Dr Prashant Kumar

Assistant Professor

1
Introduction
Malaria is a protozoal disease caused by
infection with parasites of the genus
Plasmodium and transmitted to man by
certain species of infected female
Anopheline mosquito.
The illness is characterized by paroxysms
of fever and chills, anemia and
splenomegaly.
The febrile paroxysms occur with definite
intermittent periodicity repeating every
third or fourth day.
2
Major epidemiological types of
malaria in India
TRIBAL MALARIA  Tribal areas, 50% of P.
falciparum cases.
RURAL MALARIA  An. culicifacies is the main
vector and P. vivax is predominant during lean
period and P.falciparum during periodic
exacerbation.
URBAN MALARIA  poor sanitary conditions and
low socio-economic groups living in unplanned
settlements prone to periodical epidemics.
MALARIA IN PROJECT AREAS
BORDER MALARIA

3
Malaria control : reducing the malaria
disease burden to a level at which it is no
longer a public health problem.

Malaria elimination : the interruption of

local mosquito borne malaria transmission;
reduction to 'zero' of the incidence of
infection caused by human malaria
parasites in a defined geographical area;
continued measures to prevent re-
establishment of transmission are required.
4
Certification of malaria elimination :
The chain of local human malaria
transmission by Anopheles mosquitoes has
been fully interrupted in an entire country
for at least 3 consecutive years.

Malaria eradication : permanent

reduction to 'zero' of the worldwide
incidence of infection caused by a specific
agent. Intervention measures are no longer
needed once eradication has been achieved.
5
Agent
Diseases in humans is caused by four
parasites :

4 -8%)
Plasmodium falciparum (50 (%)
Plasmodium vivax (37 – 41 %)
Plasmodium malariae (<1%)
Plasmodium ovale

6
Source & reservoir
The only reservoir is a malaria case.
The source of infection is a malaria case
with adequate number of mature viable
gametocytes circulating in the blood.
It has been estimated that in order to
infect a mosquito, the blood of a human
carrier must contain at least 12
gametocytes per mm3 and the number of
female gametocytes must be more than
the male gametocytes

7
Period of communicability
The human case of malaria becomes
infective to mosquito when mature, viable
gametocytes develop in the blood of the
patient in sufficient density

Viva  4-5 days after appearance of

asexual parasites.
Falciparum  10 – 12 days after
appearance of asexual parasites
8
Host
All ages are equally affected.
Men are more frequently exposed to risk
(via occupation, social behaviour, and
outdoor life) and clothing.
People with sickle cell trait have been
found to be relatively immune to
Plasmodium falciparum infection.
Individuals whose RBCs are Duffy -
negative are resistant to Plasmodium
vivax infection.
9
Cont’d
Pregnancy increases the risk of malaria in
women
Socio-Economic Status is inversely related
to incidence of malaria
Ill ventilated and poorly lighted houses
provide ideal resting places for mosquitoes.
Human habits  sleeping outside, refusal to
accept spraying of houses, not using
personal protective measures
Migrating population

10
Environment
Optimal conditions for malaria transmission
occur when the temperature is between
20°C and 30°C and the mean relative
humidity is at least 60%.
Sporogony does not occur at temperatures
below 16°C or at temperatures higher than
33°C.
A high relative humidity increases mosquito
longevity and therefore increases the
probability that an infected mosquito will
survive long enough to become infective.
11
Malaria infections and malaria illness are
often more common during rainy seasons
because the number of breeding sites is
increased and because female anophelines
survive longer when the humidity is high.
Too much rainfall can be deleterious to
vector larvae and pupae by washing them
away, thus decreasing transmission

12
Cont’d
Droughts may be associated with increased
transmission, as it reduces the size and flow
rates of large rivers to produce suitable
breeding sites.
The proximity of human habitation to breeding
sites directly influences vector - human contact
and, therefore, transmission.
The stability of breeding sites is influenced by
water supply, soil, vegetation, etc.
Irrigation schemes, dams, and other man - made
changes can alter the pattern of malaria
transmission
13
Vectors
An. culicifacies, An. fluviatilis, An.
stephensi, An. minimus, An. philippinensis
and An. maculatus.

The vectors of major importance are An

culicifacies in rural areas and An.
stephensi in urban areas.

14
Density
For effective transmission of malaria in a
locality, the mosquito vector must attain and
maintain a certain density.
This is called critical density and it varies
from one mosquito to another and also under
different environmental conditions.
Anopheles culicifacies needs a very high
density for transmission of malaria.

15
Breeding habits
The breeding habits of mosquitoes show a lot of
variation.

Anopheles fluviatilis in slow moving water,

Anopheles sundaicus in brackish waters,
Anopheles stephensi in wells, cisterns and over
head tanks.

