MANAGEMENT OF

MALARIA

Ananyaa Sinha
Harness innovation to reduce the 121716101011
malaria disease burden and save lives.”
WORLD MALARIA DAY 25th April
 Case Scenario
• A 67 y/o (year old) female initially presented to
the Emergency Department (ED) complaining
of fatigue and subjective fevers for the past 2
days. Patient complained that her fever was
associated with headache, chills, rigors, Index
of suspicion for malaria was high as patient had
recently traveled from an endemic region.
• Reports come back positive for P.falciparum
infection.
• Introduction
• Clinical Features
• Investigations
• Treatment of Malaria
• Questions
 INTRODUCTION
• Vector borne protozoal disease
• Infection with parasites of the genus
Plasmodium
• (falciparum, vivax, ovale, malariae, knowlesi)
• Transmitted to man by species of infected
Female Anopheles Mosquito
Epidemiological Determinants

PLASMODIUM AGENT

HUMAN
(Intermediate)
HOST

FEMALE ANOPHELES ENVIRONMENT &

MOSQUITO VECTOR
Clinical Features
SIGNS
• Pallor
• Jaundice
• Dark Pigmented Urine
(BLACKWATER FEVER )
• Hepatomegaly
• Splenomegaly
• Dry Cough
• Hemolytic Anemia
Stages
 INVESTIGATIONS
• Demonstration of parasite in the blood will
lead to diagnosis of malaria.
MICROSCOPY RAPID
SEROLOGY DIAGNOSTIC
(Giemsa , JSB ) TEST

THICK FILM – Detects parasite

fluorescent
parasite antigen
identification & antibody - +ve
density 2weeks after pLDH,HRP-2

THIN FILM – Use in Expensive

species Epidemiological Temperature
identification Studies sensitive
 Other Investigations
• Quantitative Buffy Coat
• PCR – Polymerase Chain Reaction

• CBC
• Renal Function Tests
• Blood Glucose
• Urine Analysis
• Liver Function Tests
Thick Film Thin Film
 Treatment of Uncomplicated
Malaria
• Cases of fever diagnosed as malaria should
promptly be given treatment depending on
the species.

• P.vivax
• P.falciparum
• Mixed infections
• Pregnancy
 P.vivax
CHLOROQUINE CQ (3) 25 mg/kg
25 mg/kg body weight divided (10+10+5)
over three days
10 mg/kg on day 1, PQ (14) 0.25mg/kg
10 mg/kg on day 2 and
5 mg/kg on day 3.

Relapse rate (vivax) 30%.

PRIMAQUINE
0.25 mg/kg daily for 14 days under
supervision

CONTRAINDICATED
G6PD deficient patients,
infants and pregnant women
 P.falciparum
(ACT-SP) (other states)
ARTESUNATE 3 days 4mg/kg +
SULFADOXINE (25 mg/kg) - PYRIMETHAMINE
(1.25 mg/kg )1st day.+ single dose of PRIMAQUINE
(0. 75 mg/kg) on Day 2.

(ACT-AL) (NE States)

ARTEMETHER (20 mg) +
LUMEFANTRINE (120 mg)

CONTRAINDICATIONS – ACT – SP
Not recommended during the first trimester
of pregnancy and for children weighing <5 kg
ACT – AL – first trimester of pregnancy
<5months and < 5 kgs
 2

120 mg/kg
BD for 3
days
20 mg/kg Artemether
4mg/kg

25mg/kg 0.25mg/kg

1.25mg/kg
(P. vivax + P. falciparum)
In North-Eastern states:
ACT-AL for 3 days + PRIMAQUINE 0.25 mg
per kg daily for 14 days.

In other states:
ACT-SP 3 days + PRIMAQUINE 0.25 mg per
kg body weight daily for 14 days

P. ovale should be treated as P.vivax and

P. malariae should be treated as
P.falciparum .
 Pregnant Women

1st trimester : QUININE SALT 10 mg/kg 3

times daily for 7 days.
2nd and 3rd trimester :
ACT-AL in NE
ACT-SP in other states

QUININE -HYPOGLYCAEMIA not to be

taken on empty stomach
Severe malaria
 SEVERE MALARIA

• Impaired consciousness/COMA
• Repeated generalized CONVULSIONS
• Renal failure (Serum CREATININE >3 mg/dl)
• JAUNDICE (Serum Bilirubin > 3 mg/dl)
• Severe ANAEMIA (Hb<5 g/dl)
• Pulmonary oedema/ARDS
• HYPOGLYCAEMIA (Plasma glucose <40 mg/dl)
• Metabolic acidosis
• Circulatory collapse/SHOCK (Systolic BP<80 mm
Hg,< 50 mm Hg in children)
• Disseminated Intravascular Coagulation
• Haemoglobinuria
• HYPERTHERMIA (Temperature > 106° F or 42°C)
• HYPERPARASITAEMIA ( <5% parasitized RBCs in
low endemic and > 10% in hyperendemic areas)
CHEMOTHERAPY SEVERE MALARIA

