Outline

• Introduction
• Aetiology
• Epidemiology
• Clinical features/ classification
• Diagnosis
• Differentials
• Treatment
• Prevention and control
 Introduction
• An infectious disease caused by parasite plasmodia.
Malaria remains a major public health problem in most
parts of Africa.
• Four identified species causing human malaria
• P falciparium, P. ovale, P. vivax, P. malariae
• P. falciparium commonest in most parts of Africa
accounting for more than 98% of all cases of malaria in
the region
• Parasite discovered in 1880 by Laveran in Constantine,
Algeria.
 Transmission
• Transmission to man through the bite of an
infected female Anopheles mosquito during a
blood meal.
• The female anopheles mosquito bites man
between 5PM and 7AM with maximum intensity
between 10pm and 4am.
• Other less common modes of transmission include
 transfusion malaria→→direct inoculation
Congenital malaria→→transplacentally
 Epidemiology
• An endemic disease of tropics and subtropics,
although endemic malaria has been
documented in areas both north and south of
the equator
• Transmission occurs in more than 100 countries
• Regions affected include Africa, Asia, islands of
the South, West, and central Pacific ocean,
Latin America, Caribbean islands and Turkey.
 Epidemiology
• Areas affected lie between latitudes 640N and
320S with:
High environmental temperature
High humidity
High rain fall
• All favor breeding of anopheles mosquito.
 Malarial immunity
• 2 types:
Natural: non specific, consists of intense proliferation
of RES, macrophages of liver, spleen and bone marrow
which phagocytize parasitized and unparasitized
erythrocytes during malaria infection.
Acquired : a. passive; involves transplacental transfer
of IgG and protects infants against malaria in the first 6
months of life
b. Active; dependent on active or continuous malaria
infection. Both IgG and cellular immunity play part.
 Other factors influencing susceptibility to
malaria
• HbS trait
• G6PD deficiency
• HbF
• Thalassemia
• Duffy-negative antigen
All reduce the severity of acute malaria or
prevalence of chronic malaria by reducing
ability of parasite to penetrate RBCs.
 Malaria endemicity
• Endemic malaria: constant incidence over a period of
many successive years in an area.
• Epidemic malaria: periodic or occasional sharp
increase of malaria in a given indigenous community.
• Stable malaria: amount of transmission is high
throughout the year without any marked fluctuation
over years though seasonal fluctuations can occur. >
5% of fever cases in children< 5 years are due to
malaria.
 Malaria endemicity
• Unstable malaria: there is intermittent
transmission that may be annual, bi-annual or
variable, < 5% of fever cases in children < 5
years are due to malaria
• Malaria free areas: population has no
immunity and are prone to severe malaria if
they travel to high-risk malaria areas.
 Malaria endemicity
• Describes the amount and severity of malaria in an
area.
• Determined by the parasite and spleen rates in
children aged 2-9 years in the population
Hypoendemicity: parasite or spleen rate 0-10%
Mesoendemicity: 11-50%
Hyperendemicity: >50% with adult spleen rate>25%
Holoendemicity: >75% with low adult spleen rate.
Nigeria is in a holoendemic region.
 Malaria burden
• 300-500 million episodes of malaria occur
annually ( about 90% in sub-Saharan Africa)
• 1.5-300 million people die annually from
malaria (80-85% occur in Africa)
• One child dies of malaria in Africa every 20
seconds.
• Malaria kills in one year what AIDS killed in 15
years.
 Malaria burden in Nigeria
• Commonest cause of hospital attendance in all age groups in
all parts of Nigeria.
• one of the commonest causes of childhood mortality in the
country.
• It is estimated that 50% of the population has at least one
episode of malaria each year while children under 5 have on
the average of 2 – 4 attacks in a year.