Tanks, pools, burrow pits and ditches are the

preferred breeding spots for Anopheles annularis
and Anopheles philippinensis while Anopheles
dirus is usually found breeding in forest pools,
streams and slit trenches.
16
Longevity : A mosquito must live for at
least 10 days after an infective blood meal,
to complete the development of malaria
parasites.

Tropism : Some mosquitoes like

Anopheles fluviatilis prefer human blood
and are called anthropophilic. Others like
Anopheles culicifacies preferably feed on
animal blood and are called zoophilic. This
preferential feeding habit is called
tropism.
17
Resting Habits : A female mosquito rests
either indoors (endophilic) or outdoors
(exophilic) after a blood meal for
maturation of its eggs.

 Knowledge of these habits is necessary

for organizing anti-adult measures. The
common resting places are either human
dwellings, cattle sheds or mixed dwellings.

18
Vectorial capacity

Resistance to insecticides

Flight Range :
An. culicifacies and An. stephensi  2
km.

19
Mode of transmission
Bite of the infected female anopheles
mosquito.
The mosquito is infective only if the
sporozoites are present in its salivary glands.
However, Malaria can also be transmitted by
intravenous or intramuscular injection of
infected blood or plasma in an otherwise
healthy person.
Rarely transmission can also occur from
infected mother to the newborn
20
Incubation period
This is 12 (9-14) days for falciparum
malaria, 14 (8-17) days for vivax malaria,
28 (18-40) days for quartan malaria and
17 (16-18) days for ovale malaria.

With some strains of P. vivax, the

incubation period may be delayed for as
long as 9 months; this may also occur with
other species in persons who have been
taking suppressive antimalarial drugs
21
Clinical features
In the Cold Stage, there is a general sensation
of cold followed by rigors. The temperature rises
to 40ºC and stays for nearly one hour. At this
time parasites are demonstrable in the blood.
This stage is followed by the Hot Stage which is
characterized by fever, headaches and vomiting.
The skin feels hot and dry .This lasts from 2 to 6
hours.
The last stage is the Sweating Stage. The
patient sweats profusely and temperature
returns to normal. This stage lasts from 2 - 4
hours
22
Cont’d
Classically, the attacks occur every second day
with the “tertian” parasites (Plasmodium
falciparum, Plasmodium vivax, and
Plasmodium ovale) and every third day with
the “quartan” parasite (Plasmodium malariae).
P. falciparum infection  Fever is irregular
or even continuous in first few days and then
the classical 48 hour periodicity. Headache,
nausea and vomiting are usually more severe,
and there is greater tendency towards the
development of delirium, haemolytic jaundice
and anaemia.
23
The mortality is much greater than other forms
of malaria.
P. vivax  symptoms are same but are milder
and more regularly divided into "hot" and
"cold" stages.
P. ovale  milder than P. uiuax and cease after
a few paroxysms even if no treatment is given.
P. malariae  attacks resemble those of P.
vivax but the cycle is of 72 hours instead of 48
hours.

24
Complications
P. falciparum malaria are cerebral
malaria, acute renal failure, liver damage,
gastro-intestinal symptoms, dehydration,
collapse, anaemia, blackwater fever etc.

P. uivax, P. ovale and P. malariae

infections are anaemia, splenomegaly,
enlargement of liver, herpes, renal
complications etc

25
Diagnosis
1) Microscopy
Peripheral smear examination for malarial
parasite is the gold - standard in
confirming the diagnosis of malaria.
Thick and thin smears prepared from the
peripheral blood are used for the purpose.
Thick smears are used to detect infection
and to estimate parasite concentration.
Thin film examination is the gold standard
in diagnosis of malarial infection.
26
2) Serological test
The malarial fluorescent antibody test usually
becomes positive two weeks or more after
primary infection.
But by this time the infection may have been
cured.
A positive test is therefore, not necessarily an
indication of current infection.
The test is of the greatest value in
epidemiological studies and in determining
whether a person has had malaria in the past.
27
3) Rapid diagnostic test (RDT)
It is based on the detection of circulating
parasite antigens with a simple dipstick
format.
Some of them can only detect P. falciparum
while others can detect other parasites
also.
The kits are expensive and temperature
sensitive.
The users manual should always be read
properly to avoid false negative results
28
Measurement of malaria
1. Pre-eradication era  Spleen rate, Avg
enlarged spleen, parasite rate, parasite
density index, infant parasite rate and
proportional case rate.

