (all species)from previous infection (all species)• Can not Can not always differentiate recrudescence differentiate recrudescence

from reinfectionfrom reinfection

An.culicifaciesAn.culicifacies Breeding Sites Breeding Sites

Host factorsHost factors

• Malaria affects all ages, but rare in newborn Malaria affects all ages, but rare in newborn due to presence of foetal haemoglobin and due to presence of foetal haemoglobin and maternal immunitymaternal immunity

• Common in males because of outdoor activities Common in males because of outdoor activities and clothing pattern (816 F -45% and 1014 M-and clothing pattern (816 F -45% and 1014 M-55% out of 1830 in Belgaum till August 2008)55% out of 1830 in Belgaum till August 2008)

• Duffy negative people are resistant to P.v. Most Duffy negative people are resistant to P.v. Most of the Africans are Duffy negative, this explains of the Africans are Duffy negative, this explains why P.v is not so common in Africawhy P.v is not so common in Africa

• Patients of SC trait ( Hb AS), GPatients of SC trait ( Hb AS), G66PD and PD and thalasseamia are less likely to be affected by thalasseamia are less likely to be affected by malariamalaria

High risk groupHigh risk group• Pregnant mothers-Pregnant mothers- have an increased risk of severe have an increased risk of severe

malaria especially in primigravidae, as the immunity to malaria especially in primigravidae, as the immunity to the malaria is impaired in pregnancy.the malaria is impaired in pregnancy.

• Pregnant women attract twice the number of mosquitoes than non-pregnant women

• There is a greater susceptibility to P. falciparum than P. vivax during pregnancy

ChildrenChildren - - Malaria affects cognitive development and learning abilities of children

• Malaria is a risk factor of neuro-sensory and behavioral development in children

ImmigrantsImmigrants from Europe- as they lack natural from Europe- as they lack natural immunityimmunity

ImmunityImmunity

• Occurs only after repeated exposure to the diseaseOccurs only after repeated exposure to the disease

• Influenced byInfluenced by– GeneticsGenetics– AgeAge– Health conditionHealth condition– Pregnancy statusPregnancy status– Intensity of transmission in regionIntensity of transmission in region– Length of exposureLength of exposure– Maintenance of exposureMaintenance of exposure

Incubation periodIncubation period It is the length of time between the bite of It is the length of time between the bite of

infected mosquito and appearance of first infected mosquito and appearance of first clinical feature (ie,fever). It is about 10-12 clinical feature (ie,fever). It is about 10-12 days in P.f and 10-14 days in other days in P.f and 10-14 days in other speciesspecies

Prepatent periodPrepatent period This is the length of time between the bite This is the length of time between the bite

of infected mosquito and appearance of of infected mosquito and appearance of parasites in peripheral blood parasites in peripheral blood

Clinical course Clinical course

• Following a bite by an infected mosquito, many people do not develop any signs of infection. If infection does progress, the outcome is one of three depending on the host and parasite factors enumerated in the previous slides:

– Asymptomatic parasitaemia (“clinical immunity”)

– Acute, uncomplicated malaria– Severe malaria

Asymptomatic parasitaemiaAsymptomatic parasitaemia

• This is usually seen in older children and adults who have acquired natural immunity to clinical disease as a consequence of living in areas with high malaria endemicity.

• There are malaria parasites in the peripheral blood but no symptoms.

• These individuals may be important reservoirs for disease transmission.

• Some individuals may even develop anti-parasite immunity so that they do not develop parasitaemia following infection.

Simple, uncomplicated malariaSimple, uncomplicated malaria

• This can occur at any age but it is more likely to be seen in individuals with some degree of immunity to malaria. The affected person, though ill, does not manifest life-threatening disease.

• Fever is the most constant symptom of malaria. It may occur in paroxysms when lysis of red cells releases merozoites resulting in fever, chills and rigors (uncontrollable shivering).

The periodicity of malaria feverThe periodicity of malaria fever

• The first febrile attack corresponds to the The first febrile attack corresponds to the development of parasites in the RBCs.development of parasites in the RBCs.

