Malaria

Malaria continues to be a major health problem in the country. The nature of malaria as a public
health problem requires sustained and systemic efforts toward two major strategies, namely
prevention of transmission through vector control and the detection and early treatment of cases
to reduce morbidity and prevent mortality.

Causative Agent: Genus Plasmodium

4 Plasmodia produces Malaria in humans:

1. Plasmodium Falciparum
2. Plasmodium Vivax
3. Plasmodium Ovale
4. Plamodium Malariae

The severity and characteristic manifestation of the disease are governed by the infecting species,
the magnitude of the parasitemia, the metabolic effects of the parasite, the cytokines released as
the result of the infection.

Life Cycle of Malaria

Diagnosis

I - Microscopy
Microscopy of stained thick and thin blood smears remains the gold standard for confirmation of
diagnosis
of malaria.

The advantages of microscopy are:

- The sensitivity is high. It is possible to detect malarial parasites at low densities. It also helps ti
quantify the
parasite load.
- It is possible to distinguish the various species of malaria parasite and their different stages.

II - Rapid Diagnostic Test

Rapid Diagnostic Tests are based on the detection of circulating parasite antigens. Several types
of RDTs
are available
Some of them can only detect P. falciparum, while others can detect other parasite species also.
The latter kits are expensive and temperature sensitive.

Early diagnosis and treatment of cases of malaria aims at:

- Complete cure
- Prevention of progression of uncomplicated malaria to severe disease.

- Prevention of deaths
- Interruption of transmission
- Minimizing risk of selection and spread of drug resistant parasites.

Signs and Symptoms:

Fever is the cardinal symptom of malaria. It can be intermittent with or without periodicity or
continuous. Many cases have chills and rigors. The fever is often accompanied by headache,
myalgia, arthralgia, anorexia, nausea and vomiting. The symptoms of malaria can be non-
specific and mimic other diseases like viral infections, enteric fever etc.

- Running nose, cough and other signs of respiratory infection

- Diarrhoea/dysentery
- Burning micturition and/or lower abdominal pain
- Skin rash/infections
- Abscess
- Painful swelling of joints
- Ear discharge
- Lymphadenopathy
 Principles Of Treatment
Treatment of malaria depends on the following factors:
1. Type of infection.
2. Severity of infection.
3. Status of the host.
4. Associated conditions/ diseases.
Type of infection: Treatment obviously depends on the type of infection. Patients with P.
falciparum malaria should be evaluated thoroughly in view of potential seriousness of the
disease and possibility of resistance to anti malarial drugs.
P. vivax: Only Chloroquine 25 mg/kg + Primaquine for 14 days.
P. falciparum: Treat depending on severity & sensitivity. Primaquine as gametocytocidal is a
must to prevent spread.
Mixed infections: Blood schizonticides as for P. falciparum and Primaquine as for P. vivax.
Severity of infection: All patients with malaria should be carefully and thoroughly assessed for
complications of malaria. Acute, life-threatening complications occur only in P. falciparum
malaria. Malaria is probably the only disease of its kind that can be easily treated in just 3 days,
yet if the diagnosis and proper treatment are delayed, it can kill the patient very quickly and
easily.

- All cases of severe malaria should be presumed to have P. falciparum malaria.

-If there is any uncertainty about the drug sensitivity of the parasite, it is safer to treat these
cases as chloroquine resistant malaria with drugs like quinine or artemisinin.
• All cases of severe malaria should be admitted to the hospital for proper evaluation,
treatment and monitoring.
• All cases of severe malaria should be treated with injectable antimalarials (chloroquine,
quinine, artemisinin) so as to ensure adequate absorption and plasma drug levels. It is
better to use two blood schizonticidal drugs, one fast acting and another slow acting, to
ensure complete treatment. Newer drugs available for only oral administration (eg.
Mefloquine, Halofantrine) should be avoided.
• All associated conditions should be carefully assessed and treated.

Status of the host: Treatment of malaria is also dependent on host factors.

• Patient's age and weight should be recorded so as to administer adequate doses of anti
malarial drugs.
• Functional capacity- independent, dependent, bed ridden etc. All patients with severe
prostration and who are looking ill should be admitted to a hospital and monitored.
• Patients with nausea and vomiting should be given anti emetic drugs to ensure adequate
treatment. While high-grade fever frequently stimulates vomiting, this may be further
aggravated by anti malarial drugs. Therefore it is better to avoid administration of oral
antimalarials at the height of fever. One can wait for the fever to subside before taking
the drugs. If the patient vomits within one hour of taking the anti malarial drugs, the
same should be re-administered. In case of persistent vomiting, patient should be
admitted and vomiting should be controlled with parenteral anti emetics. Parenteral anti
malarials are needed only in cases of severe malaria or uncontrolled vomiting.
• Adequate hydration should be ensured.
Vector control of malaria

The principal objective of vector control is the reduction of malaria morbidity and mortality by
reducing the levels of transmission. Vector control methods vary considerably in their
applicability, cost and sustainability of their results.

