Malaria is a vector-borne infectious disease

caused by protozoan parasites.

Malaria has infected humans for over 50,000
years, and may have been a human pathogen for the
entire history of our species.
It causes about 400–900 million cases of fever and
approximately one to three million deaths annually.
This represents at least one death every 30
seconds.
If the prevalence of malaria stays on its present
upwards course, the death rate could double in the
next twenty years.
The term malaria
originates from Medieval
Italian: mala aria — “ bad
air"; and the disease was
formerly called ague or
marsh fever due to its
association with swamps
over 40% of the popu-
lation lives in areas
where malaria trans-
mission occurs (i.e.,
parts of Africa, Asia, the
Middle East, Central and
South America, His-
paniola, and Oceania).
Source: WHO, 2003
The primary vector species are A. culicifacies and
A. stephensi.
In most parts of the country, the transmission
occurs post-monsoon, between July and November
1998

2001

2002

2003
1999

2000

2002
2003

2002
2003

2002
2003

2002
2003

2002
2003
Sindh Baluchistan NWFP FATA Punjab

Roll Back Malaria Monitoring and

Evaluation Generated:4/27/2005
PATHOGENESIS
 Plasmodium species which
infect humans

Plasmodium vivax (tertian)

Plasmodium ovale (tertian)
Plasmodium falciparum (tertian)
Plasmodium malariae (quartan)
Malaria Life Sporogony
Cycle Oocyst

Sporozoites

Mosquito Salivary
Zygote Gland

Hypnozoites
Exo- (for P. vivax
and P. ovale)
erythrocytic
(hepatic) cycle
Gametocytes

Merozoites pre-
Schizont
erythrocytic
Erythrocytic
Cycle sporogony
Schizont
Schizogony Merozoites
Trophozoites
 Some characteristics of infection with
four species of human Plasmodia
P.v. P.o. P.m. P.f.
15 (12-17)
Incubation 17 (16-18) 28 (18-40)
or up to 6- 12 (9-14)
period (days) or longer or longer
12 months
Erythrocytic
48 (about) 50 72 48
cycle (hours)
Severe in
Mild-
Primary attack Mild Mild non-
severe
immunes
Febrile
16-36 or
paroxysms 8-12 8-12 8-10
(hours) longer

Relapses ++ ++ - -
 Schizogenic periodicity and fever
patterns

• Schizogenic periodicity is length of asexual

erythrocytic phase
– 48 hours in P.f., P.v., and P.o. (tertian)
– 72 hours in P.m. (quartan)
• Initially may not see characteristic fever pattern if
schizogeny not synchronous
• With synchrony, periods of fever or febrile
paroxsyms assume a more definite 3 (tertian)- or
4 (quartan)- day pattern
 Malaria Diagnosis

• Clinical Diagnosis
• Malaria Blood Smear
• Fluorescent microscopy
• Antigen Detection
• Serology
• Polymerase Chain Reaction
 Malaria Clinical Diagnosis

• Early symptoms
– Headache
– Malaise
– Fatigue
– Nausea
– Muscular pains
– Slight diarrhea
– Slight fever, usually not intermittent
• Could mistake for influenza or gastrointestinal
infection
 Malaria Clinical Diagnosis

• Signs
– Anemia
– Thrombocytopenia
– Jaundice
– Hepatosplenomegaly
– respiratory distress syndrome
– renal dysfunction
– Hypoglycemia
– Mental status changes
 Malarial Clinical Diagnosis,
Paroxysm
– Slight fever may worsen just prior to paroxysm
• Paroxysm
– Cold stage - rigors
– Hot stage – Max temp can reach 40-41o C,
splenomegaly easily palpable
– Sweating stage
– Lasts 8-12 hours, start between midnight and
midday
 Malaria Lab Diagnosis
Blood Smear
• Remains the gold standard for
diagnosis
• Giemsa stain
• distinguishes between species
and life cycle stages
• parasitemia is quantifiable
• Threshold of detection
• thin film: 100 parasites/l
Schizont Ring form
• thick film: 5 -20 parasites/l

Gametocytes Trophozoite
 Malaria Antigen Detection
• Immunologic assays to detect
specific antigens
• Commercial kits now
available as
immunochromatographic
rapid diagnostic tests (RDTs),
used with blood

-P. falciparum histidine-rich protein 2 (PfHRP-2)

-parasite LDH (pLDH)
• Cannot detect mixed infections
• Cross reactivity with rheumatoid factor reportedly
corrected
RBM Partnership Secretariat, Malaria Medicines & Supplies Services

