RÉPUBLIQUE DU CAMEROUN REPUBLIC OF CAMEROON

Paix-Travail-Patrie Peace-Work-Fatherland
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MINISTÈRE DE L’ENSEIGNEMENT MINISTRY OF HIGHER EDUCATION
SUPERIEUR **********
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UNIVERSITÉ DE NGAOUNDÉRÉ UNIVERSITY OF NGAOUNDERE
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INSTITUT UNIVERSITAIRE SAINT-JÉRÔME CATHOLIC
CATHOLIQUE UNIVERSITY INSTITUTE OF
SAINT-JÉRÔME DE DOUALA DOUALA
********** **********

SAINT -JÉRÔME SCHOOL OF HEALTH SCIENCES

THEME: PREVALENCE OF MALARIA IN THE

CATHOLIC HOSPITAL SAINT ALBERT THE
GREAT
THERMAL REPORT

Written and presented with a view to obtain a Bachelor’s Degree in Health Sciences

Speciality: Biomedical Sciences

Written by:

KENFACK AZAFACK MICHELLE CAROLINE

Registration number: UN17H021SJ

Level: License III

Supervised by;

Mr. Pierre FONGHO SUH Mr. MONGUI ESSIBEN David

Lecturer General supervisor
(Academic supervisor) (Professional framer)
 Academic Year: 2019-2020
DEDICATION

To

My family for their multiform support.

ACKNOWLEDMENT

I to show my gratefulness to:

God who gave me this spirit to carry out my internship with an open mind and the will
to learn from other so as to fulfil my objectives and theme.

The great chancellor my lord Samuel KLEDA, the general administrator Mr.
Emmanuel POHOWE who provide us with adequate, sustainable and enrich knowledge
which enable us to withstand in any host structure.

I thank the team management of the catholic university saint Jerome Douala to provide
us internship in different hospital in which we face different working environment.

The general Director of the LAQUINITINIE HOSPITAL to allow us to carry out

our internship in this hospital for us to learn and attain our objectives.

The general director of Saint Albert the Great Catholic Hospital that allows us to collect data
in their registers.

My academic framer Mr. Pierre FONGHO SUH for the support and help he gave
me.

My marvelous mother and sister for their selflessness and multiform support
throughout this internship.

Everybody from near or far that help me in achieving this report.

TABLE OF CONTENTS
LIST OF FIGURES
Figure 1: Localization chart of Laquintinie hospitals.

Figure 2: Picture showing the Organizational chart of Laquintinie.

Figure 3: Picture showing positive result of a blood thick smear.

Figure 4: Picture showing results of TPHA.

Figure 5: Morphology of malaria parasite causative agents.

Figure 6: Life cycle of Plasmoduim.

Figure 7: Physiopathology of malaria.

LIST OF TABLES
TABLE I: Number of personnel present in each service.
LIST OF ABBREVIATION

LLINs: Long Lasting Insecticites Nets

SAGCH: Saint Albert the Great Catholic Hospital

ABSTRACT
SUMMARY
GENERAL INTRODUCTION
An internship is a period through which student passes from theory to practical’s, been
in the third year of biomedical we were send in hospital for us to acquired knowledge in the
analyses of different samples in the laboratory with specifics themes to work on. This theme
guide us throughout the internship while working in different services in the laboratory.
PART I: PRESENTATION OF THE HOST STRUCTURE AND UNROLLING
INTERNSHIP
INTRODUCTION

The studies in the field of biomedical require theory through notes and practical through
internship. This enable us to join the theory with practical that will enable us to analyses,
exercise and put into practice the theory for us to be competent future medical professional.
Biomedical is a vast field of microorganism that through it studies enable us to be competent
biologist through the analysis and identification of different microorganism, by the
application of different techniques which make up our objectives like; mastering different
techniques carryout in parasitology, serologic, hematologic, bacteriologic, virology and
biochemical post. This report will be divided into two parts, the first part comprised two
chapters which are the presentation of the host structure and the activities carryout. Part two
which is the research theme has three chapters 3 which are; literal revue, the methods and
diagnosis and results and discussions.
CHAPTER I: PRESENTATION OF THE HOST STRUCTURE
I.1- LOCALISATION
Laquintinie is a hospital located in Akwa, it is a second category and is a third
references hospital in the first districts BP 4035 Douala and is extent up to 9 hectares.

Figure 1: Localization chart of Laquintinie Hospital of Douala

I.2. Background
From it Construction in 1931, the unworthy hospital of Douala was subjected to the
system of unworthy by the French administration. It was reserve to black patients which
access to the General Hospital of Douala was forbidden.

In the 50s it took the name of Laquintinie in tribute to the doctor Jean Auguste Laquintinie,
military doctor who stays two times in Cameroon. This hospital is a 2 nd category reference
hospital who has a mission to assure good care in medical and medico sanitary qualitative and
quantitative in response to different cases.

I.3. Description of the different services

This hospital extend over 9 hectare and has 40 flag and has over 800 personnel. It has
a capacity of over 732 beds of which 644 are available and receive about 150000 patients per
year. It has the following services;

I.3.1. Department of biomedical analysis

It has 5 services: service of clinical biology engaged in a process of certification by

OMS, service of pharmacy and the service of imaging functional exploration equipped with a
scanner of 16 barrettes anatomo-pathology service which cover the unit of thanapraxy
effectively and finally the blood bank.