• The fever may be continuous or remittent The fever may be continuous or remittent before it becomes classically intermittentbefore it becomes classically intermittent

• Intermittent nature of the fever is due to Intermittent nature of the fever is due to cyclical release of merozoites following rupture cyclical release of merozoites following rupture of infected RBCsof infected RBCs

• It is once in 48 hours in case of P.v, P.f (36 hrs- It is once in 48 hours in case of P.v, P.f (36 hrs- sub-tertian) and P.o whereas 72 hours in P.m sub-tertian) and P.o whereas 72 hours in P.m

(erythrocytic schizogony(erythrocytic schizogony is the time taken is the time taken for trophozoites to mature into merozoites for trophozoites to mature into merozoites before release when the cell ruptures). before release when the cell ruptures).

Contnd…Contnd…• A typical attack involves 3 distinct stages A typical attack involves 3 distinct stages

(in a person from non-endemic area).(in a person from non-endemic area).

Cold stageCold stageBegins with feeling of cold, shivering and Begins with feeling of cold, shivering and

headacheheadachePatient covers himself with blankets, BT Patient covers himself with blankets, BT

reaches 39-41reaches 39-4100CCIt may continue for 15 mins to 1 hourIt may continue for 15 mins to 1 hour

Parasites are demonstrable in the bloodParasites are demonstrable in the blood

ContndContnd……

Hot stage Hot stage The fever raises so high so the patient The fever raises so high so the patient

feels burning hot and takes off the clothesfeels burning hot and takes off the clothesThe patient feels intense headache with The patient feels intense headache with

nausea and vomitingnausea and vomitingPulse is of bounding type, patient feels Pulse is of bounding type, patient feels

thirsty and it may continue for 2-6hrsthirsty and it may continue for 2-6hrs

Sweat stageSweat stage Fever comes down with profuse Fever comes down with profuse

sweatingsweatingHe goes usually into deep sleepHe goes usually into deep sleepLasts for 2-4 hoursLasts for 2-4 hoursFebrile herpes is very commonFebrile herpes is very common

Malaria- one clinical febrile episode of malaria consumes 5,000 k Cal.

Note how the frequency of spikes of fever differ according to the Plasmodium species. In practice, spikes of fever in P. falciparum, occur irregularly - probably because of the presence of parasites at various stages of development.

Other features of simple, uncomplicated malaria include: Malaria is a multisystem disease. Other common

clinical features are:o Vomitingo Diarrhoea – more commonly seen in young children

and, when vomiting also occurs, may be misdiagnosed as viral gastroenteritis

o Convulsions – commonly seen in young children. In an endemic area, cerebral malaria should be ruled out if any child fails to regain consciousness within an hour after an episode of febrile convulsion.

o Pallor – resulting mainly from the lysis of RBCs. Malaria also reduces the synthesis of red blood cells in the bone marrow.

o Jaundice – mainly due to haemolysis.

Contnd…Contnd…

o Anorexiao Cougho Headacheo Malaiseo Muscle acheso Splenomegalyo Tender hepatomegaly

These clinical features occur in “mild” malaria. However, the infection requires urgent diagnosis and management to prevent progression to severe disease.

HepatosplenomegalyHepatosplenomegaly

Severe and complicated malariaSevere and complicated malaria

• Although severe malaria is both preventable and treatable, it is frequently a fatal disease.

• 0.5 -2% of the total P.f malaria develop complications and of which 50% are fatal

• The following are 8 important severe manifestations of malaria

1. Severe malaria anaemia

2. Cerebral malaria

3. Hypoglycaemia

4. Metabolic acidosis

5. Acute renal failure

6. Pulmonary oedema

7. Circulatory collapse, shock or “algid malaria”

8. Blackwater fever

Note: It is common for an individual patient to have more than one severe manifestation of malaria!

