Malaria

Part (2)

Dr. Nanees Ahmed Ismail

 antibody test past infection
Dipstick for detection of P. falcip. in field.
Period of communicability

• Malaria is communicable as long as

mature; viable gametocytes exist in the
circulating blood in sufficient density to
infect vector mosquitoes.
Relapse
• Two types (species) of parasites, Plasmodium vivax
and P. ovale, have dormant liver stages that can
remain silent for years. Left untreated, these liver
stages may reactivate and cause malaria attacks
("relapses") after years(>3 years) without symptoms.
Patients diagnosed with P. vivax or P. ovale are often
given a second drug to help prevent these relapses.
• Another type (species), P. malariae, if left untreated,
has been known to persist in the blood of some
persons for several decades (40years) .
Prevention :
A- Mosquito control (Vector control):

1.Control of the larval stages can be done by:

a) Removal of vegetations.
b) Draining of collections of water
c) Spraying of oil or kerosene on surface of water
d) Using larvicides as Paris Green or D.D.T.
e) Using Gambusia fish.
f) Changing the character of water to become
unsuitable to larvae breeding.
 Prevention :
A- Mosquito control (Vector control):
• 2.Control of adult stages :
• a) Using mosquito nets and
screens on windows and doors.
• b) Spraying insecticides as D.D.T
• c) Using repellents applied to the
exposed skin.
• d) Animal barriers to deviate
mosquitoes from man to animals.

Source: google web site

Prevention :
B- Health education

• should be provided to reduce vector

populations and provide protection from
mosquito bites.
 Prevention :
C) For travelers to endemic areas
Chemoprophylaxis:
Weekly administration of chloroquine (5mg base/kg)
beginning approximately 2 weeks prior to exposure and
continuing for at least 6 weeks after exposure is
recommended. Same schedule can be given to the
pregnant female.
• For chloroquine-resistant P.falciparum: Fansidar is given.
• The recommended dosage for adults: one tablet once a
week. This weekly dose of Fansidar should be given in
addition to the weekly dose of chloroquine.
Control:
For patients:
• 1-Notification: obligatory report to local
health authority.
• 2- Isolation in mosquito proof areas.
Patients control:

• 3.Treatment
• For chloroquine sensitive strains,
chloroquine is the drug of choice
except for the treatment of drug
resistant falciparum malaria.
• The standard dosage is oral
administration of a total of 25mg of
chloroquine base/kg over a 3 day
period.
• For children and infants, the dose
never exceeds 5mg base/ kg in S.C.
injection.
Patients control:
• To prevent relapse: In case of vivax or
ovale malaria, treatment of clinical attack is
by chloroquine followed by a course of
primaquine (adult dose is 15 mg base daily
for 14 days).
• In the treatment of falciparum malaria:
• it is essential to monitor the response to
treatment by examination of blood smears
at least once daily. If the parasite density
remains unchanged or is higher 48 hours
later, the presence of a resistant strain
should be suspected and an alternative
drug should be administered.
Patients control:
• Treatment of drug resistant falciparum malaria:
By using one of the following:-
• 1)Quinine sulfate followed by fansidar.
• 2) Quinine sulfate & tetracycline administered
concurrently.
• 3) Mefloquine.
Control
For contacts:
• Investigate for source of infection.
• Ask about previous infection or possible
exposures.
• Treat those with positive blood smear.
International Measures
• 1.Dis-insectization of aircraft before departure from
endemic areas or in transit using a space-spray
application of an insecticide of a type to which the
vectors are susceptible.
• 2.Dis-insectization of aircraft, ships and other vehicles
on arrival if the health authority at the place of arrival
has reasons to suspect the importation of malaria
vectors.
• 3.Maintaining rigid anti-mosquito sanitation within the
mosquito flight range of all ports and airports.
• 4.Administer anti-malarial drugs to potentially infected
migrants or workers (those coming from endemic
areas) who will work in countries where malaria has
been eliminated.
 Vaccine Development
• 1. Against the sporozites: They avoid
infection in the vertebrate host and produce
a sterile resistant state opposing infection
with plasmodium.
• 2. Against the merozoites: prevent them from
infecting the erythrocytes, thus opposing the
production of those parasitic forms, which
generate clinical signs of disease, while
diminishing the reservoir of gametocytes.
• 3. Against the gametes: They inactivate male
gametes and make fertilization impossible,
thus reducing transmission of the disease.
cdc.gov
Malaria Eradication:
• Malaria eradication implies an intensive short-
term effort for the elimination of malaria
parasites from the human population so that
there is no further occurrence of malaria even
in the presence of carrier mosquitoes.

