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Malaria H2012

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Title: Malaria H2012


1
MalariaH2012
  • Protozoan Disease
  • 108 countries
  • 3 billion people
  • 1 million deaths each year

2
In the late twentieth Eliminated United
States, Canada, Europe, Russia
  • Prevalence rose in many parts of the tropics

3
Resurgence
  • Increases in the drug resistance of the parasite
  • Insecticide resistance of its vectors
  • Human travel and migration

4
Etiology
  • Five species of the genus Plasmodium cause nearly
    all malarial infections in humans.
  • Falciparum
  • Vivax
  • Ovale
  • Malariae
  • Knowlesi
  • (in Southeast Asiathe monkey malaria parasite )

5
Almost all Deaths
  • Falciparum

6
Female Anopheline Mosquito
  • Sporozoites
  • Liver
  • Asexual Reproduction
  • Single Sporozoite eventually 10,000 to gt30,000
    Daughter Merozoites
  • Liver cell eventually bursts
  • 100 million parasites in the blood of an adult,
    the symptomatic stage of the infection begins

7
Vivax and Ovale
  • Intrahepatic forms
  • Dormant(Hypnozoites) for a period ranging from 3
    weeks to a year or longer before reproduction
    begins
  • Relapses

8
Duration of Erythrocytic Cycle (hours)
  • Falciparum 48 h
  • Vivax 48 h
  • Ovale 50 h
  • Malariae 72 h

9
Red Cell Preference
  • Falciparum
  • Younger cells (but can invade cells of all ages)
  • Vivax
  • Reticulocytes and cells up to 2 weeks old
  • Ovale
  • Reticulocytes
  • Malariae
  • Older cells

10
Morphology
  • Falciparum
  • Usually only ring forms Banana-shaped
    gametocytes
  • Vivax
  • Irregularly shaped large rings and trophozoites
    enlarged erythrocytes Schüffner's dots
  • Ovale
  • Infected erythrocytes, enlarged and oval with
    tufted ends Schüffner's dots
  • Malariae
  • Band or rectangular forms of trophozoites common

11
Relapses
  • Vivax , Ovale Yes
  • Falciparum , Malariae No

12
  • Parasitemias of gt2 are suggestive of Falciparum
    infection

13
Vivax
  • Duffy blood-group antigen Fya or Fyb
  • Most West Africans and people with origins in
    that region carry the Duffy-negative FyFy
    phenotype and are therefore resistant to P. vivax

14
Disease
  • Direct effects of RBC invasion and destruction by
    the asexual parasite and the host's reaction

15
Epidemiology
  • Falciparum predominates in Africa, New Guinea,
    and Hispaniola (i.e., the Dominican Republic and
    Haiti)
  • Vivax is more common in Central America
  • Malariae is found in most endemic areas
  • Ovale is relatively unusual outside of Africa

16
Endemicity
  • Parasitemia rates or palpable-Spleen rates in
    children 29 years
  • Hypoendemic (lt10)
  • Mesoendemic (1150)
  • Hyperendemic (5175)
  • Holoendemic (gt75)

17
Holo- and Hyperendemic areas
  • (e.g., certain regions of tropical Africa or
    coastal New Guinea) where there is intense
    Falciparum transmission, people may sustain more
    than one infectious mosquito bite per day and are
    infected repeatedly throughout their lives
  • Morbidity and Mortality during early Childhood
  • Adulthood, most infections are Asymptomatic

18
Stable Transmission
  • Constant
  • Frequent
  • Year-round infection

19
Unstable Transmission
  • Transmission is low, Erratic, or Focal, full
    protective immunity is not acquired, and
    symptomatic disease may occur at All Ages
  • Usually exists in Hypoendemic

20
An Epidemic
  • Changes in Environmental, Economic, or Social
    conditions, such as heavy rains or migrations
    (usually of Refugees or Workers) from a
    nonmalarious region to an area of high
    transmission a breakdown in malaria control and
    prevention service
  • All Age Groups