2. Eradication era  API, ABER, AFI, SPR

& SFR

29
Pre-eradication era
1. SPLEEN RATE : It is defined as the
percentage of children between 2 and 10
years of age showing enlargement of spleen.
It is used for measuring the endemicity of
malaria.
2. AVERAGE ENLARGED SPLEEN: Average size
of the enlarged spleen.
3. PARASITE RATE : It is defined as the
percentage of children between the ages 2
and 10 years showing malaria parasites in
their blood films.
30
4. PARASITE DENSITY INDEX : It indicates the
average degree of parasitaemia in a sample of
well-defined group of the population.
5. INFANT PARASITE RATE : It is the percentage
of infants showing malaria parasites in their
blood films. It is the most sensitive index of
recent transmission of malaria in a locality. If
the infant parasite rate is zero for 3
consecutive years in a locality, it is regarded as
absence of malaria transmission .

31
6. PROPORTIONAL CASE RATE : It is
defined as the number of cases
diagnosed as clinical malaria for every
100 patients attending the hospitals and
dispensaries.

32
Eradication era
1. Annual parasite index (API)

 Areas with API >2 per 1000 population

per year have been classified as high risk
areas in India

33
2. Annual blood examination rate (ABER)

 ABER is an index of operational efficiency

 The aim is to screen 10 per cent of the

population
34
3. Annual falciparum incidence
4. Others
5. Slide positivity rate : slide positivity rate is the
percentage of slides found positive for malarial
parasite, irrespective of the type of species.
6. Slide falciparum rate : It is the percentage of
slides positive for P. falciparum parasite.

They provide information on the trend of

malaria transmission.
35
Vector indices
a) HUMAN BLOOD INDEX : It is the proportion
of freshly-fed female Anopheline mosquitoes
whose stomach contains human blood. It
indicates the degree of anthrophilism.
b) SPOROZOITE RATE : It is the percentage of
female anophelines with sporozoites in their
salivary glands.
c) MOSQUITO DENSITY: It is usually expressed
as the number of mosquitoes per man-hour-
catch.

36
d) MAN-BITING RATE : It is defined as the
average incidence of anopheline bites per
day per person. It is determined by
standardized vector catches on human bait
e) INOCULATION RATE: The man-biting rate
multiplied by the infective sporozoite rate
is called the inoculation rate.

All these rates are employed in the

quantitative assessment of malaria.
37
Diagnosis and treatment of
malaria

38
39
40
Severe & complicated malaria
1. Impaired consciousness/coma
2. Repeatd generalized convulsions
3. Renal failure (Serum Creatinine >3 mg/di)
4. Jaundice (Serum Bilirubin >3 mg/di)
5. Severe anaemia (Hb <5 g/dl)
6. Pulmonary oedema/acute respiratory
distress syndrome
7. Hypoglycaemia (Plasma glucose <40 mg/di)
8. Metabolic acidosis
41
9. Circulatory collapse/shock (Systolic
BP<80 mm Hg, < 50 mm Hg in children)
10.Abnormal bleeding and DIC
11.Haemoglobinuria
12.Hyperthermia (Temperature > 106°F or
42°C)
13.Hyperparasitaemia ( <5% parasitized
RBCs in low endemic and > 10% in
hyperendemic areas)
42
43
Chemoprophylaxis
Short term (< 6 wks)
Weekly chloroquine (300mg once in a wk
or 100 mg 6 days in a wk) should be
started 1 week before arrival.
Weekly mefloquine (250 mg once in a
wk ), started 2-3 weeks before departure.
All prophylactic drugs should be taken
with unfailing regularity for the duration
of the stay in the malaria risk area, and
should be continued for 4 weeks.

44
Chemoprophylaxis
Long term (> 6 wks)
Chloroquine (300mg once in a wk or 100 mg 6
days in a wk)
Screening  wkly dose  5 yrs for retinal
changes.
If daily dose  screen after three years
Proguanil (200 mg OD)
No increased risk of serious side-effects with
long-term use of mefloquine (250 mg once in a wk
)
Available data on long-term chemoprophylaxis
with doxycycline (100 mg OD) is limited.
45
ACTIVE INTERVENTION MEASURES
1. STRATIFICATION OF THE PROBLEM
2. VECTOR CONTROL STRATEGIES
(a) Anti-adult measures
(b) Anti-larval measures

46
The malaria prevention and control
measures aimed at breaking the ‘man -
mosquito - man’ cycle of transmission
include a number of methods which are
complementary to each other.
None of the measures will be successful if
applied alone in any given environment.

47
Personal protective measures
Vector engineering
Environmental management

48
Malaria vaccine
Despite considerable effort and expense, a
generally available and highly effective malaria
vaccine has till date not been developed.
An ideal malaria vaccine is one that would
prevent the infection at the first instance and if
this is not possible, should decrease the intensity
of infection and should be successful in
preventing malaria transmission.
The path of vaccine development has proved long
and strewn with pitfalls, but there has been
progress. Research is now concentrated on all
stages of the parasite life cycle : the sporozoite,
the liver stage, the asexual blood stage, and the
gametocyte
49
50