Anaemia in Anaemia in malariamalaria

It is severe in P.f It is severe in P.f infections as it infections as it attacks 20-35% of attacks 20-35% of total RBCs whereas total RBCs whereas only 1% is affected only 1% is affected in other plasmodiain other plasmodia

Immediate blood Immediate blood transfusion is transfusion is required in majority required in majority of patientsof patients

Contnd…Contnd…

CausesCausesHaemolysis of infected RBCsHaemolysis of infected RBCsHaemolysis of uninfected RBCsHaemolysis of uninfected RBCsDyserythropoiesisDyserythropoiesisSplenomegaly-erythrocyte Splenomegaly-erythrocyte

sequestrationsequestrationDepletion of folate storesDepletion of folate stores

Cerebral Cerebral malariamalaria• The most well-The most well-

known severe known severe manifestation of manifestation of malariamalaria

• Defined as:Defined as:– unarousable unarousable

coma persisting coma persisting for more than for more than one hour one hour

– with asexual with asexual forms of forms of P. P. falciparumfalciparum in the in the peripheral bloodperipheral blood

– other common other common causes of causes of encephalopathy encephalopathy excluded excluded (WHO1999)(WHO1999)

A young girl with cerebral malaria. Note the abnormal, decerebrate posturing

• Common in P.f Common in P.f infections where infections where the erythrocytic the erythrocytic schizogony takes schizogony takes place in the smaller place in the smaller capillaries of the capillaries of the internal organsinternal organs

• Results in the Results in the blockage of blockage of capillaries by capillaries by parasitized RBCsparasitized RBCs

CerebralCerebral malariamalaria

A 4 year old boy who was deeply comatose and had persistent deviation of the eyes

• Occurs most commonly in young Occurs most commonly in young children although non-immune adults children although non-immune adults are also at riskare also at risk

• Cerebral malaria can rapidly progress Cerebral malaria can rapidly progress to death, even with appropriate to death, even with appropriate treatment. Case fatality is between treatment. Case fatality is between 20-50%. 20-50%.

Cerebral malariaCerebral malaria

• The illness may start with drowsiness and confusion and then progress to coma.

• The loss of consciousness is often preceded by repeated convulsions.

• Retinal haemorrhages may be seen on fundoscopy.

• In survivors, resolution of coma usually occurs In survivors, resolution of coma usually occurs within 1-2 days in children and within 2-4 days in within 1-2 days in children and within 2-4 days in adults but may be complicated by neurological adults but may be complicated by neurological sequelae in ~5% adults and >10% of children.sequelae in ~5% adults and >10% of children.

CerebralCerebral malariamalaria

3. Hypoglycaemia

• Blood sugar <2.5 mmol/LBlood sugar <2.5 mmol/L• Increases the risk of mortality and sequelae in Increases the risk of mortality and sequelae in

children with cerebral malaria; may present with children with cerebral malaria; may present with convulsions or a deterioration in level of convulsions or a deterioration in level of consciousness.consciousness.

• Results Results from a combination of factors:from a combination of factors:– reduced glycogen stores because of reduced reduced glycogen stores because of reduced

food intakefood intake– increased metabolism due to fever and repeated increased metabolism due to fever and repeated

convulsionsconvulsions– glucose consumption by malaria parasitesglucose consumption by malaria parasites– cytokine or quinine-stimulated hyperinsulinaemiacytokine or quinine-stimulated hyperinsulinaemia

4. Metabolic acidosis

• Lactic acidosis is a major contributor and Lactic acidosis is a major contributor and

probably results from tissue anoxia and probably results from tissue anoxia and

anaerobic glycolysisanaerobic glycolysis

• Presents with deep, rapid respirations (as Presents with deep, rapid respirations (as

in diabetic ketoacidosis)in diabetic ketoacidosis)

5. Acute renal failure

• occurs almost exclusively in adults and occurs almost exclusively in adults and

older children in areas of unstable older children in areas of unstable

malariamalaria

• affected patients are usually oliguric affected patients are usually oliguric

(urinary output <400 ml/day) or anuric (urinary output <400 ml/day) or anuric

(<50 ml/day)(<50 ml/day)

• serum creatinine levels are elevatedserum creatinine levels are elevated

NephrosisNephrosis

P. Malariae quarten nephrosis

6. Acute pulmonary oedema6. Acute pulmonary oedema

This is a grave and usually

fatal manifestation of

severe falciparum malaria

and occurs mainly in

adults.