I.3.2. Department of hygiene and medico-sanitary technology

This is a service in charge of medical equipment maintenance, central sterilization and

hygiene in the hospital and environment.

I.3.3. Department of obstetrics gynecology

This is the service in charge maternity and maternal protection.

I.3.4. Pediatric department

This service is made up of neonatology which has a unit of kangaroo babies of

reference in central Africa and has a Centre of sickle cell care.

I.3.5. Medicine department

This service has 9 specialty; cardiology, neurology, psychiatric, respiratory disease

center, endocrinology, infectiology, dermatology, rheumatology and gastro enterology.

I.3.6. Surgical department

This department has 7 services: pediatric surgery, neurosurgery, ORL, ophthalmology,

urology, orthopedic and traumatology.

I.3.7. Department of care

It has 5 services: oncology, the center of care for individuals living with the HIV virus,
external consultation, hospitalization of high and medium standing, and care and the
contracted service with a care unit and personnel security.

I.3.8. Urgency, reanimation and anesthesiology department

It has 2 services and is an excellent service for care of medical and surgical
emergencies. In addition it is the biggest service of reanimation of Douala with 16 beds.

I.3.9. Cooperation, study and quality department

It has 2 services one for quality control and the other for study and cooperation.
I.4. Staff per service

I.5. Average number of patients received in each service

This is the average number of patient receive per services and since the internship was carry
out in the laboratory the amount of patient in the laboratory is recorded according to the post
and is represented on the table below.

I.6. Organizational chart

An organizational chart is a diagram that visually conveys a company's internal
structure by detailing the roles, responsibilities and relationships between individuals within a
company and the figure 7 below represent the internal organization of Laquintinie.

Figure 2: Picture showing the Organizational chart of Laquintinie

CHAPTER II: INTERNSHIP DEVELOPMENT
II.1. Activities carried out in the service laboratory
Biomedical research is a broad area that involve the investigation of biological process
and the causes of disease through careful experimentation, observation, analysis and testing.
This service is divided into blood collection and analysis which has 6 post which are
hematology, serology, bacteriology, virology, parasitology and biochemistry. During this
internship we didn’t visit the blood collection but different post and the activities carryout are
detail below.

II.1.1. Serology

This post deal with the red tube and carryout the following exam; widal, ASLO, HIV,
TPHA, hormones (T3, alpha feto protein, procalcitonin, Beta-HCG, PSA), cancer antigen.

II.1.1.1. Widal

This is an exam done to confirm the diagnosis of typhoid cause be Salmonella Typhi.

Materials: reagent (AO BO CO TO AH BH CH TH), plasma, micropipette.

Principle: This test consist of putting into contact a suspension of somatic antigens of the cell
wall (0) and flagella (H) of Salmonella typhi with the patient serum to visualized
agglutination if antibodies are present.

Procedure: The blood collected is centrifuge since only plasma is needed. The micropipette
is use to collect 20ul of each reagent and put on the slide, then add 20ul of plasma close to the
reagent and the mix to have a homogenous mixture and turn the slide circularly during 2
minutes while observing agglutination.

Results: If agglutination are absent the exam is negative and if present a quantitative test will
be done. To quantify mix 50ul of the reagent with the strongest agglutination with 10ul of
serum and observe agglutination, if absent the result is 1/160 and is present dilution has to be
done still there is no agglutination. So another dilution will be done that mix 50ul of reagents
with the strongest agglutination and 5ul of plasma and observe agglutination, if present result
is more than 1/320 and if absent it is less than that.
II.1.1.2. TPHA (Treponema pallidum Haemaglutination) test

This is an exam to detect the antibodies of Treponema Palladium which cause

syphilis.

Principle: This test is an indirect haemaglutination for the determination of antibodies of

Treponema Palladium in serum or plasma. Stabilized erythrocytes are sensibilised by the
antigenic component of Treponema Palladium. These cells agglutinate in presence of
antibodies specifique to and will form images in the micro wells.

Material: buffer, plasma, micropipette, test cells, control cells and micro wells.

Procedure: Add 190ul of diluent to well 1 then 10ul of plasma and mix, then transfer 25ul of
well 1 to well 2 and 3. Add 75ul of control cells to well 2 and 75ul of test cells to well 3, then
mix the contents thoroughly. Cover the plate and incubate for 45-60 minutes in an area which
is away from heat, direct sunlight and vibrations.

Results: Observe for holes or mat of cells, if present the exam is positive if not it is negative.
If the exam is positive a quantitative test has to be done.

For the quantitative test each sample require 9 wells, add 190ul of diluent to well 1,
then 25ul of diluent to well 4-9, add 10ul of serum to well 1 and mix. Transfer 25ul of well 1
to wells 2, 3, 4 and 5. Add 75ul of test cells to wells 3, 4, 5, 6, 7 and 8 then add 75ul of
control cells to well 2 and mix. Allow the mixture for 45-60 minutes in the same condition as
above.

Results: this is shown in the figure below.