• Malaria has severe negative effects on maternal health and

birth outcomes. It causes maternal anaemia, increases
miscarriage and low birth weight.
 Malaria burden
• P. falciparum is the most predominant parasite specie
accounting for about 98% of malaria cases in the country.
• P. malariae usually occurs as a mixed infection with P.
falciparum. Anopheles gambiae is the main vector of malaria
in Nigeria, but An. funestus and An. arabiensis are also
commonly encountered.

• An. melas is found in the coastal areas

• Malaria is characterized by a stable, perennial, transmission in

all parts of the country.
 Malaria burden in Nigeria
Economic Burden
• Malaria impedes human development and is
both a cause and consequence of under
development.
• Every year, the nation loses over N132 billion
from cost of treatment and absenteeism from
work, schools and farms.
Life cycle of malaria parasite
 Life cycle
• Asexual cycle (schizogony) in man. Has 2 phases→pre-
erythrocytic (tissue) and erythrocytic.
• Starts with inoculation of sporozoites by infected
female anopheles mosquito during a bite.
• The sporozoites disappear into the liver cells within
half an hour of injection into the blood stream where
they multiply and develop into pre-erythrocytic
schizonts.
• Pre-erythrocytic schizonts→→tissue merozoites to
complete the tissue phase of asexual cycle.
 Life cycle
Erythrocytic phase
• Tissue merozoites invade erythrocytes, starts asexual
division forming ring forms which mature into trophozoites.
• Trophozoites grow, divide, develop and eventually form 8-24
merozoites/RBC
• RBCs burst to release merozoites and hypnozoites.
• Released merozoites reinvade fresh erythrocytes to repeat
the process with higher parasitaemia.
• The erythrocytic phase takes about 36-48 hours for P.
Falciparium , Vivax and Ovale and 72hrs for Malariae.
 Life cycle
• TNF and other cytokines are also released as erythrocytic merozoites
are released and these are responsible for the characteristic
manifestations of the disease (paroxysms of fever).
• Secondary invasion of liver cells occur at end of pre-erythrocytic phase
in P. Vivax and Ovale infections (exo-erythrocytic cycle) and this can be
repeated several times. Responsible for relapse
• A small proportion of erythrocytic merozoites undergo transformation
into male and female gametocytes.
• Mature gametocytes appear in blood stream after a variable period and
are picked up by mosquito during a bite. P. falciparum infects both
immature and mature erythrocytes while P. ovale and P. vivax
primarily infect immature erythrocytes, and P. malariae infects only
mature erythrocytes.
 Sexual phase (sporogony)
• Occurs in mosquito
• Male + female gametocytes fuse→ zygote→ookinete
which penetrates gut wall and becomes oocyst.
• Oocyst divides asexually into numerous sporozoites
which reach salivary gland of the mosquito ready to
be transmitted
• On biting a man these sporozoites are inoculated
into human blood to recommence the asexual
phase.
 Classification of malaria
Uncomplicated malaria (acute malaria)