Hyperparasitaemia, renal

failure and pregnancy are

recognised predisposing

factors and the condition is

commonly associated with

hypoglycaemia and

metabolic acidosis.

7. Circulatory collapse, shock, 7. Circulatory collapse, shock, “algid malaria“algid malaria””

•Features of circulatory collapse (cold/clammy skin, hypotension, peripheral cyanosis, weak/thready pulses) may be seen in patients with severe P. falciparum malaria.

•“Algid malaria” is characterised by hypotension, vomiting, diarrhoea, rapid respiration and oliguria. This condition is associated with a poor prognosis.

8. Haemoglobinuria or “Blackwater Fever”

• Characterized by rapid, severe Characterized by rapid, severe intravascular haemolysisintravascular haemolysis

• It is associated with infection by P.f, most It is associated with infection by P.f, most commonly seen in a non-immune person commonly seen in a non-immune person who has resided in the endemic country who has resided in the endemic country for the last 6 months to 1 year and for the last 6 months to 1 year and inadequately treated by quinineinadequately treated by quinine

• In these cases, quinine is a precipitating In these cases, quinine is a precipitating factorfactor

• It is triggered by exposure to cold, sun, It is triggered by exposure to cold, sun, fatigue, trauma, pregnancy, X-rays etc,.fatigue, trauma, pregnancy, X-rays etc,.

Contnd…Contnd…

The condition presents with severe pallor, jaundice and passage of dark urine due to haemoglobinuria.

It may be associated with acute renal failure.

A 3 year old boy with severe anaemia (Hb% 3.3 g/dl) and dark urine (shown in the container)

DiagnosisDiagnosisMalaria is a multisystem disease.Malaria is a multisystem disease. It presents with a wide variety of non-It presents with a wide variety of non-

specific clinical features.specific clinical features. None of the clinical features are

pathognomonic.Many patients have fever, general aches Many patients have fever, general aches

and pains and malaise and are initially and pains and malaise and are initially misdiagnosed as having “flu”. misdiagnosed as having “flu”.

P. falciparumP. falciparum malaria can be rapidly malaria can be rapidly progressive and fatal.progressive and fatal.

DiagnosisDiagnosis• A good history

– Residence or a recent visit (in the preceding 3 months) to a malaria endemic area

– History of fever – Recognise significance of non-specific clinical features

such as vomiting, diarrhoea, headache, malaise• Physical examination

– Identify signs consistent with malaria: fever, pallor, jaundice, Splenomegaly

– Exclude other possible causes of fever (e.g. signs of viral and bacterial infections)

The diagnosis of malaria should be considered in any unwell person who has been in a malarious area recently

Laboratory InvestigationsLaboratory Investigations

Blood Film ExaminationThick and thin blood films (or “smears”) have remained

the gold standard for the diagnosis of malaria. The films are stained and examined by microscopy.

Thick blood film - Used for detecting malaria: a larger volume of blood is examined allowing detection of even low levels of parasitaemia. Also used for determining parasite density and monitoring the response to treatment.

Thin blood filmThin blood film – Gives more information about the – Gives more information about the parasite morphology and, therefore, is used to identify parasite morphology and, therefore, is used to identify the particular infecting species of Plasmodium. the particular infecting species of Plasmodium.

Appearance of Appearance of P. falciparumP. falciparum in thin in thin blood filmsblood films. . Ring forms or trophozoites; many red cells infected – some with more than one parasite

Other methods of diagnosis of malaria

These are not routinely used in clinical These are not routinely used in clinical practice. practice.

a)a) Antigen capture kitsAntigen capture kits. Uses a dipstick . Uses a dipstick

and a finger prick blood sample. Rapid and a finger prick blood sample. Rapid test - results are available in 10-15 test - results are available in 10-15 minutes. Expensive and sensitivity drops minutes. Expensive and sensitivity drops with decreasing parasitaemia.with decreasing parasitaemia.

b)b)PCR based techniques. PCR based techniques. Detects DNA or Detects DNA or mRNA sequences specific to Plasmodium. mRNA sequences specific to Plasmodium. Sensitivity and specificity high but test is Sensitivity and specificity high but test is expensive, takes several hours and expensive, takes several hours and requires technical expertise.requires technical expertise.