Figure 3: Picture showing the Results of TPHA

II.1.2.2.1.3. CD4 COUNT

This exam is to know the number of CD4 cells infected by HIV in immune-deficiency
patients.
Procedure: The blood collected in the violet tube is passed in a centrifuge. Once done 20µl of
the pipette CD4 antibody is put in a measure tube. Add 20ul of the blood centrifuge, mix and
incubated for 15 minutes in darkness. Then 800ul of buffer solution is added to the mixture
centrifuge, and the measure tube is place in the aspiration catheter which is the read using a
cyflow. This method is the most accurate but for laboratory without this machine another
technique is use which is name as visitect CD4.
Visitect CD4 require the following material: test device, sampling device, buffer, total
blood, micropipette, gloves and timer.
Procedure: Write the patient identity on the device and put on gloves, using the micropipette
collect 30ul of the total blood and put it into well A of the test device and wait for 3minutes
using the timer. The add 1drop of buffer into well A and wait for 17minutes, followed by
3drop f buffer in well B and wait for 20minutes and then read the result as shown on the
figure bellow.

II.1.1.4. ASLO (Antistreptolysin 0)

This is an exam done to detect the antibodies antistreptolysin produce by the immune
system in response to streptolysine O, secreted by the streptococcal Beta hemolytic of group
A in the patient serum which cause angora and acute rheumatoid arthritis.
Principle: The mixture of the serum containing the antibodies antistreptolysin produce an
agglutination when superior or equal to 200ul/ml.

Material: reagent, saline, micropipette, serum and card.

Procedure: Mix 20ul of serum and latex reagent, rotate the card for 2 minutes and observe
agglutination if present exam positive and if absent negative. In case of exam positive a
quantitative exam is done by putting 20ul of saline in 3 circle, then add the same quantity of
the reagent in the first circle and mix the mixture by drawing up and down in the pipette.
Redraw 20ul of the mixture into the second circle mix as explain above and redraw 20ul of
the mixture from the second circle to the third circle and discard the last 20ul.Then add 20ul
of the reagents in each circle and mix in a circular manner for 1 minutes and observe for
agglutination in the different circle.

Results: observe for agglutination in different card, multiply 200 by the highest dilution with
positive reaction.

II.1.2. Parasitology

This is a branch of the laboratory that identify parasite in stool, blood and urine. This
service has the following materials: slide, cover slide, immersion oil, reagents MGG,
microscope, urinary strip and micropipette. Below are some of the exams carryout.

II.1.2.2.1. Stool test

This is an exam to identify parasite in stool. The aim of this exam is to identify
parasite eggs, cyst and amoeba, epithelial cells, yeast, bacteria era, erythrocytes and
leucocytes.

Materials: slide, cover slide, stool, distilled water and lugnol.

Procedure: A macroscopic exam is done by describing the color and consistency of the stool.
One drop is distill water is put on one site of the slide, the stool is mix to increase the
possibility to find parasite and a bit is collect and mix in the distill water. If the stool is liquid
there is no need of distill water. This is cover with a cover slide and the same thing is done at
the opposite side of the slide with lugnol and mount on the microscope at objective 10 to
observe for helminthes and then objectives 40 for protozoa. Lugnol enable to increase the
visibility of cyst if present.
II.1.2.2.2. Urine test

This is an exam to identify parasite eggs, cyst and amoeba, epithelial cells, yeast,
bacteria era, erythrocytes and leucocytes in urine.

Materials: slide, cover slide, urine and urinary strips.

Procedure: For this exam the urinary strip is inserted in urine and the colors then appear on
the strip are compare to the one on the strips container. This exam test for the presence of
glucose, nitrite, red blood cells, white blood cells, ketone bodies, protein, crystal, and ph. To
confirm this result the urine is centrifuge and the sediment is collected and put on a slide and
cover with a cover slide. This is then, mount on the microscope at objectives 10 and 40 to
observe parasite like Schistosoma haematobuim eggs.

II.1.2.2.3. Thick blood smear

This is exam done to identify Plasmodium falciparum trophozoid, schizont,

gametophyte and microfilaria in blood.

Principle: Giemsa is a metachromatic colorant made up of eosine which is acid and

methylene azur which is alkaline. It has the property to give to certain tissue a different color
than their real color. The cell constituent which are acid attach to the alkaline colorant and
alkaline cells constituent attach to the acid colorant. It give the nucleus a blue or violet color
and the cytoplasm bleu (for basophile element) and pink color (for acidophil).

Material: slide, immersion oil, blood and giemsa.

Procedure: 10-15ul of blood is collected and put on a slide, using another slide the blood id
spread on the slide while destroying red blood cells by applying some strength while
spreading the blood. This is allow to dry, once done the slide is cover with giemsa and allow
for 10-15minutes, after this the slide is rinse in water and allow to dry. This is then mount on
the microscope at objective 100. In case that the there is confusion between the colorant and
trophozoid an MGG coloration is done as explain.

For the MGG coloration a thin blood smear is done by putting the same quantity of
blood as said above, another slide is put in contact with the blood so that blood spread at the
edge of the slide by capillarity. This slide is inclined at an angle of 45° and spread the blood
on the slide so as to form a blood smear a thin as a ‘cat tongue’ and is allow to dry. Once dry
the slide is cover with MG and allow for 3minutes then water is added on the slide and allow
for 1minutes. Then the slide is rinse in water and cover with giemsa with the same protocol as
said above. This thin blood smear enable to observe trophozoid in the red blood cells as well
as neutrophil, eosinophil, monocyte, lymphocyte and basophile. After this the number if
trophozoid per blood micro liters is calculated using the formula bellow.