• Malaria with no life threatening manifestations

• Fever:
 commonest symptom of malaria
 shows remarkable periodicity which corresponds to maturation
and release of RBC merozoites and TNF and other cytokines
Occurs every 48 hours (tertian) in P. Vivax and Ovale and every
72 hours (quartan) in P. Malariae
Irregular pattern in P. falciparium (malignant tertian)
 Uncomplicated malaria
• Headache
• Vomiting
• Convulsion (cld be febrile convulsion or not.)
• Body aches
• General malaise
• Anorexia
P/E may reveal nothing or
Pyrexia
Pallor
Hepatomegaly
Splenomegaly
Hepatosplenomegaly
jaundice
 Complicated malaria
• Defined by the demonstration of asexual
forms of P. falciparium in a patient with
potentially fatal manifestations provided other
causes of such manifestations has been ruled
out.
• Exclusively caused by P. falciparium
• Common in under fives, pregnant women and
the non –immune.
 Complicated malaria
• The presence of one or more of the following
clinical or laboratory features in a patient with
asexual parasitaemia and in which there is no
other confirmed cause for their symptoms
describes complicated malaria.
1. Prostration : inability to sit and/or stand
without support
2. Severe anaemia: PCV < 15% or Hb < 5mg/dl
 Complicated malaria
3. hyperpyrexia: rectal temperature ≥ 400C
4. hyperparasitaemia: Density of asexual forms
of P. falciparium in peripheral blood smear
exceeding 5% of erythrocytes (more than
250,000 parasites per µl of blood.
5. hypoglycaemia: random blood sugar
<2.2mmol/l
6. Jaundice: serum bilirubin> 50µmol/l
 Complicated malaria
7. Cerebral malaria:
unarousable coma for more than 30 minutes
Exclusion of other encephalopathies
Demonstration of asexual form of P. falciparium in
peripheral blood , bone marrow or brain smear.
Ring haemorrhage(ie post-mortem)
8. Multiple convulsions : > 2 generalized convulsions
in 24 hours with regaining of consciousness.
 Complicated malaria
9. renal failure: urine output of less than 400ml/24 hours or
< 12ml/kg/24hours in children or serum creatinine
>265µmol/l (>3mg/dl), failing to improve after rehydration.
10. Pulmonary oedema: demonstrated clinically or
radiologically
11. Bleeding and Clotting disturbances: significant bleeding
from gums, nose, gut, retinal haemorrhage and/or
evidence of DIC.
12. fluid, electrolyte or acid-base disturbances: requiring IVF,
pH<7.25 or plasma bicarbonate<15mmol/l ; venous
lactate >6mmol/l.
 Complicated malaria
13. complicating or associated infections:
aspiration bronchopneumonia, septicaemia.
14. shock: hypotension, rapid thready or
impalpable pulse.
 Cerebral malaria
• Most serious complication of P. falciparium malaria
• Occurs most commonly in under five children
• Due to reduced deformability and cytoadherance of
parasitized and unparasitized RBCs causing
obstruction in cerebral microcirculation after being
sequestered in the capillaries and arterioles.
• TNF and other cytokines play very important roles
 Cerebral malaria
• Obstruction of microcirculation→hypoxia, local
ischaemia, substrate depletion
• Pathognomonic feature is presence of ring
haemorrhages surrounding capillaries and arterioles in
brain necro-biopsy.
• Following initial symptoms of malaria, patient with CM
presents with
• Persistent fever, headache, vomiting, disorientation,
alteration of consciousness and culminating into coma.
• CSF is essentially normal.
 Anaemia
• Commonest complication of malaria
• Multifactorial:
• Haemolysis of parasitized RBCs
• sequestration of RBCs in deep tissues and
reticuloendothelial system
• Capillary haemorrhages
• TNF depression of erythropoiesis
• Immune mediated haemolysis.
• Convulsions may be due to high temperatures,
hypoglycaemia, hypoxaemia from severe
anaemia or effect of administered herbal
concoctions
• Hypoglycaemia may be due to decreased
intake, excess loses through vomiting,
antimalarial mediated, decreased
gluconeogenesis
• Breathing difficulties may be due to:
 heart failure from severe anaemia
Pulmonary oedema
ARDS due to sequestration of malaria
parasites in the lungs
Acidosis
Aspiration
 CLINICAL ASSESSMENT OF MALARIA

History
• Ask about: fever, chills rigor, head aches in the older patient. In addition you should
ask about the following in assessing severe malaria.
• Extreme weakness:
• Change in behavior:
• Convulsions;- ask about the number of episodes, part of the body involved, previous
history and time of onset of last episode. Also enquire about treatment given
• Drowsiness or deteriorating level of consciousness
• Time of last drink or food since the onset of the illness.
• Fast breathing which may be due to pulmonary oedema, acidosis or aspiration or
coexisting pneumonia.
• Reduced urinary out put (time patient last passed urine).
• Colour of urine whether dark or coca cola coloured (this may suggest excessive
breakdown or red blood cells or dehydration).
Physical Examination:
• Assessing for the presence of signs of severe
malaria.
• Identifying other possible causes of disease.
• Central nervous system: Assess the level of
consciousness using an objective coma scale.
• Respiratory system: check for respiratory distress
• Cardiovascular: rate, volume of pulse, BP
• Abdomen: Feel for the spleen and the liver.
 A COMA SCALE FOR CHILDREN