Methods

- Integrated vector management

A decision-making process for the management of vector populations.
An IVM approach takes into account the available health infrastructure and resources and
integrates all available and effective measures, whether chemical, biological, or environmental.
IVM also encourages an integrated approach to disease control.

- Indoor residual spraying

Reduces transmission by reducing the survival of malaria vectors entering houses or sleeping
units.
IRS remains a valuable intervention in malaria control when the following conditions are met:
• high percentage of the structures in an operational area have adequate sprayable
surfaces, and can be expected to be well sprayed;
• majority of the vector population is endophilic, i.e. rests indoors;
• vector is susceptible to the insecticide in use.

- Insecticide-treated materials

Insecticide treated nets, if used by the total population, have shown to be able to lower
transmission by 90%, malaria incidence by 50% and all case child mortality by 18 %.
Insecticide-treated materials include ITNs and other materials. ITNs are a form of effective
vector control, when coverage rates are high and a large proportion of human-biting by local
vectors takes place after people have gone to sleep. It can also be used for personal protection.
Their use has repeatedly been shown to reduce severe disease and mortality due to malaria in
endemic regions.

- Other methods
In some cases environmental management and/or larviciding can be recommended as effective
malaria control tools.

The choice of vector control

The choice of vector control will depend on:

• the magnitude of the malaria burden;
• the feasibility of timely and correct application of the required interventions;
• the possibility of sustaining the resulting modified epidemiological situation.
 Syphillis

Syphilis is a sexually transmitted disease caused by the spirochetal bacterium Treponema

pallidum subspecies pallidum. The route of transmission of syphilis is almost always through
sexual contact, although there are examples of congenital syphilis via transmission from mother
to child in utero or at birth.
The signs and symptoms of syphilis are numerous; before the advent of serological testing,
precise diagnosis was very difficult. In fact, the disease was dubbed the "Great Imitator" because
it was often confused with other diseases, particularly in its tertiary stage.
Syphilis can generally be treated with antibiotics, including penicillin. If left untreated, syphilis
can damage the heart, aorta, brain, eyes, and bones. In some cases these effects can be fatal.
Many people infected with syphilis do not have any symptoms for years, yet remain at risk for
late complications if they are not treated. Although transmission occurs from persons with sores
who are in the primary or secondary stage, many of these sores are unrecognized. Thus,
transmission may occur from persons who are unaware of their infection.

Primary Stage
The primary stage of syphilis is usually marked by the appearance of a single sore (called a
chancre), but there may be multiple sores. The time between infection with syphilis and the start
of the first symptom can range from 10 to 90 days (average 21 days). The chancre is usually
firm, round, small, and painless. It appears at the spot where syphilis entered the body. The
chancre lasts 3 to 6 weeks, and it heals without treatment. However, if adequate treatment is not
administered, the infection progresses to the secondary stage.

Secondary Stage
Skin rash and mucous membrane lesions characterize the secondary stage. This stage typically
starts with the development of a rash on one or more areas of the body. The rash usually does not
cause itching. Rashes associated with secondary syphilis can appear as the chancre is healing or
several weeks after the chancre has healed. The characteristic rash of secondary syphilis may
appear as rough, red, or reddish brown spots both on the palms of the hands and the bottoms of
the feet. However, rashes with a different appearance may occur on other parts of the body,
sometimes resembling rashes caused by other diseases. Sometimes rashes associated with
secondary syphilis are so faint that they are not noticed. In addition to rashes, symptoms of
secondary syphilis may include fever, swollen lymph glands, sore throat, patchy hair loss,
headaches, weight loss, muscle aches, and fatigue. The signs and symptoms of secondary
syphilis will resolve with or without treatment, but without treatment, the infection will progress
to the latent and possibly late stages of disease.