Contnd… Contnd… c) Fluorescent techniques- Relatively low

specificity and sensitivity. Cannot identify the parasite species. Expensive and requires skilled personnel.

d) Serologic tests- Based on immunofluorescence detection of antibodies against Plasmodium species. Useful for epidemiologic and not diagnostic purposes.

TreatmentTreatment The treatment of The treatment of

malaria depends on a malaria depends on a

number of factorsnumber of factors

• Severity of the Severity of the

infection: infection: whether whether

simple, uncomplicated or simple, uncomplicated or

severe, complicated severe, complicated

malaria.malaria.

• ParasiteParasite factors: factors:

species, drug sensitivityspecies, drug sensitivity

• Patient factors: Patient factors: age, age,

pregnancy, prior pregnancy, prior

chemoprophylaxis, chemoprophylaxis,

known allergies, known allergies,

likelihood of drug likelihood of drug

compliance.compliance.

ChloroquineChloroquine

A 4-aminoquinoline, orally- well absorbed.A 4-aminoquinoline, orally- well absorbed. Has rapid blood schizointicidal activity against all speciesHas rapid blood schizointicidal activity against all species Has gametocidal activity against P.v, but not against PfHas gametocidal activity against P.v, but not against Pf No action on liver schizoints, hence it cannot clear the No action on liver schizoints, hence it cannot clear the

parasiteparasite Safe in pregnancySafe in pregnancy Therapeutic concentration-plasma-30 mins-oralTherapeutic concentration-plasma-30 mins-oral Low margin of safety in childrenLow margin of safety in children Dosage -25mg/kgbw given over 3 days for treatment and Dosage -25mg/kgbw given over 3 days for treatment and

5mg/kgbw weekly once for chemoprophylaxis5mg/kgbw weekly once for chemoprophylaxis Given after food, cheapest, rapid action, symptomatic Given after food, cheapest, rapid action, symptomatic

reliefrelief Pruritus may be seen in dark skinned peoplePruritus may be seen in dark skinned people Cardiovascular toxicity with hypotension and Cardiovascular toxicity with hypotension and

arrhythmias-deatharrhythmias-death

2)2) PrimaquinePrimaquine

An 8-aminoquinolone, readily absorbed orally

Highly active against gametocytes of all human malaria parasites and hypnozoites of P.v

Haemolysis occurs in G6PD deficiency people and in infants with foetal haemoglobin

It crosses placental barrier, not to be given in pregnancy

Also causes methaemoglobinaemia and suppression of myeloid activity

3)3) Quinine-Quinine- Since 1638 malaria has been treated with an Since 1638 malaria has been treated with an

extract from the bark of the cinchona tree, extract from the bark of the cinchona tree, known as quinine.known as quinine.

DOC to treat severe malaria and uncomplicated DOC to treat severe malaria and uncomplicated malaria resistant to chloroquine, S-P and malaria resistant to chloroquine, S-P and mefloquine. mefloquine.

Severe side effects, extremely bitter, long Severe side effects, extremely bitter, long regimen, therefore not often used as oral regimen, therefore not often used as oral treatment.treatment.

Use restricted for CRPF infection Use restricted for CRPF infection Intravenous treatment suitable for treating Intravenous treatment suitable for treating

pregnant women and children pregnant women and children 10mg/kgbw,slow infusion IV in isotonic soln or 10mg/kgbw,slow infusion IV in isotonic soln or

5% dext5% dext

4) Sulfa drug/Pyrimethamine 4) Sulfa drug/Pyrimethamine combination (SP)combination (SP)

Highly active against blood schizoints of P.f but Highly active against blood schizoints of P.f but less effective against P.v.less effective against P.v.