21
Anophelines
  • gt400 can transmit malaria, and the 40
    considerably in their efficiency as malaria
    vectors
  • Life cycle within the mosquitofrom gametocyte
    ingestion to subsequent inoculation
    (sporogony)lasts 830 days
  • mosquito must survive for gt7

22
Sporogony
  • Is not completed at cooler temperatures lt16C for
    P. vivax and lt 21C for Falciparum
  • transmission does not occur below

23
The most effective mosquito vectors
  • such as Anopheles gambiae in Africa, which are
    long-lived, occur in high densities in tropical
    climates, breed readily, and bite humans in
    preference to other animals

24
Entomologic Inoculation Rate (EIR)
  • the number of sporozoite-positive mosquito bites
    per person per year is the most common measure of
    malaria transmission and varies from lt1 in some
    parts of Latin America and Southeast Asia to gt300
    in parts of tropical Africa.

25
Erythrocyte Changes
  • Consumes and degrades intracellular proteins
  • principally hemoglobin
  • Alters the RBC membrane by changing its transport
    properties, exposing cryptic surface antigens,
    and inserting new parasite-derived proteins. The
    RBC becomes more irregular in shape, more
    antigenic, and less deformable.

26
  • Severe malaria is also associated with reduced
    deformability of the uninfected erythrocytes,
    which compromises their passage through the
    partially obstructed capillaries and venules and
    shortens RBC survival.

27
  • In the other three ("benign") human malarias,
    sequestration does not occur, and all stages of
    the parasite's development are evident on
    peripheral-blood smears. Whereas Vivax, Ovale,
    and Malariae show a marked predilection for
    either young RBCs (Vivax, Ovale) or old cells
    (Malariae) and produce a level of parasitemia
    that is seldom gt2, Falciparum can invade
    erythrocytes of all ages and may be associated
    with very high levels of parasitemia.

28
Host Response
  • Initially, nonspecific defense mechanisms
  • Splenic immunologic and filtrative clearance
  • Removal of both parasitized and uninfected
    erythrocytes
  • Strain-specific immune response then controls the
    infection

29
  • Exposure to sufficient strains confers protection
    from high-level parasitemia and disease but not
    from infection
  • Infection without illness ,asymptomatic
    parasitemia is common among adults and older
    children living in regions with stable and
    intense transmission (holo- or hyperendemic
    areas).
  • Immunity is mainly specific for both the species
    and the strain of infecting malarial parasite.
    Both humoral immunity and cellular immunity are
    necessary for protection

30
  • Passively transferred IgG from immune adults has
    been shown to reduce levels of parasitemia in
    children although parasitemia in very young
    infants can occur, passive transfer of maternal
    antibody contributes to the relative (but not
    complete) protection of infants from severe
    malaria in the first months of life

31
  • Immunity to disease declines when a person lives
    outside an endemic area for several months or
    longer.
  • Parasites may persist in the blood for months
    (or, in the case of P. malariae, for many years)

32
  • Temperatures of 40C damage mature parasites
  • Tertian, every 2 days Quartan, every 3 days) are
    seldom seen today

33
Geographic Distributions
  • Sickle Cell disease
  • Hemoglobins C and E
  • Hereditary Ovalocytosis
  • Thalassemias
  • G6PD (glucose-6-phosphate dehydrogenas
    edeficiency )
  • closely resemble that of falciparum malaria
    before the introduction of control measures. This
    similarity suggests that these genetic disorders
    confer protection against death from falciparum

34
Clinical Features
  • First symptoms of malaria are nonspecific
  • Lack of a sense of well-being
  • Headache
  • Fatigue
  • Abdominal discomfort
  • Muscle aches
  • followed by Fever
  • similar to the symptoms of a minor viral illness

35
  • Headache
  • Chest pain
  • Abdominal pain
  • Arthralgia
  • Myalgia
  • Diarrhea

36
Common
  • Nausea
  • Vomiting
  • Orthostatic hypotension

37
Classic malarial paroxysms
  • Fever spikes
  • Chills and rigors
  • occur at regular intervals, are relatively
    unusual and suggest infection with P. Vivax or P.
    Ovale

38
Fever
  • Irregular at first (that of falciparum malaria
    may never become regular) the temperature of
    nonimmune individuals and children often rises
    above 40C in conjunction with Tachycardia and
    sometimes Delirium.