The following coma scale-the “Blantyre coma scale” – modified from the widely used
Glasglow coma scale (1974), is applicable to children including those who have not
learnt to speak.

Score
1. Best motor response:
•Localizes painful stimulus -2
•Withdraws limb from pain -1
•Non-specific or absent response -0

2. Verbal response:
•Appropriate cry- 2
•Moan or inappropriate cry -1
•None-0
 Diagnosis of malaria
Clinical : though there are no specific symptoms and
signs, malaria should be considered in a child with fever
in a malaria endemic zone Laboratory:
1. Thin and thick blood film;thin film identifies the specie
of MP. Thick smears are used to identify the parasites
and thin smears for identifying the species.
• Staining methods include Giemsa and Lieshman’s
• An experienced technician can detect as few as 5
parasites/µI in a thick film and 200/µ1 in a thin film.
.
3. Eye movements:
• Directed -1
(e.g. follows mother’s face)
• Not directed- 0

Total : 0-5
• A state of unarousable coma is reached at a score of <3.
• This scale can be used repeatedly to assess
improvement or deterioration.
• Microscopy using thin and thick blood films is the main
stay of diagnosis.
• + 1 – 10 parasites per 100 thick film fields
• ++ 11 – 100 parasites per 100 thick film fields
• +++ 1 - 10 parasites per one thick film field
++++ >10 parasites per one thick film field
2. Identification of parasite antigens or rapid diagnostic tests
e.g para Sight F. uses test strips
3.Detection of antibodies by radio immuno assay
 DIFFERENTIALS
• MENINGITIS
• STATUS EPILEPTICUS
• ACUTE VOC
• TYPHOID FEVER
• EBOLA VIRAL DISEASE
• UTIs
 Treatment of malaria
• Uncomplicated malaria:
chloroquine used to be the drug of choice for
treatment of uncomplicated malaria. However
due to high level of resistance, WHO now
recommends combination therapy based on
artemisinin ( ACT).
 Treatment
• Recommended dose of chloroquine in
treatment of uncomplicated malaria is
25mg/kg: day 1= 10mg/kg
day 2= 10mg/kg
day 3= 5mg/kg, given orally
It is safe, cheap, effective
• 2nd line drugs: Pyrimethamine/Sulphadoxine
Amodiaquine, Primaquine, Halofantrine.
 Treatment of uncomplicated malaria

• Available combinations based on artemisinin:

1. Artemether-lumefantrine as first line in
Nig(eg Coartem)
2. Artesunate-amodiaquine
3. Artesunate-mefloquine

Current policy in malaria treatment in Nigeria

disallows use of monotherapy.
 ACT
• Artemether- lumefantrine comes as 20mg/
120mg per tablet
• Artesunate dose is 4mg/kg
• Amodiaquine 10mg/kg
• Mefloquine 15-25mg/kg
• Treatment is given for 3 days.
 Treatment of complicated malaria
• Artemisinin derivatives or Quinine given parenterally is choice of
treatment for severe malaria.
 