No gametocidal activitiesNo gametocidal activities Use restricted for CRPF infection which is not Use restricted for CRPF infection which is not

complicatedcomplicated Active in a single dose of 3 tablets (adults)Active in a single dose of 3 tablets (adults) Not used in pregnancy, lactation and infancyNot used in pregnancy, lactation and infancy Hypersensitivity involving skin and mucous Hypersensitivity involving skin and mucous

membrane (SJ syndrome)membrane (SJ syndrome) Resistance to S-P has also been found Resistance to S-P has also been found

5) Mefloquine

a 4-quinoline methanol chemically related a 4-quinoline methanol chemically related to quinineto quinine

Potent long acting blood schizonticide Potent long acting blood schizonticide active against all speciesactive against all species

Use restricted to multi-resistant P.f Use restricted to multi-resistant P.f infectionsinfections

Not safe in pregnancyNot safe in pregnancyNot available in India, to be importedNot available in India, to be imported

6) Artemisenin and its 6) Artemisenin and its derivatives:derivatives:

Artemisenin, Artesunate and Artemether used to Artemisenin, Artesunate and Artemether used to treat complicated malaria of CRPF, S-P and treat complicated malaria of CRPF, S-P and Mefloquine. Mefloquine.

Indicated when quinine is not advisableIndicated when quinine is not advisable It acts on the broadest range of parasite stages, It acts on the broadest range of parasite stages,

gives the most rapid cure, has the least side effects. gives the most rapid cure, has the least side effects. Artesunate 4mg/kgbw for 3 days. Available Artesunate 4mg/kgbw for 3 days. Available

strength is 50mg tabsstrength is 50mg tabs Arteether inj. I.M.- 3mg/KG B.Wt. daily for 3 days. Arteether inj. I.M.- 3mg/KG B.Wt. daily for 3 days.

Available as 150mg/ ampouleAvailable as 150mg/ ampoule

Site ofSite of ActionAction

ChloroquineQuinine, SP

Artemisinin

Quinine & Chloroquine in P.V. and Primaquine in

P.F.

Primaquine

NA-not active, A-active,NA-not active, A-active,

Drug Sporozoites

Primary tissue phase

Asexual

parasite

Gametocyte

Hypnozoite

Quinine NA NA A A-P.v NA

Chloroquine NA NA A A-P.v NA

Primaquine A A A

in toxic dose

A A

SP Less A Little A on P.f

Incomplete NA NA

Mefloquine NA NA A NA NA

Avoid these combinationsAvoid these combinations• Most antimalarial drugs have a long plasma half-life. Most antimalarial drugs have a long plasma half-life.

Therefore, adding similar drugs half way through the Therefore, adding similar drugs half way through the treatment will only add to the adverse effects and not treatment will only add to the adverse effects and not to the therapeutic benefit. The following combinations to the therapeutic benefit. The following combinations should therefore be avoided, concurrently or within a should therefore be avoided, concurrently or within a short interval:short interval:(1.) Chloroquine + Quinine(1.) Chloroquine + Quinine

(2.) Chloroquine + Mefloquine(2.) Chloroquine + Mefloquine (3.) Quinine + Mefloquine (3.) Quinine + Mefloquine (4) Quinine + Primaquine(4) Quinine + Primaquine (5.) Quinine + Halofantrine (5.) Quinine + Halofantrine (6.) Mefloquine + Primaquine(6.) Mefloquine + Primaquine (7.) Administration of Primaquine on the same day is (7.) Administration of Primaquine on the same day is

also not advisable. also not advisable. Both sulpha and primaquine can precipitate hemolytic Both sulpha and primaquine can precipitate hemolytic

crisis in patients with crisis in patients with Glucose 6-phosphate dehydrogenase deficiency.

Treatment of uncomplicated malariaPresumptive treatmentPresumptive treatment: It is given to : It is given to 1.1. All fever cases with H/O fever during past 15 daysAll fever cases with H/O fever during past 15 days2.2. All fever cases irrespective of age and sex All fever cases irrespective of age and sex 3. No Primaquine to infants and pregnant women. 4. Each Chloroquine tab available as 150 mg and

Primaquine tab as 2.5 mg & 7.5 mg.