39
  • Childhood Febrile Convulsions may occur with any
    of the malarias, generalized seizures are
    specifically associated with falciparum malaria

40
Physical Findings
  • Fever
  • Malaise
  • Mild Anemia
  • Palpable Spleen
  • (in some cases)

41
Anemia
  • Common among young children living in areas with
    stable transmission

42
Slight enlargement of the liver
  • Common, particularly among Young Children

43
Mild jaundice
  • Common among adults it may develop in patients
    with otherwise uncomplicated malaria and usually
    resolves over 13 weeks

44
Malaria is not associated with a rash
  • Petechial hemorrhages in the skin or mucous
    develop only rarely in severe falciparum malaria

45
Severe Falciparum Malaria
  • Appropriately and promptly treated, uncomplicated
    falciparum malaria (i.e., the patient can swallow
    medicines and food)
  • Mortality rate of 0.1

46
Severe Falciparum Malaria
  • Cerebral malaria/convulsion
  • Acidemia/acidosis
  • Severe normochromic, normocytic anemia
  • Renal failure
  • Pulmonary edema/adult respiratory distress
    syndrome
  • Hypoglycemia
  • Hypotension/shock
  • Bleeding/disseminated intravascular coagulation
  • Hemoglobinuria

47
Hypoglycemia
  • Important and common complication of severe
    malaria, is associated with a poor prognosis and
    is particularly problematic in Children and
    Pregnant women.
  • Hepatic Gluconeogenesis
  • Increase in the consumption of glucose by both
    host and, to a much lesser extent, the malaria
    parasites
  • Quinine ,Quinidine

48
Jaundice
  • Mild hemolytic jaundice is common in malaria
  • Severe jaundice is associated with P. falciparum
    is more common among adults and results from
  • Hemolysis
  • Hepatocyte injury
  • Cholestasis

49
Other
  • HIV/AIDS predisposes to more severe malaria in
    nonimmune individuals
  • Worsened by intestinal helminths, Hookworm in
    particular
  • Septicemia may complicate severe malaria,
    particularly in children(specifically Salmonella
    bacteremia )
  • Aspiration Pneumonia

50
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  • Anemia
  • Convulsions
  • Hypoglycemia

51
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  • Jaundice
  • Renal failure
  • Pulmonary edema

52
Pregnancy
  • Stable transmission area
  • Mothers Asymptomatic
  • Falciparum malaria in primi- and secundigravid
    women is associated with Low Birth Weight
  • Increased infant and childhood mortality
  • Maternal HIV infection predisposes newborns to
    congenital malarial

53
Pregnancy
  • Unstable Transmission
  • Mother
  • High-level parasitemia
  • Anemia
  • Hypoglycemia
  • Acute pulmonary edema
  • Fetal distress, premature labor, and stillbirth
    or low birth weight are common

54
Pregnancy
  • Congenital malaria occurs in lt5 of newborns
  • P. Vivax malaria in pregnancy is also associated
    with a reduction in birth weight but, in contrast
    to the situation in falciparum malaria, this
    effect is more pronounced in Multigravid

55
Transfusion
  • Blood Transfusion
  • Needle-Stick Injury
  • IVDU
  • Organ Transplantation
  • Incubation period in these settings is often
    short because there is no preerythrocytic stage
  • Clinical features and management are the same as
    for naturally acquired infections.
  • Primaquine is unnecessary for transfusion-transmit
    ted P. vivax and P. ovale infections.