Results: This is illustrated in the figure bellow

Parasite Density = Number of parasites counted

*8000

Figure 4: Picture showing positive result of a blood thick smear

PART II: THEMATIC RESEARCH WORK

THEME: PREVALENCE OF MALARIA

INTRODUCTION

Malaria is a disease cause by the protozoan plasmodium, transmitted through the bite of the
female anopheles mosquito during her blood meal from 11pm – 6am. Up to 52 anopheline
species have been reported in the country so far, with 16 recognized as main or secondary
vectors. Six of the species are among the most efficient vectors in sub-Saharan Africa,
namely, An. gambiae, An. coluzzii, An. arabiensis, An. funestus, An. nili and An. Moucheti.
The causative agent of malaria are Plasmodium falciparum, Plasmodium vivax, Plasmodium
ovale, Plasmodium malariae and Plasmodium knowlesi, with Plasmoduim falciparum been
the most virulent in Africa. The people most at risk are children less than 5years due to the
immune system not fully develop, HIV aids patients and pregnant women because of foetal
sufferance due to low erythrocytes level. Malaria is one of the world’s biggest killers.

Although drugs are available for treatment, malaria is still considered by many to be the most
important infectious disease of humans: there are approximately 200 million to 500 million
new cases each year in the world, and the disease is the direct cause of 1 million to 2.5 million
deaths per year. According to the World Health Organization (WHO) a child dies every 45
seconds as a result of the disease and is mostly present is tropical and subtropical region such
as; Africa, Asia, Nord and Central America and Oceania.
Malaria exist in two form simple or uncomplicated and severe malaria with their
manifestations and treatments been different. The manifestation of malaria include fever up to
41°, chills, headache, myalgia, asthenia, nausea and diahrea, this can lead to complications
such as anaemia and cerebral lesion (AVIQ 2016). The early diagnosis of malaria will prevent
the development of such complications. There are many method to diagnose malaria that is;
thick blood smear, thin blood smear, test strips, PCR and antigenic tests, in Cameroon the
main exam carryout is the thick blood smear which has a high sensitivity compare to the thin
blood smear blood. The treatment of malaria will depends on the species identify, status of the
patient (age group and pregnancy) and the resistance if develop by the patient. Treatment
include artesunate, arthemeter and quinine (cdc 2019) which are antimalarial drug , but with
time increase resistance develops to this drugs.In addition preventive methods are puts in
place to reduce contamination through chemoprophylaxis, LLINS and insecticides.

Problematic

Malaria is a life threatening diseases transmitted by the female anopheles mosquito. It is a

major health problem affecting all age group particularly children, immunosuppressed persons
and pregnant women. It’s mostly present in developing countries due to low sanitation,
activities, environment and adequate climatic condition that favour the proliferation of the
parasite. The city of Douala is a coastal areas making it environment adequate for the
anopheles to lay eggs. In addition due to continuous use of insecticide in houses, mosquito
nets, body repelant and in agriculture these anopheles develop resistance which increases it
prevalence in urban areas. For this reason we carry out the prevalence of malaria in Saint
Albert the Great Catholic hospital that receive patients from unsanitary neighbourhood.

Objectives and interest of the study:

 General Objective
Determine the prevalence of malaria in SAGH.
 Specific objectives

Determine the age group mostly infected by plasmodium.

Determine the relationship between plasmodium and seasons.

Determine the gender mostly infected by plasmodium.

Determine the prevalence of plasmodium with habitat.

 RESEARCH HYPOTHESIS
A hypothesis is a tentative statement about the relationship between two or more variables.
We have two of these hypotheses which are; Null and Alternative hypothesis.
 Null Hypothesis
The prevalence of malaria is not significant in patients receive at Saint Albert the Great
Catholic hospital.
 Alternative Hypothesis
The prevalence of malaria is significant in patients receive at Saint Albert the Great Catholic
hospital.

CHAPTER III. LITERATURE REVIEW

III.1. Malaria

This disease is cause by plasmodium species and has human reservoir. This parasites affects
the liver and erythrocytes.

III.2. Cause

 Bites from female anopheles mosquitoes.

 Rainy seasons.
 Stagnant water.

But the most frequent mode frequent is through mosquito bites.

III.3. Morphology

Malaria has four stage of development in humans (hepatic schizonts and the intraerythrocytic
trophozoite, schizonts and gamonts) and three developmental stages in mosquitoes (ookinetes,
oocysts and sporozoites).

In humans;

 Liver schizonts appear as spherical multinucleated clusters of small basophilic bodies

located within the host hepatocytes measuring 40-80um in diameter when mature.
 Intraerythrocytic consist of small rounded trophozoite measuring 1-2um in diameter.
  Schizonts are amorphous, multinucleated and measure 7-8um in length.
 Gamonts there are two type microgametocytes which have a large nucleus and
microgametocytes with a dark cytoplasm.

In mosquito

 Ookinetes measuring 15-20um.

 Oocysts are form by the fusion of a microgamete and macrogamete measure 50um in
diameter.
 Sporozoites are produces by the oocysts measuring about 15um long which infects the
salivary glands (parasite.ord.au). Below is the image of various causative agents.

Figure 5: Morphology of malaria causative agents.