Radical Treatment:1.1. Given after microscopic confirmationGiven after microscopic confirmation2. No Primaquine to infants and pregnant women. 3. Each Chloroquine tab available as 150 mg and

Primaquine tab as 2.5 mg & 7.5 mg.

Treatment in low risk areasTreatment in low risk areas Presumptive treatment- only one daytab Chloroquine(10mb/kgbw) 600mg

Radical treatment- 1 day in P.f and 14days in P.v infections

P.V. infections - tab Chloroquine(10mb/kgbw) 600mg single dose, with Primaquine (0.25mg/kgbw) 15mg daily for 14 days

P.F. cases-tab Chloroquine(10mg/kgbw) 600mg with Primaquine (0.75mg/kgbw) 45mg single dose.

Treatment in high risk areasTreatment in high risk areas

• For P.V.-For P.V.- Here, as we have already given Here, as we have already given chloroquine base (1500mg) spread over 3 chloroquine base (1500mg) spread over 3 days and 45mg Primaquine (adult dose), days and 45mg Primaquine (adult dose), chloroquine need not be given again, but chloroquine need not be given again, but Primaquine 0.25mg daily (15mg/day- Primaquine 0.25mg daily (15mg/day- adult) must be given for 14 days.adult) must be given for 14 days.

• For P.F.-For P.F.- R.T. with Primaquine is not R.T. with Primaquine is not required as we have already given required as we have already given required dose.required dose.

In Chloroquine resistant P.F. cases (HRAs)

- 236 PHCs in 19 states are identified as 236 PHCs in 19 states are identified as Chloroquine resistant.Chloroquine resistant.

- Sulfadoxine(25mg/kgbw) and Sulfadoxine(25mg/kgbw) and Pyrimethamine (1.25mg/kgbw) available Pyrimethamine (1.25mg/kgbw) available as 500mg tab and 25mg tabs given as as 500mg tab and 25mg tabs given as single dose for single dose for Presumptive treatment.Presumptive treatment.

- For radical treatment- Primaquine 0.75mg For radical treatment- Primaquine 0.75mg as single dose.as single dose.

Criteria for high risk areaCriteria for high risk area

Subcentre is the basic unit considered for Subcentre is the basic unit considered for selection of HRA.selection of HRA.

Criteria for identification of high risk areas are:Criteria for identification of high risk areas are:

• Deaths due to malaria recorded during any of Deaths due to malaria recorded during any of the last three yearsthe last three years

• Average SPR of last three years is 5% or Average SPR of last three years is 5% or moremore

• Doubling of SPR during last three years Doubling of SPR during last three years provided the SPR in second and third reaches provided the SPR in second and third reaches 4% or more4% or more

• Pf proportion is 30% or more provided SPR Pf proportion is 30% or more provided SPR is 3% or more during the last three yearsis 3% or more during the last three years

• An area having a focus of Chloroquine An area having a focus of Chloroquine resistant foci.resistant foci.

• Tropical segregation of labour in project Tropical segregation of labour in project areasareas

Based on the above criteria, Karnataka had Based on the above criteria, Karnataka had 64 PHCs and Belgaum had 5 PHCs in the 64 PHCs and Belgaum had 5 PHCs in the year 2006 and 10 PHCs in 2007 &2008year 2006 and 10 PHCs in 2007 &2008

MOH has to calculate- 3 years data-SC wise MOH has to calculate- 3 years data-SC wise

Mass drug administrationMass drug administration

• Recommended in API>5 per 1000 popn (WHO)Recommended in API>5 per 1000 popn (WHO)• Not for under 5 childrenNot for under 5 children

ChemoprophylaxisChemoprophylaxis- Use of anti-malarial drugs to prevent the Use of anti-malarial drugs to prevent the

development of malaria is known as development of malaria is known as chemoprophylaxis. chemoprophylaxis.

- Unreliable with development of drug resistanceUnreliable with development of drug resistance- Started 1 week before arrival in the malarious Started 1 week before arrival in the malarious

area and continued for atleast 4 weeks, area and continued for atleast 4 weeks, preferably 6 weeks after leaving a HRA.preferably 6 weeks after leaving a HRA.

