Malaria epidemiology, clinical features & treatment

5/7/2020 1Malaria - Epidemiology, Clinical Features & Treatment Dr. Animesh Gupta

Dr Animesh Gupta
MBBS, MD, FDM, FAGE
Associate Professor
Dept. of Community Medicine, NMCH, Jamuhar (Bihar)

▪Malaria is a protozoal disease caused by infection with
parasites of the genus Plasmodium and transmitted by
certain species of infected female Anopheles mosquito.
▪Four species of Plasmodium can infect and be spread by
humans.
▪Humans occasionally become infected with Plasmodium
species that normally infect animals, such as P. knowlesi

▪ Hippocrates was the first person who described feature of malaria
in man – 400 BC
▪ Charaka mentioned as fever is the main symptom of malaria – 300
BC
▪ Charles Louis Alphonse Laveran discovered P. malariae parasite
in the blood of soldier – 1880
▪ Ronald Ross discovered the disease transmission by mosquito
▪ Grassi and Feletti discovered P. vivax parasite 1890
▪ WilliamWelch discovered P. falcifarum parasite 1897
▪ Stephenes discovered P. ovale parasite

▪In 2018 an estimated 228 million cases of malaria occurred
worldwide and 405 000 people died.
▪Children aged under 5 years are the most vulnerable group
affected by malaria.
Source :WHO Malaria Report 2019

▪Globally, 53% of the P.
vivax burden is in the
WHO South-East Asia
Region, with the majority
being in India (47%).

Reported cases of Malaria (2018)
▪ Total cases- 429928
▪ P. falciparum cases- 204733
▪ P. vivax – 222730
▪ Mixed - 2465
▪ Deaths- 96
Source :WHO Malaria Report 2019

▪ Tribal malaria – contributes about 50% of the cases in country
(AP, MP, Gujarat, Jharkhand, Bihar, Maharashtra, Odhisa).
▪ Infants, young children & pregnant women are considered as
high risk group.
▪ Rural malaria – irrigated areas of Haryana, Punjab, western
U.P., & parts of Rajasthan
▪ Urban malaria – 15 major cities like Delhi, Mumbai, Chennai,
Kolkata, Hyderabad, Bengaluru.
▪ Malaria in project areas
▪ Border malaria
▪ Forest malaria 5/7/2020 10Malaria - Epidemiology, Clinical Features & Treatment Dr. Animesh Gupta

Parasite Vector
Host
Environment

▪Agent factor
▪ Malaria is caused by 4 distinct species -
P.falciparum, P.vivax, P.ovale, and P.malariae.
▪ P.falciparum causes about 60% of the infections in India, 4-8%
is mixed infections, and rest due to P.vivax.
▪ P.malariae has a restricted distribution and contributes to 1%
of the infections.

5/7/2020
13Malaria - Epidemiology, Clinical Features & Treatment Dr. Animesh Gupta

▪ Reservoir Of Infection
▪ With the possible exception of chimpanzees in tropical Africa,
which may carry P.Malariae.
▪ Human reservoir - one who harbours sexual forms of the parasite
▪ Conditions to serve as a reservoir :
▪ Must harbor both sexes of gametocyte in blood
▪ Gametocytes must be mature
▪ Gametocytes must be viable
▪ Gametocytes must be present in sufficient density to infect
mosquitoes.
145/7/2020Malaria - Epidemiology, Clinical Features & Treatment Dr. Animesh Gupta

▪ Period Of Communicability
▪ Malaria is communicable as long as mature, viable
gametocytes exist in the circulating blood in sufficient
densities to infect vector mosquitoes.
▪ Gametocytes appear in the blood 4-5 days after asexual
forms appear in P.vivax,and they do not appear until 10-12
days after asexual forms in P.falciparum.

1. Age- Affects all ages
2. Sex- Males are affected more frequently than females
3. Race- People with AS hemoglobin (sickle cell trait) have a
milder illness with falciparum infection. People whose RBC’s
are “Duffy negative” are resistant to P.vivax infection
4. Pregnancy- malaria during pregnancy have severe
manifestation
5. Housing- ill-ventilated, ill- lighted houses provide ideal
indoor resting place for mosquitoes.