III.4. Taxonomy of Plasmoduim sp

KINGDOM: Protista

PHYLUM: Apicomplexa

CLASS: Sporozoasida

ORDER: Eucoccidiorida

FAMILY: Plasmodiidae

GENUS: Plasmodium

SPECIES: falciparum, malaria, ovale, vivax, knowlexi.

III.5. Epidemiology
In 2018 there was as estimation of 228 million malaria cases with an estimation of 405000
death, from this children of less than 5years accounted for 272000 that is 67%. P. falciparum
accounted for 99.7%,of estimated malaria cases in the WHO of which 50% Africa
region( 25% Nigeria, 12% RDC, 5% Uganda and 5% for ivory coast, Niger and
Mozambique), 71% Eastern Mediterranean, 65% Western Pacific.

The disease is still widely transmitted in the tropics and subtropics. In these areas malaria
transmission may be endemic, occurring predictably every year, or it may be epidemic,
occurring sporadically when conditions are correct. Endemic transmission of malaria may be
year-round or seasonal. In some areas of Africa, 90% to 100% of children less than 5 years
old have malaria parasites circulating in their blood all the time. Because naturally acquired
immunity develops with increasing exposure, in endemic areas malaria disease is primarily
found in children. In epidemic areas, on the other hand, naturally acquired immunity falls off
between epidemics, and malaria therefore affects all age groups during epidemics.

In Cameroon, malaria affects over 90% of the population and is responsible for 35% of the
annual mortality, with 40 to 45% medical consultations and 30 to 47% hospitalizations. A
study carryout by Antonio-Nkondjio et al. Parasites Vectors in 2019 in Far Nord reveals that
before the use of LLINS the prevalence of malaria in children between 2 and 9 years-old,
varying from 8.5% at the end of the dry season to 40.8% during the rainy season with enable
to put forward the relationship between malaria and season. In the South West region prior to
LLINs use the prevalence was 35-85.4% in children from 6 months to 15 years. Furthermore
after the use of LLINs the level of infection drop but was still high because of the fact that
entomological surveys were undertaken in different sites before and after LLINs scale-up.

Another study carryout by Antonio-Nkondjio et al. Parasites Vectors in 2011 in the city of
Douala reveal malaria occur mostly in the rainy season due to high humidity. The anopheles
present was An. Gambiae caring P. falciparum. These anopheles develop resistance to most
chemical constituents of insecticides there increasing their prevalence in urban areas.

An article on malaria in school children from 0-10 years reveals that children less than five
years are the most infected and reduces as they get older because immunity against malaria
becomes stronger over time following recurrent infecting mosquito bites especially in highly
endemic areas. Furthermore children sleeping under the mosquito nets have nearly the same
prevalence as those who don’t due to anopheles resistant (Lehman et al. 2018)
III.5.1. Mode of transmission

 Malaria is transmitted by the bite of an infective female Anopheles mosquito.
  Transfusion of blood from infected persons (heathstage 2014). 
 Use of contaminated needles and syringes are other potential modes of transmission. 
 Congenital transmission of malaria from mother to unborn infant before or during
delivery.
 Organ transplants (CDC 2017).

III.5.2. Risk Factors

According to the article of Heidi Moawad, MD 2017 the risk factors of malaria are;

 Pregnant women are at risk because of decreased or lowered immunity.

 Blood transfusion through a donor previously infected but not manifesting illness and
who is not test for the parasite presence.
 Living and visiting an area of endemic of malaria parasite.
 Lack of long sleeves clothes, bed net and insects repellant.

According to the article of C. Mikeal Gibson, M.D 2014 risk factor include;

 Standing water in irrigation ditches or burrow pits.

 Agricultural work such as harvesting increase the nighttime exposure to mosquito
bites.

III.6. Life cycle

Figure 6: life cycle of Plasmodium.

(1) During a blood meal, a malaria-infected (2) female Anopheles mosquito inoculates
sporozoites into the human host. (3) Sporozoites infect liver cells within 30 minutes of
inoculations and mature into schizonts, (4) which rupture and release 2000-40000 merozoites.
(In P. vivax and P. ovale a dormant stage [hypnozoites] can persist in the liver and cause
relapses by invading the bloodstream 1-2years.) (A) After this initial replication in the liver
(exoerythrocytic schizogony takes 5-21days), (B) the parasites undergo asexual multiplication
in the erythrocytes (erythrocytic schizogony). (5) Merozoites infect red blood cells. The time
required for erythrocytic schizogony-which determines the interval between the releases of
successive generations of merozoites-varies with the species of plasmodium and is responsible
for the classic periodicity of fever in malaria. The ring stage trophozoite mature into
schizonts, (6) which rupture releasing merozoites. (7) Some parasites differentiate into sexual
erythrocytic stages (gametocytes). Blood stage parasites are responsible for the clinical
manifestations of the disease. (8) The gametocytes, male (microgametocytes) and female
(macrogametocytes), are ingested by an Anopheles mosquito during a blood meal. (9) The
parasites’ multiplication in the mosquito is known as the sporogonic cycle. While in the
mosquito's stomach, the microgametes penetrate the macrogametes generating zygotes. (10)
The zygotes in turn become motile and elongated (ookinetes) (11) which invade the mid gut
wall of the mosquito where they develop into oocysts. (12) The oocysts grow, rupture, and
release sporozoites (it takes 1-2 weeks for sporozoites to be produce), which make their way
to the mosquito's salivary glands. Inoculation of the sporozoites into a new human host
perpetuates the malaria life cycle (CDC 2020).