- Should be complemented by personal Should be complemented by personal protection and other VCMsprotection and other VCMs

ChemoprophylaxisChemoprophylaxis

- Recommended for Recommended for

1.1.Travellers from non endemic areasTravellers from non endemic areas

2.2.As a short measure for soldiers, police As a short measure for soldiers, police and labours serving in highly endemic and labours serving in highly endemic areasareas

3.3.All ANCs in HRAs- initiated in II All ANCs in HRAs- initiated in II semestersemester

Contnd…Contnd…

• Start with a loading dose of 10mg/kgbw and Start with a loading dose of 10mg/kgbw and followed by a weekly dose of 5 mg/kgbw till followed by a weekly dose of 5 mg/kgbw till 1 month after delivery and in travellers till 1 month after delivery and in travellers till one month after return from HRA.one month after return from HRA.

• Not recommended for >3 years with Not recommended for >3 years with Chloroquine- cumulative toxicityChloroquine- cumulative toxicity

• In CRAs, chemoprophylaxis is In CRAs, chemoprophylaxis is recommended with Chloroquine 5mg/kgbw recommended with Chloroquine 5mg/kgbw weekly and Proguanil 100mg daily. weekly and Proguanil 100mg daily.

Treatment of Complicated Treatment of Complicated MalariaMalaria• All the patients are to be hospitalisedAll the patients are to be hospitalised

• Choice of antimalarial is quinine injectionChoice of antimalarial is quinine injection

• 10mg/kg BW.IV in 5% dextrose 810mg/kg BW.IV in 5% dextrose 8thth hourly hourly till the patient regains consciousnesstill the patient regains consciousness

• Switch over to oral dose as early as Switch over to oral dose as early as possible- Oral quinine 600mg tds for 7-10 possible- Oral quinine 600mg tds for 7-10 daysdays

• Total duration of treatment -7 days Total duration of treatment -7 days including both parenteral and oral dose including both parenteral and oral dose

• Corrections of other associated metabolic Corrections of other associated metabolic disordersdisorders

MALARIA TREATMENT COST OF

AN ADULT IN INDIADrugs Cost (Rs.)

 Chloroquine 3.50-10.00

Chloroquine injection + fluids 200.00

Sulfadoxine Pyrimethamine 7.00-30.00

Mefloquine 240.00-300.00

Artemether injections 390.00-1000.00

Arteether injections 275.00

Artesunate injections 1120.00

Quinine tables + Tetracycline 270.00-210.00

Quinine injections+IV fluid+Tetracycline 800-910 

*Antipyretics @ Rs. 5.00-10.00 per treatment

I/V fluid may be required during Artemisinin treatment

Pregnant women and their Pregnant women and their fetus/newbornfetus/newborn•HIV HIV doesdoes make malaria in pregnancy make malaria in pregnancy

worseworse– More and higher density malaria, more illness, More and higher density malaria, more illness,

more anemia, more low birth weightmore anemia, more low birth weight

•Malaria Malaria maymay make HIV worse make HIV worse– Higher HIV viral load Higher HIV viral load – ? impact on Mother-to-Child Transmission ? impact on Mother-to-Child Transmission

(MTCT)(MTCT)

The Worlds Priorities? Annual ExpenditureThe Worlds Priorities? Annual ExpenditureGlobal Reduction in Malaria $ 1 billion

Basic education for all $ 6 billion

Cosmetics in the US $ 8 billion

Safe water and sanitation $ 9 billion

Ice cream in Europe $ 11 billion

Reproductive health for all women $ 12 billion

Perfumes in Europe and the US $ 12 billion

Basic health and nutrition $ 13 billion

Pet food in Europe and the US $ 17 billion

Business entertainment in Japan $ 35 billion

Cigarettes in Europe $ 50 billion

Alcoholic drinks in Europe $ 105 billion

Narcotic drugs in the world $ 400 billion

Military spending in the world $ 780 billion

Source-Favaloro et al Circulation 1999

•Prevention and Control of Prevention and Control of MalariaMalaria

Thank youThank you Any ????Any ????