6. Occupation – predominantly a rural disease and is closely
related to agricultural practices.
7. Human habits – such as sleeping outdoors, not using
personal protection measures (example: bed nets)
8. Immunity – immunity is acquired only after repeated
exposure after several years.
In endemic areas a state of collective immunity becomes
established slowly and the people develop a considerable
degree of resistance.

1. Season – maximum prevalence is from July to November (post
monsoon)
2. Temperature – 20 to 30 degree Celsius
3. Humidity – relative humidity of 60% ensures long life span. If
humidity is high they are more active and feed more.
4. Rainfall – provides opportunities for breeding of mosquitoes and may
give rise to epidemics.
5. Altitude – Anophelines are not found at altitudes above 2000 meters
6. Man-Made Malaria – burrow pits, garden pools, canals, irrigation
channels and engineering projects like construction of hydroelectric
dams, roads, bridges

▪ An.culicifacies- Rural, periurban
▪ An.fluviatilis- Forest, Hilly areas
▪ An.stephensi- Urban, Industrial
▪ An.minimus,An.philippinensis,An.sundaicus – Foothills
▪ An. dirus : forest in NE states
▪ An. epiroticus – Andaman & Nicobar Island

▪Life Span – 10-12 days
▪Resting Habits – Endophily, Exophily, Endophagic,
Exophagic
▪Breeding Habits – moving water, wells, cisterns, fountains,
overhead tanks, garden pools
▪Time Of Biting – Nocturnal feeding between dusk to dawn

▪Vector transmission
▪Direct transmission
▪Congenital Malaria

▪ P.falciparum : 12 days (9-14 days)
▪ P.vivax : 14 days (8-17 days)
▪ P.malariae : 28 days (18-40 days)
▪ P.ovale : 17 days (16-18 days)

❑ Uncomplicated Malaria
▪ The classical malaria attack lasts 6-10 hours. It consists of
▪ Cold stage (sensation of cold, shivering) – 1 hr
▪ Hot stage (fever, headaches, vomiting; seizures in young children &
Skin is hot and dry to touch) – 2 to 6 hrs
▪ Sweating stage (sweats, return to normal temperature, tiredness) – 2
to 4 hrs.
▪ Symptoms appear 7 days or more (usually 10–15 days) after the
infective mosquito bite.

▪ Fever
▪ Chills
▪ Sweats
▪ Headaches
▪ Nausea and vomiting
▪ Body aches
▪ General malaise

The manifestations of severe malaria include
▪ Cerebral malaria
▪ Severe anemia due to hemolysis
▪ Hemoglobinuria due to hemolysis
▪ Acute respiratory distress syndrome (ARDS),
▪ Abnormalities in blood coagulation
▪ Low BP
▪ Hyperparasitemia, where > 5% of the RBCs are infected by malaria
parasites
▪ Metabolic acidosis often in association with hypoglycemia.

▪ Microscopy- Thick film and Thin film.
Thick film – detection of parasite
Thin slide – identifying or confirmation of species
▪ Serological Tests- Malarial Fluorescent Antibody test usually
becomes positive two weeks or more after primary infection
▪ RDT- Rapid Diagnostic Tests- based on detection of circulating
parasite antigens by a simple dipstick.

▪ P. vivax cases
✓ Chloroquine 25 mg/kg bw – divided dosage – 3 days
✓Primaquine – 0.25 mg/kg bw daily – 14 days
✓ Primaquine is contraindicated in infants, pregnant women and
individuals with G6PD deficiency.
[When primaquine is administered to individuals with G6PD deficiency,
its metabolites lead to more severe hemolysis by inducing
oxyhemoglobin generation, GSH depletion and stimulation of the hexose
monophosphate pathway]

Age in years Chloroquine (10 mg/kg bw or
150 mg)
Primaquine
(2.5 mg)
Day 1 Day 2 Day 3 For 14 days
< 1 ½ ½ ¼ Nil
1-4 1 1 ½ 1
5-8 2 2 1 2
9-14 3 3 1½ 4
15 & above 4 4 2 6
5/7/2020 30
Chloroquine – 600 mg on day 1 & Day 2 ; 300 mg on day 3
Primaquine – 12.5 mg for 14 days
Malaria - Epidemiology, Clinical Features & Treatment Dr. Animesh Gupta

▪ ACT is not to be given
in 1st trimester of
pregnancy.
▪ Quinine can be given
in 1st trimester

Malaria epidemiology, clinical features & treatment

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