ARTEMISININ DERIVATIVES:
• Due to their efficacy and very rapid onset of action, these are now
preferred over quinine in the management of malaria 
Dosage:
• Artesunate:-2.4 mg/kg IV bolus, repeat 1.2mg/kg after 12 hours and
then 1.2mg/kg daily for 6 days.
• Artemether:- 3.2 mg/kg IM on the first day and then 1.6mg/kg daily
for a maximum of 3 days until the patient can take oral treatment or
another effective anti-malarial.
• QUININE
Recommended dosage:
• Intravenous quinine
• Children:
• Give 20mg/kg of Quinine dihydrochloride salt as loading dose
diluted in 10ml/kg of 4.3% dextrose in 0.18% saline or 5%
dextrose over a period of 4 hours. Then 12 hours after the
start of the loading dose, give 10mg salt/kg infusion over 2
hours every 12 hours until when patient is able to take orally.
Change to quinine tablets 10mg/kg every 8 hours to complete
7 days of treatment OR give ACT
 SUPPORTIVE TREATMENT

High temperature.
• Give paracetamol (oral/rectal) if temperature is > 38.5 OC, wipe the body with wet
towel and fan the patient to lower the temperature.
 
Pulmonary oedema
• Prop up the patient, give oxygen and furosemide 2-4 mg/kg IV and exclude
anaemia as the cause of the heart failure. 
 
Renal failure
• If patient is dehydrated, give 20ml/kg of normal saline and challenge with
furosemide 1-2mg/kg. Pass a urinary catheter to monitor urinary output.
• If patient does not pass urine within 24 hours, refer for peritoneal or
haemodialysis.
Profuse bleeding
• Transfuse with screened fresh whole blood, give pre-referral treatment
and refer urgently.
Hypoglycemia
• Unconscious children should be given dextrose regularly to prevent
starvation hypoglycemic. It is most conveniently provided as 5%
dextrose in saline infusion, but if this would be likely to lead to fluid
overload, smaller volumes of more concentrated dextrose may be given
at regular intervals.
• If hypoglycemia occurs, give intravenous 50% dextrose in a dose of
1.0ml/kg of body weight (0.5/kg) diluted in approximately the same
volume of IV fluid slowly over several minutes.
 NURSING AND QUALITY OF CARE

Severe malaria is a serious condition and the clinicians and nurses should closely
monitor patients. Therefore nursing care should include all of the following:-
• Monitor vital signs
• Pulse
• Temperature
• Respiratory rate
• Blood pressure
• These should be monitored at least 6 hourly but may be frequent at the initial
stages
• Monitor input and output
• A strict 24-hour input/output chart should be kept in all patients with severe
malaria
• Examine regularly for signs of dehydration or fluid overload.
• Monitoring unconscious patient
• Unconscious or comatose patients need close
monitoring of all vital signs more regularly to assess
their progress. Monitor the level of consciousness at
least 6 hourly. Patients should be frequently turned in
bed to avoid bedsores.
• Drug chart
• A clear drug chart where all drugs given are recorded
should be kept and should include dose given, time
given and number of times a day.
 Prevention and control
Health education
• Environmental sanitation
• Mosquito repellants
• Insecticides
• ITNs
• LLITNs
• Malaria eradication has been achieved in developed
western countries but not in poor developing
countries because of huge cost and lack of education.
 Roll back malaria
• World wide partnership for malaria control
• RBM partners include national , state and local
governments; international organizations-
UNICEF, WHO, WORLD BANK, UNDP; G8
nations and the private sector
• These partners contribute human and
financial resources as well as technical aids
and materials to fight malaria.
 RBM
• The RBM intervention strategy has four key
elements:
• i. Patients with malaria should have access to
appropriate and adequate treatment within 24
hours of the onset of symptoms

• ii. Pregnant women particularly in their 1st and

2nd pregnancies should have access to effective
antimalarial prophylaxis and treatment
 RBM
• iii. Insecticide treated nets and other materials
should be available and accessible to persons
at risk of malaria particularly pregnant women
and children under 5 years of age.

• iv. Epidemics of malaria should be recognized

and steps initiated for their containment
within one week of their onset.
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Improved Neuro-Cognitive Outcome. Pediatr Res. Jul 2 2010;[Medline].
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[Medline].
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due to risk of serious psychiatric and nerve side effects. Available at
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THANK YOU