MALARIA

Carta Gunawan
National Expert Committee on Malaria
Global Warming Increases Malaria, Dengue Fever Threat,
UN Says
By Jason Gale and Bill Varner - November 27, 2007 07:00 EST

Nov. 27 (Bloomberg) -- Global warming will put millions more people at risk of malaria and
dengue fever, according to a United Nations report that calls for an urgent review of the health
dangers posed by climate change.
Increases in rainfall, temperature and humidity will favor the spread of malaria-transmitting mosquitoes
over a wider range and to higher altitudes, according to the 2007-2008 Human Development Report,
released today. That could put 220 million to 400 million additional people at greater risk of the disease
that kills about 1 million a year, mostly in Africa.
``Ill health is one of the most powerful forces holding back the human development potential of poor
households,'' the report said. ``Climate change will intensify the problem.''
The 384-page report commissioned by the UN Development Program was released a week before
delegates to a UN-sponsored conference on Bali, Indonesia, will try to convince the U.S. to join a new
emissions-limiting treaty that will pick up after 2012, when the Kyoto Protocol ends.
Droughts, floods and storms will worsen unless measures are taken to cut emissions in half by 2050
relative to 1990 levels, the report said. About 262 million people were affected by climate disasters
from 2000 to 2004, most of them in developing countries.
Changes in weather patterns may also increase the number of people exposed to dengue fever to 3.5
billion from 1.5 billion by 2080. The potentially lethal viral disease, which is also transmitted by
mosquitoes, is found at higher elevations in previously dengue-free areas of Latin America, the report
said.
``A major public health threat is coming from the vector- borne diseases that depend on
temperature and on humidity,'' said Martin Krause, UNDP's Bangkok-based technical adviser on
climate change for the Asia-Pacific region. ``Occurrences of malaria and dengue fever in
communities'' traditionally unaffected by these diseases would place an additional strain on
public health services, he said.
NATIONAL MALARIA CONTROL

Objectives :
In 2030, Indonesia achieves malaria free
transmission for healthy life people,
and malaria cases reduction of 2 per
1,000 inhabitants (2010) to less than 1
per 1,000 inhabitants (2030), and
malaria endemic areas declines 50 %
STRATEGY OF PROGRAM
1. Diagnosis
confirmed by microscopy or rapid diagnostic test
(RDT)
STOP CLINICAL MALARIA DIAGNOSIS
2. Treatment
Artemisinin Combination Therapy (ACT)
STOP MONOTHERAPY
3. Prevention
Long-lasting Insecticidal Net (LLIN), Indoor
Residual Spraying (IRS), etc
4. Partnership
WHAT ARE NEW ABOUT MALARIA
IN THE LAST DECADE ?
P. vivax is proved to cause severe malaria
(2000)
P. knowlesi is reported as the fifth
plasmodium species that causes human malaria,
and also causes severe malaria (2004)

Treatment of uncomplicated malaria should

use combination drugs (ACT) (WHO, 2006)

Treatment of complicated (severe) malaria :

parenteral artemisinin derivatives (WHO, 2006)
P. knowlesi (the fifth human plasmodium)
Natural host : Macaca fascicularis/ Macaca
nemestina
First reported in 2004 from Sarawak, Malaysia
Morpholgy similar to P. malariae
Diagnosis by PCR
No hipnozoite
Fever every 24 hours, diarrhea, abdominal pain
Can cause severe malaria (10 % of infected cases;
mortality 1-2 %)
Complications reported : ARDS, liver/ kidney
dysfunction, hypotension
Sensitive to chloroquine
CLINICAL MANIFESTATIONS
and
DIAGNOSIS
Manifestations of plasmodium infection

Benign malaria (uncomplicated malaria)

Severe malaria

(malaria with complications)

2 10 % of malaria cases
mortality rate 10 - 50 %
untreated cases : mortality almost 100 %
P. vivax, P. knowlesi severe malaria

cerebral malaria
severe anemia
severe thrombocytopenia
P. vivax
jaundice
acute renal failure
rupture of spleen
ARDS

P. knowlesi
 SEVERE MALARIA -2010
DEFINITION : patient with plasmodium asexual parasitemia, with
one or more CLINICAL or LABORATORY FEATURES :
PROSTRATION
FAILURE TO FEED
IMPAIRED CONSCIOUSNESS SEVERE ANEMIA (< 5 gr%/15 %)
RESPIRATORY DISTRESS HYPOGLYCEMIA (<40 mg%)
MULTIPLE CONVULSIONS, >2x/ 24 hrs ACIDOSIS (< 15 mmol/L)
CIRCULATORY COLLAPSE RENAL IMPAIRMENT (> 3 mg%)
(systolic < 70, chlidren < 50 ) HYPERLACTATEMIA (> 5mmol/L)
PULMONARY EDEMA ( radiology ) HYPERPARASITEMIA (>2%/ 5%)
ABNORMAL BLEEDING ( spontaneous )
JAUNDICE + other vital organ
dysfunction
HEMOGLOBINURIA
WHO: Guidelines for the Treatment of Malaria 2010- second edition
Severe manifestations of P. falciparum

White NJ. Mansons Tropical Diseases. 22nd edition. 2010

Plasmodium infection in pregnancy

mother fetus
immune system parasite
sequestration
tends to present as in placenta
severe malaria IUGR, IUFD,
low birth weight,
fetal distress,
mortality risk 3 times premature
higher labor
than non-pregnant women(congenital malaria)
DIAGNOSIS

History of traveling to endemic malaria

area
Clinical signs and symptoms
Laboratory examinations and other
examinations
 Patients with fever or fever in the last 3
days (with headache, nausea, vomiting,
diarrhea, muscle pain)

Malaria blood smear (microscopic

examination) or RDT

Positive Negative

Repeat malaria Search for

Malaria
blood smear other causes
every 24 hour of fever
until 48 hour

Positive
Treat
based on
Malaria etiology

Pedoman Tatalaksana Malaria 201

 Laboratory examinations
- Blood smear (thick and thin blood
film)
- Rapid Diagnostic Test
(immunochromatography)
- QBC (quantitative buffy coat)
- PCR (polymerase chain reaction)
MICROSCOPIC EXAMINATION
Giemsa stain (3%); detection threshold 50-
100 parasites/L blood
Thin blood film (better for evaluation parasites
morphology) and thick blood film (higher
sensitivity)
Thick blood film

semiquantitative : +, ++, +++. ++++

quantitative : parasite/ 200 leucocyte x WBC
. parasites/ L blood
Thin blood film : parasite in 25 view fields x 100 %
RBC in 25 view fields
Malaria Rapid Diagnostic Test

Immunochromatographic assay
Monoclonal antibodies directed against the
target parasite antigen
Need small amount of blood, 5-15 L
Results obtained in 5-20 minutes
Room temperature 4-300C
For useful diagnostic, RDT must achieve >
95 % sensitivity
Detection threshold > 100 parasites/L
blood