• In other words, malaria eradication does not

mean eradication of mosquitoes.
Objectives of malaria eradication:

• Ending the transmission of malaria.

• Elimination of the reservoir of infection.
• Prevention of reestablishment of
malaria.
The strategy of malaria
eradication:

• a- Spraying of all human dwellings and

other roofed structures where
mosquitoes rest, with residual
insecticides e.g. DDT to kill mosquitoes
and interrupt transmission of malaria.
• b- Malaria surveillance
Malaria Prophylaxis

Additional information from: www.cdc.gov

Prophylaxis only in areas with
chloroquine-sensitive P. falciparum
Drug Adult dose Pediatric dose Comments

Chloroquine 200 mg base 5 mg/kg base Begin 1-2 weeks

phosphate (500 mg salt) (8.3 mg/kg salt) before travel to
(Aralen™ and orally, orally, malarious areas.
generic once/week once/week, up Take weekly on
to maximum the same day of
adult dose of the week while in
300mg base the malarious
areas and for 4
weeks after
leaving such
areas.
Prophylaxis in areas with chloroquine-
resistant P. falciparum
Drug Adult dose Pediatric dose Comments
Mefloquine 228 mg base ≥9 kg: 4.6 mg/kg Begin 1-2 weeks before
(Lariam™ (250 mg salt) base (5 mg/kg travel to malarious
and orally, salt) orally, areas. Take weekly
)generic once/week once/week while in the malarious
10-19 kg: ¼ areas and for 4 weeks
tablet once/week after leaving such
20-30 kg: ½ areas.
tablet, Contraindicated in
once/week persons allergic to
mefloquine and in
31-45 kg: ¾ persons with major
tablet once/week .psychiatric disorders
≥46 kg: 1 tablet,
once/week
 Prophylaxis in areas with chloroquine-
resistant or mefloquine-resistant
Plasmodium Falciparum

Drug Adult dose Pediatric dose Comments

Atovaquone Adult tablets Pediatric tablets Begin 1-2 days before
/proguanil contain 250 mg contain 62.5 mg travel to malarious
(Malarone™ atovaquone and atovaquone and 25 areas. Take daily
) 100 mg proguanil mg proguanil while in the
hydrochloride. malarious area, and
hydrochloride.
1 adult tablet for 7 days after
11-20 kg: 1 tablet
orally, daily leaving such areas.
21-30 kg: 2 tablets
Contraindicated in
31-40 kg: 3 tablets
persons with severe
41 kg or more: 1
renal impairment. Not
**adult tablet daily
recommended for
children < 11 kg,
pregnant women, and
women breastfeeding
infants weighing <11
kg.
Prophylaxis in areas with chloroquine-
resistant or mefloquine-resistant P. falciparum

Drug Adult dose Pediatric dose Comments

Doxycycline 100 mg 8 years of age or Begin 1-2 days before
(Many brand orally, daily more: 2 mg/kg up travel to malarious
names and to adult dose of areas. Take daily at the
)generic 100mg/day same time each day
while in the malarious
area and for 4 weeks
after leaving such
areas.
Contraindicated in
children < 8 years of
age and pregnant
women.
 Anti-relapse therapy

Drug Usage Pediatric dose Comments

Primaquine Used for 0.5 mg/kg base Indicated for persons

presumptive (0.8) mg/kg salt) who have had prolonged
anti-relapse up to adult dose exposure to P. vivax and
therapy orally, once/day P. ovale or both.
(terminal for 14 days after Contraindicated in
prophylaxis) to departure from persons with G6PD (1)
decrease the the malarious deficiency. Also
risk of relapses area. contraindicated during
of P. vivax and pregnancy and lactation
P. ovale unless the infant being
breast-fed has a
documented normal
G6PD level

Thank you