III.7. Pathogenesis

At the completion of the schizogony within the red cells, each cycle lasting 24-72 hours.
Haemoglobin release by haemolysis causes the kidney to overload and is partially converted
into bilirubin by the liver. The excess is release in urine causing hemoglobilinuria. On the
other hand the use of haemoglobin by the parasites causes the granule pigment (hemozoin) to
precipitate it cytoplasms, it release when the red blood cells burst is partially responsible of
fever This pigment accumulate in the schizont cytoplasms and when the merozoites are
release they invade the plasma. It will then be phagocytes by monocytes macrophages and
polymorphonuclear neutrophils. Merozoites are released by the lysis of infected erythrocytes
and along with them, numerous known and unknown waste substances, such as red cell
membrane products, hemozoin pigment, and other toxic factors such as
glycosylphosphatidylinositol (GPI) are also released into the blood. These products,
particularly the GPI, activate macrophages and endothelial cells to secrete cytokines and
inflammatory mediators such as TNF, ITF-γ, IL-1, IL-6, IL-8, M-CSF, and lymphotoxin, as
well as superoxide and nitric oxide (NO). The liver and spleen becomes hypertrophic due to
excess production and destruction of red blood cells. The systemic manifestations of malaria
such as headache, fever and rigors, nausea and vomiting, diarrhea, anorexia, tiredness, aching
joints and muscles, thrombocytopenia, immunosuppression, coagulopathy, and central
nervous system manifestations have been largely attributed to the various cytokines released
in response to these parasite and red cell membrane products. These phenomenon is
represented in the figure below.

Pathogenesis of Severe Malaria

The infection of the red cells by malaria parasites, particularly P. falciparum, results in
progressive and dramatic structural, biochemical, and mechanical modifications of the red
cells that can worsen into life-threatening complications of malaria. While the vast majority of
severe malaria and related mortality are caused by P. falciparum infection, complications can
occur in non-falciparum infections as well. In recent years, several cases of severe infection
and even deaths have been reported following infections with P. vivax and P.
knowlesi infections. Several pathophysiological factors such as the parasite biomass; ‘malaria
toxin(s)’ and inflammatory response; cytoadherence, resetting and sequestration; altered
deformability and fragility of parasitized erythrocytes; endothelial activation, dysfunction and
injury; and altered thrombostasis have been found to be involved in the development of severe
malaria. All these phenomena are more profound and wide spread in P. falciparum infection
compared to non-falciparum infections. As a result, except for severe anaemia, complications
such as cerebral malaria, hypoglycaemia, metabolic acidosis, renal failure, and respiratory
distress are more commonly seen in P. falciparum infections.

Figure 7: Physiopathology of malaria.

III.6. Sign and Symptoms

The incubation period is influenced by several factors such as the species of infecting
parasites, the way of parasite transmission, the degree of previous immune status of the host,
the chemoprophylactic use of antimalarial drugs, and the density of parasite inocula.
Incubation period ranges from 9 to 30 days with P. falciparum infections, tending to present
the shortest time, and P. malariae the more prolonged times. In most of P. falciparum and P.
vivax malaria, the incubation period is approximately two weeks. In blood-induced infections,
the incubation period is usually shorter with symptoms developing within 10 days of
transfusion for P. falciparum, 16 days for P. vivax, and 40 days or longer for P.
malariae. (Mediterr J Hematol Infect Dis. 2012)

The most characteristic symptom of malaria is fever. Other common symptoms include chills,
headache, myalgias, nausea, jaundice, hypertrophy of the spleen and liver and vomiting.
Diarrhea, abdominal pain, and cough are occasionally seen. As the disease progresses, some
patients may develop the classic malaria paroxysm with bouts of illness alternating with
symptom-free periods. The malaria paroxysm comprises three successive stages. The first is a
15-to-60 minute cold stage characterized by shivering and a feeling of cold. Next comes the
2-to-6 hour hot stage, in which there is fever, sometimes reaching 41°C, flushed, dry skin, and
often retro-orbital headache, nausea, vomiting, extreme thirst, altered consciousness and
convulsion may occur in children. Finally, there is the 2-to-4 hour sweating stage during
which the fever drops rapidly and the patient sweats. The entire paroxysm, which more
frequently begins in late afternoon or evening, lasting 6-10 hours.

In all types of malaria the periodic febrile response is caused by rupture of mature schizonts.
In P vivax and P ovale malaria, a brood of schizonts matures every 48 hr, so the periodicity of
fever is tertian (“tertian malaria”), whereas in P malariae disease, fever occurs every 72 hours
(“quartan malaria”). The fever in falciparum malaria may occur every 48 hr, but is usually
irregular, showing no distinct periodicity (James M. Crutcher and Stephen L. Hoffman.
1996). 

The manifestation of severe anaemia include; renal failure, metabolic acidosis,

hypoglycaemia, hyperparasitisms, low blood pressure, acute respiratory distress syndrome,
altered consciousness, shock, prostration, coma, pulmonary oedema severe anaemia,
convulsions and jaundice. The table below represents the manifestations of severe malaria in
children and adults.

Table 2: Severe manifestations of Plasmodium falciparum malaria in adults and

children.