PQ one dose 2nd day

3.2g /kg bw,1.6mg/kg
PQ one dose 2nd day

150mg I.M. 3 DAYS PQ one dose 2nd day

Microscopy Results in 24hrs
When report not available in 24hrs and RDT
used
SUSPECTED CASE
 CHEMOPROPHYLAXIS
• Recommended for travellers from non-
endemic areas
• Short term measure (soldiers, police and
labour forces )serving in highly endemic areas.
• Chemoprophylaxis + Personal Protection
MOSQUITO CONTROL MEASURES
 SOURCE REDUCTION &
PERSONAL PROTECTION
 ANTI- LARVAL MEASURES

• Physical – MLO 200L/hectare

• Chemical – Temephos 200L/hectare
• Biological – Larvivorous Fish – Gambusia
• Anti-Larval Bacilli – Bacillus thuringiensis

Gambusia affinis
 VACCINE
• A malaria vaccine is used to prevent malaria.
The only approved vaccine, as of 2021,
is RTS,S, known by the brand name
Mosquirix.
• In October 2021, the WHO for the first time
recommended the large-scale use of a malaria
vaccine for children living in areas with
moderate-to-high malaria transmission.
• Four doses
• Children
• first dose given at 5 months of age.
• first 3 doses are administered monthly
• Third should be completed by 9 months of
age.
• Fourth dose should be administered at 15–18
months.
 Questions
• What drugs used in the treatment of
Uncomplicated P.vivax infection ?

• Chloroquine, Primaquine

CQ (3) 25 mg/kg
(10+10+5)
PQ (14) 0.25mg/kg
• What drugs are used for treatment of
P.falciparum in NE States ?
• ACT-AL

(ACT-AL) (NE States)

ARTEMETHER (20 mg) +
LUMEFANTRINE (120 mg)
BD 3 days
• Name two drugs used in the
chemoprophylaxis of malaria.
• Doxycycline, Mefloquine
• One contraindication of Primaquine
• G6PD deficient patients, infants and pregnant
women
• https://youtu.be/NBIrJhQXiRo
• https://www.medmastery.com/guide/malaria-
clinical-guide/how-identify-type-malaria-blood
-smear
• http://www.annalsofcommunityhealth.in/ojs/i
ndex.php/AoCH/pages/view/ivm
 DON’T’S
• Do not use corticosteroids
• Do not give intravenous mannitol, do not use
heparin as anticoagulant.
• Do not administer adrenaline or do not over
hydrate
 TREATMENT FAILURE
EARLY TREATMENT LATE CLINICAL LATE PARASITOLOGICAL
FAILURE (ETF) FAILURE (LCF) FAILURE (LPF)

•severe malaria severe malaria Severe malaria

•presence of
parasitaemia
•On- D1,D2,D3 D4 and D28 in patients parasitaemia between D7
•D2 ^ D0 who do not meet and D28 with
previous criteria axillary temp <37.5 °C in
•parasitaemia on D3 patients who did not
•axillary temp > previously meet any of the
37.5°C+ parasiteamia Parasitaemia between criteria of early treatment
on D3 >25% of count D4 and D28 with failure
on Day 0. axillary temperature
>37.5°C who do not Alternate ACT or
meet previous criteria Doxycycline
 AGENT
• Plasmodium sp.
• India 50 % infections P.falciparum
• 4-8 % Mixed Infection
• Rest due to P vivax.
• RESERVOIR – Man, Chimpanzee ( In tropical Africa
only P.malariae)
• Relapse – P.malariae 30-40 years, P.vivax 2-3 years
• Recrudescence – P.falciparum 2-2.5 years
 HOST
• All ages can be affected
• Newborns resistant due to fetal Hb
• Duffy negative RBC immune to vivax
• Sickle Cell Trait mild resistance to P.falciparum.
• Host immunity : People in endemic areas are
immune.
• A child born to an immune mother is immune for
3-5 months of age IgG antibodies from the mother
impart
 ENVIRONMENT
• July to November
• Malaria month: June
• World Malaria Day: 25th April
• Temperature: 16- 30°C
• Humidity 50-60%
• Altitude - Mosquito not seen above
2000-2500 m sea level
Mosquito vectors in India
Vector Areas

An. culicifacies Rural and peri-urban peninsular

regions

An. Stephensi urban and industrial

An. fluviatilis main vector in hilly forests and

forest fringes.

An. minimus foot hills of North-Eastern states

An.dirus forest vector in the North-East

An.epiroticus Andaman and Nicobar Islands

Plasmodium under microscope