Late and Latent Stages

The latent (hidden) stage of syphilis begins when primary and secondary symptoms disappear.
Without treatment, the infected person will continue to have syphilis even though there are no
signs or symptoms; infection remains in the body. This latent stage can last for years. The late
stages of syphilis can develop in about 15% of people who have not been treated for syphilis, and
can appear 10 – 20 years after infection was first acquired. In the late stages of syphilis, the
disease may subsequently damage the internal organs, including the brain, nerves, eyes, heart,
blood vessels, liver, bones, and joints. Signs and symptoms of the late stage of syphilis include
difficulty coordinating muscle movements, paralysis, numbness, gradual blindness, and
dementia. This damage may be serious enough to cause death.
The syphilis bacterium can infect the baby of a woman during her pregnancy. Depending on how
long a pregnant woman has been infected, she may have a high risk of having a stillbirth (a baby
born dead) or of giving birth to a baby who dies shortly after birth. An infected baby may be
born without signs or symptoms of disease. However, if not treated immediately, the baby may
develop serious problems within a few weeks. Untreated babies may become developmentally
delayed, have seizures, or die.

Diagnosis:

Some health care providers can diagnose syphilis by examining material from a chancre
(infectious sore) using a special microscope called a dark-field microscope. If syphilis bacteria
are present in the sore, they will show up when observed through the microscope.
A blood test is another way to determine whether someone has syphilis. Shortly after infection
occurs, the body produces syphilis antibodies that can be detected by an accurate, safe, and
inexpensive blood test. A low level of antibodies will likely stay in the blood for months or years
even after the disease has been successfully treated. Because untreated syphilis in a pregnant
woman can infect and possibly kill her developing baby, every pregnant woman should have a
blood test for syphilis.

Syphilis and HIV

Genital sores (chancres) caused by syphilis make it easier to transmit and acquire HIV infection
sexually. There is an estimated 2- to 5-fold increased risk of acquiring HIV if exposed to that
infection when syphilis is present.
Ulcerative STDs that cause sores, ulcers, or breaks in the skin or mucous membranes, such as
syphilis, disrupt barriers that provide protection against infections. The genital ulcers caused by
syphilis can bleed easily, and when they come into contact with oral and rectal mucosa during
sex, increase the infectiousness of and susceptibility to HIV. Having other STDs is also an
important predictor for becoming HIV infected because STDs are a marker for behaviors
associated with HIV transmission.

Treatment

Syphilis is easy to cure in its early stages. A single intramuscular injection of penicillin, an
antibiotic, will cure a person who has had syphilis for less than a year. Additional doses are
needed to treat someone who has had syphilis for longer than a year. For people who are allergic
to penicillin, other antibiotics are available to treat syphilis. There are no home remedies or over-
the-counter drugs that will cure syphilis. Treatment will kill the syphilis bacterium and prevent
further damage, but it will not repair damage already done.
Because effective treatment is available, it is important that persons be screened for syphilis on
an on-going basis if their sexual behaviors put them at risk for STDs.
Persons who receive syphilis treatment must abstain from sexual contact with new partners until
the syphilis sores are completely healed. Persons with syphilis must notify their sex partners so
that they also can be tested and receive treatment if necessary.
Recur?

Having syphilis once does not protect a person from getting it again. Following successful
treatment, people can still be susceptible to re-infection. Only laboratory tests can confirm
whether someone has syphilis. Because syphilis sores can be hidden in the vagina, rectum, or
mouth, it may not be obvious that a sex partner has syphilis. Talking with a health care provider
will help to determine the need to be re-tested for syphilis after being treatment.

How to Prevent

The surest way to avoid transmission of sexually transmitted diseases, including syphilis, is to
abstain from sexual contact or to be in a long-term mutually monogamous relationship with a
partner who has been tested and is known to be uninfected.
Avoiding alcohol and drug use may also help prevent transmission of syphilis because these
activities may lead to risky sexual behavior. It is important that sex partners talk to each other
about their HIV status and history of other STDs so that preventive action can be taken.
Genital ulcer diseases, like syphilis, can occur in both male and female genital areas that are
covered or protected by a latex condom, as well as in areas that are not covered. Correct and
consistent use of latex condoms can reduce the risk of syphilis, as well as genital herpes and
chancroid, only when the infected area or site of potential exposure is protected.
Condoms lubricated with spermicides (especially Nonoxynol-9 or N-9) are no more effective
than other lubricated condoms in protecting against the transmission of STDs. Use of condoms
lubricated with N-9 is not recommended for STD/HIV prevention. Transmission of an STD,
including syphilis cannot be prevented by washing the genitals, urinating, and/or douching after
sex. Any unusual discharge, sore, or rash, particularly in the groin area, should be a signal to
refrain from having sex and to see a doctor immediately.