Copenhagen – 31 January 2006

Malaria distribution and reported case
of resistance or treatment failure
 Malaria diagnosis
Parasitological confirmation (microscopy or RDT)
before treatment

Exceptions:
– children under 5 years of age, from areas of high
transmission where treatment is based on
clinical diagnosis
– suspected severe malaria where parasitological
confirmation is not immediately possible
Changing antimalarial treatment
policy

• Treatment failure of >10% (as assessed

through monitoring of therapeutic efficacy
at 28 days)

• New treatment – an average cure rate

of > 95% as assessed in clinical trials
 Treatment of uncomplicated
falciparum malaria

Artemisinin-based combination therapies (ACT) are

the treatments recommended for all cases of
uncomplicated falciparum malaria including:
– in infants,
– in people living with HIV/AIDS
– for home-based management of malaria
– pregnant women in the 2nd and 3rd trimesters
Exception:
• 1st trimester of pregnancy
 Treatment of uncomplicated
falciparum malaria
First-line treatment:
• The following ACTs are presently recommended:
– artemether-lumefantrine
– artesunate + amodiaquine
– artesunate + mefloquine
– artesunate + sulfadoxine-pyrimethamine
• Efficacy of ACTs depend on the efficacy of the
partnermedicine

The artemisinin derivatives (oral formulations)

and partner medicines of ACTs are not
recommended as monotherapy
 Artemether-lumefantrine
Currently available as co-formulated tablets
> 14 Yrs
containing Tab.
20Artem
mg DSofplus
artemether and 120 mg of
2+0+2 (for 3 days)
lumefantrine.
The total recommended treatment is a 6-dose
3-8 Yrs
regimen ofTab. Artem DS plus 1+0+1 (for 3 days)
artemether-lumefantrine twice a day for 3
days.
 Treatment of uncomplicated
falciparum malaria
Second-line treatment:
– alternative ACT
– quinine + tetracycline
or doxycycline or clindamycin

Artesunate (2 mg/kg OD)+ tetracycline (4 mg/kg 6 hourly)

Artesunate (2 mg/kg OD)+ doxycycline (3.5 mg/kg OD)
Any of these
Artesunate (2 mg/kg OD)+ clindamycin (10 mg/kg BD). combinations
to be given
Quinine (10 mg salt/kg three times a day) + tetracycline for 7 days
Quinine (10 mg salt/kg three times a day) + doxycycline
Quinine (10 mg salt/kg three times a day) + clindamycin.
Treatment of severe falciparum
malaria
Any of Inj.
theArtem 80 mg
following I/M 2 stat then
antimalarial medicines are
recommended
Inj. Artem 80 mg I/M x OD for 4 days
– Artesunate i.v. or i.m
– artemether i.m.
– quinine (i.v. infusion or i.m. injection).

Full course of ACT or quinine + clindamycin or

doxycycline when patient can tolerate oral
treatment
 Treatment of Plasmodium Vivax &
Ovale Infection
Tab. Nivaquine 4 stat then 2 after 6 hrs. then
1+0+1 for next two days (total 10 tab.)
Chloroquine phosphate 1 Gm stat, followed by 500
+ Tab. Primaquine 30mg 1xOD for 14 days
mg at 6, ______________________________________
24 & 48 hours + Primaquine 30 mg base
daily for 14 days.
>14 Yrs ( provided G6PD normal)
Tab. Artem DS plus 2+0+2 (for 3 days)
+ Tab. Primaquine 30mg 1xOD for 14 days
Where ACT has been adopted as the first-line
treatment 3-8
forYrs
P. falciparum malaria, it may also be
used for Tab.
P. Artem DS plus
vivax 1+0+1 (for
malaria in 3combination
days) with
+ Tab. Primaquine 30mg 1xOD for 14 days
primaquine for radical cure.
Approaches That Should Be Avoided

• Partial treatments should not be given even when

patients are considered to be semi-immune or the
diagnosis is uncertain.
• A full course of effective treatment should always
be given once a decision to give antimalarial
treatment has been reached.
• The artemisinins and partner medicines of ACTs
should not be available as monotherapies.
 Malaria Vaccine
An effective vaccine
against malaria has been
developed and could be
licensed by 2010.
(BBC NEWS 15 October 2004)

The research is very high

quality and the findings are
very encouraging.
(Allan Shapira of Roll Back Malaria)

We believe a malaria

vaccine, even of moderate
efficacy, could make a huge
impact. (Lead researcher Professor
Pedro Alonso)
CONTACT:
alauddinsarwar@gmail.com
doctoralauddin@yahoo.co.in