Clinical manifestation Children Adult

Impaired consciousness +++ ++

Respiratory distress +++ ++
Multiple convulsion +++ +
Prostration +++ +++
Shock + +
Pulmonary oedema +/_* +
Abnormal bleeding +/_* +
Jaundice + +++
III.7. Complication

The most common complication of malaria is anaemia, jaundice with cerebral malaria been
ery rare and the most lethal which are discuss below.

Anaemia

This is due to the destruction of red blood cells by malaria parasite. Though red blood cells
are unable to carry enough oxygen to the body muscles and organs. It manifest itself by
weakness, asthenia, tachycardia, pallor of skin and conjunctiva (NHS 2018).

Jaundice

This is a condition that cause yellowing of the skin and sclera. This is due to excess rupture of
red blood cells that suppress the liver and are free bilirubin is found is plasma.

Cerebral malaria

Human cerebral malaria (HCM) is the most severe complication of P. falciparum infection.
HCM can occur in less than two weeks after a mosquito bite and may develop after 2 to 7
days of fever. Seizures, retinopathy and brainstem alterations due to elevated intracranial
pressure and brain swelling are also clinical features frequently observed during HCM.
(Virulence. 2012)

III.8. Diagnostic

The key diagnosis of malaria is the thick blood smear explain below.

Thick blood smear

This is exam done to identify Plasmodium falciparum trophozoid, schizont,

gametophyte and microfilaria in blood.

Principle: Giemsa is a metachromatic colorant made up of eosine which is acid and

methylene azur which is alkaline. It has the property to give to certain tissue a different color
than their real color. The cell constituent which are acid attach to the alkaline colorant and
alkaline cells constituent attach to the acid colorant. It give the nucleus a blue or violet color
and the cytoplasm bleu (for basophile element) and pink color (for acidophil).

Material: slide, immersion oil, blood, microscope and giemsa.

Procedure: 10-15ul of blood is collected and put on a slide, using another slide the blood is
spread on the slide while destroying red blood cells by applying some strength while
spreading the blood. This is allow to dry, once done the slide is cover with giemsa and allow
for 10-15 minutes, after this the slide is rinse in water and allow to dry. This is then mount on
the microscope at objective 100X. In case that the there is confusion between the colorant and
trophozoid an MGG coloration is done as explain below.

For the MGG coloration a thin blood smear is done by putting the same quantity of
blood as said above, another slide is put in contact with the blood so that blood spread at the
edge of the slide by capillarity. This slide is inclined at an angle of 45° and spread the blood
on the slide so as to form a blood smear a thin as a ‘cat tongue’ and is allow to dry. Once dry
the slide is cover with MG and allow for 3minutes then water is added on the slide and allow
for 1minutes. Then the slide is rinse in water and cover with giemsa with the same protocol as
said above. This thin blood smear enable to observe trophozoid in the red blood cells as well
as neutrophil, eosinophil, monocyte, lymphocyte and basophile. After this the number if
trophozoid per blood micro liters is calculated using the formula bellow.

Results: This is illustrated in the figure bellow

Parasite Density = Number of parasites counted

*8000

Figure: Picture showing positive result of a blood thick smear

III.9. Treatment

III.9.1. Preventive treatment

Personnel measure
To avoid mosquito bites, the CDC recommends the following:

 Apply insect repellent to exposed skin. The recommended repellent contains 20-35%
percent N, N-Diethyl-meta-toluamide (DEET).
 Wear long-sleeved clothing and long pants if you are outdoors at night.
 Use a mosquito net over the bed if your bedroom is not air-conditioned or screened.
For additional protection, treat the mosquito net with the insecticide permethrin.
 Spray an insecticide or repellent on clothing, as mosquitoes may bite through thin
clothing.
 Spray pyrethrin or a similar insecticide in your bedroom before going to bed.
 Chemoprophylaxis drugs is advice for everybody except pregnant women.
 Intermittent preventive treatment: It is advised to pregnant women during their
prenatal visits. sulfadoxine-pyrimethamine is the most effective on pregnant women despite
the development of resistance and two is required during pregnancy.
 Delivery of preventive measure

Indoor residual spraying

 Sleeping under LLINs

Collective measure

 Development of new molecules and that contain the combination treatment.

 Breeding site reduction/environment management strategies: modify the local
environment preventing the larvae having access to suitable breeding conditions for
example, covering or removing water containers, filling in ditches or effective
drainage.
 Research of vaccine.
 Sanitations of affected countries. (WHO 2005)

III.9.2. Curative treatment

The treatment of malaria will depend if it is severe or simple.

Uncomplicated anaemia

Artemisinin-based combination therapies (ACTs). ACTs are, in many cases, the first line
treatment for malaria. There are several different types of ACTs. Examples include artemether
lumefantrine (Coartem), Amodiaquine + Artesunate and artesunate-amodiaquine. Each ACT
is a combination of two or more drugs that work against the malaria parasite in different ways.
These are fixed dose combination medicines that can be used for non-pregnant adult and
pediatric patients. Quinine sulfate plus doxycycline, tetracycline, or clindamycin is the next
treatment option. artemether lumefantrine (Coartem)is advice for pregnant women in the
second and third semester.

Severe malaria

All patients with severe malaria, regardless of infecting species, should be treated with
intravenous (IV) artesunate. (CDC 2020)

CHAPTER IV: MATERIALS AND METHODS

IV.1- STUDY DESIGN

This will be a retrospective study.

IV.2- STUDY AREA

This will be carry out in SAGCH.

IV.3- STUDY DURATION

This will be carryout for a period of two weeks.

IV.4- STUDY POPULATION

Everybody who carry out a thick blood smear in SAGCH.

IV. 5-CALCULATION OF PARASITOLOGICAL INDICES

IV.6- SAMPLE TECHNIQUE
The random technique will be use.
7- SAMPLE SIZE CALCULATION
The size of the sample will be determined on two criteria, which is the time allocated for our
study. The sample is calculated based on biostatistics.
IV.8. - SELECTION CRITERIA
These are strategies put in place to know who will participate in this study. Two criteria will
be identified.
IV.8.1- Inclusion Criteria
Everybody who carry out a thick blood smear test in the SAGCH and whose results are found
in the laboratory registers.

IV.8.2-Exclusion Criteria

Everybody who carry out a thick blood smear test in the SAGCH and whose results are not
found in the laboratory registers.

IV.9- DATA COLLECTION

Data will be collected from the laboratory registers.

IV.9.1- Procedure

A copy of a request from the administration will be given to the laboratory technician and
analysis will be made from the data collected in registers. From that analysis, results will be
obtained and statistics are drawn from it given in percentages, tables and charts.

IV.9.1.1- Interpretation and expression

IV.10- DATA ANALYSIS

The data will be analysed using Microsoft excel and total will be represented on the different
forms given in percentage, tables and charts.

A total number of 243 patients were enrolled in our studies of three months, in which the
majority were female (166) while the minority were male (77). The age group was 0-90 years,
the table below represent the distribution of the study age group.

DEMOGRAPHIC CHARACTERISTIC OF PARTICIPANTS

Table 3: Distribution of the study population with respect to age and gender.

Age group Number of Male Number of female 0-10

0-10 38 46 11*20
nov-20 19 40 21-30
21-30 3 30 31-40
31-40 4 30 41-50
41-50 5 9 51-60
51-60 3 5 61-70
61-70 2 5 71-80
71-80 2 1 81-90
81-90 1 0 Total
Total 77 166
The table above represent the study population with respect to age group and their sex. The
patients within the age group 0-10 years were 84, those within 11-20 years were 59, those
within 21-30 were 33, those within 31-40 years were 34, those within 41-50 years were 14,
those within 51-60 years were 8, those within 61-70 years were 7, those within 71-80 years
were 3 and those within 81-90 were 1. The major age group was from 0-10 years with 38
males and 46 females and the minority age group was within 81-90 years with 1 male and no
female. In total there is 77 male and 166 female for a total population of 243 patients.
Table 4: Distribution of the study population according to Habitat

Quater Frequency male Frequency female Total Total Percentages%

4 etage 0 2 2 0,80%
Akwa 1 1 2 0,80%
B'dalle 0 4 4 1,60%
B'dibo 0 2 2 0,80%
Bekoko 1 1 2 0,80%
Besengue 1 2 3 1,20%
Besseke 0 2 2 0,80%
Bilongue 0 2 2 0,80%
B'mbappe 5 5 10 4,10%
B'mokano 0 17 17 7%
Bojongo 2 5 7 2,90%
bomono 3 3 6 2,50%
Bonodibong 0 1 1 0,40%
BP cite 0 1 1 0,40%
B'ssadi 0 1 1 0,40%
B'ssama 1 3 4 1,60%
Cebec 1 0 1 0,40%
Centre caisse 1 3 4 1,60%
Dakar 1 0 1 0,40%
Deido 2 1 3 1,20%
Foret bar 0 4 4 1,60%
Grand baoba 4 1 5 2,07%
Grand hangar 11 10 21 8,60%
Kumba 0 5 5 2,02%
Lycee 1 0 1 0,40%
Mabanda 14 38 52 21,41%
Mpanjo 1 3 4 1,60%
Ndibonbarri 0 1 1 0,40%
Ndobo 9 13 22 9,50%
Ndogbong 0 1 1 0,40%
Nestle 0 2 2 0,80%
Ngodi 1 1 2 0,80%
Ngwelle 5 12 17 7%
PK 14 0 2 2 0,80%
Pt baoba 1 1 2 1,20%
Rail 4 0 4 1,60%
Roi bell 0 1 1 0,40%
Royal palace 0 1 1 0,40%
Sodiko 6 8 14 5,80%
Souza 1 6 7 2,90%
Total 77 166 243 100,00%
The table above represent 243 patient tested in SAGCH, most of the patient inhabits Mabanda
(21.41%) and the minority inhabits rail, Akwa, Bessengue, Bekoko, Nestle, Grand hangar,
Bonassama, Souza, Bilongue, Ndogbong, Bonadibong, Dakar and Royal palace.

PREVALENCE OF Malaria.

Figure : General prevalence of Malaria in the population.

IV.11- ETHICAL CONSIDERATION
Are based according to the following;
 Ethical clearance will be obtained from the school.
 Plagiarism will be avoided.
 An authorisation from the school and the hospital concern.
 An authorisation from the Ministry of Higher Education.
IV.12- BUDGET

CHAPTER V: RESULTS AND DISCUSSION

CONCLUSION
REFERENCES