56
Tropical Splenomegaly (Hyperreactive Malarial
Splenomegaly)
  • Chronic or repeated
  • in some cases malarial parasites cannot be found
    in peripheral-blood smears
  • Massive Splenomegaly, Hepatomegaly
  • Hypergammaglobulinemia normochromic, normocytic
    anemia
  • Antimalarial chemoprophylaxis results usually
    good

57
Quartan Malarial Nephropathy
  • Chronic or repeated infections with P. Malariae
    (and possibly with other malarial species
  • soluble immune-complex
  • Nephrotic Syndrome

58
Burkitt's Lymphoma
  • Strongly associated with Epstein-Barr virus
  • The prevalence of this childhood tumor is high in
    malarious areas of Africa.

59
Diagnosis
  • Asexual
  • Giemsa (preferred)
  • Field's
  • Wright's
  • Leishman's stain
  • Both thin and thick

60
RDTs
  • Rapid, simple, sensitive, and specific
    antibody-based diagnostic stick or card tests
    that detect P. falciparumspecific, in
    finger-prick blood samples are now being used
    widely in control programs
  • RDTs are replacing microscopy in many areas
    because of their simplicity and speed, but they
    are relatively expensive and do not quantify
    parasitemia.

61
PCR
  • Antibody and PCR tests have NO role in the
    diagnosis of malaria except that PCR is
    increasingly used for genotyping and speciation
    in mixed infections

62
  • Gametocytemia may persist for days or weeks after
    clearance of asexual parasites

63
  • Phagocytosed malarial Pigment is sometimes seen
    inside peripheral-blood Monocytes or
    Polymorphonuclear leukocytes and may provide a
    clue to recent infection if malaria parasites are
    not detectable

64
Laboratory Findings
  • Normochromic, Normocytic Anemia is usual
  • WBC count is generally normal, although it may be
    raised in very severe infections
  • Monocytosis, Lymphopenia, and Eosinopenia, with
    reactive Lymphocytosis and Eosinophilia in the
    weeks after the acute infection
  • ESR,CRP High
  • Severe infections may be accompanied by
    prolonged PT and partial thromboplastin times and
    by more severe Thrombocytopenia

65
Treatment
  • Repeat blood smears
  • at least every 1224 h for 2 days
  • Alternatively, a rapid antigen detection card or
    stick test

66
  • Any doubt about the resistance, it should be
    considered resistant
  • Antimalarial drug susceptibility testing can be
    performed but is rarely available, has poor
    predictive value in an individual case, and
    yields results too slowly to influence the choice
    of treatment

67
Chloroquine
  • Choice for the non-falciparum malarias
  • Vivax
  • Ovale
  • Malariae
  • Knowlesi
  • except in Indonesia and Papua New Guinea, where
    high levels of resistance in P. vivax are
    prevalent.

68
Chloroquine-Sensitive
  • Vivax
  • Malariae
  • Ovale,
  • Knowlesi
  • Falciparuma

69
  • Chloroquine
  • (10 mg of base/kg stat followed by 5 mg/kg at
    12, 24, and 36 h or by 10 mg/kg at 24 h and 5
    mg/kg at 48 h)
  • or
  • Amodiaquine
  • (1012 mg of base/kg qd for 3 days)

70
Radical Treatment
  • Vivax or Ovale
  • Primaquine
  • (0.5 mg of base/kg qd) should be given for 14
    days to prevent relapse.
  • In mild G6PD deficiency, 0.75 mg of base/kg
    should be given once weekly for 68 weeks.
  • Not be given in severe G6PD deficiency

71
Falciparum
  • Artesunatec (3 days)
  • Sulfadoxine/Pyrimethamine as a single dose
  • or
  • Artesunatec (3 days)
  • Amodiaquine (3 days)

72
Multidrug-resistant Falciparum
  • Artemether-Lumefantrinec
  • (bid for 3 days with food)
  • or
  • Artesunatec (3 days)
  • Mefloquine (3 days )

73
Second-line treatment/treatment of imported
  • Artesunatec (7 days) or Quinine (tid for 7 days)
  • plus 1 of the following 3
  • 1. Tetracycline (qid for 7 days)
  • 2. Doxycycline (qd for 7 days)
  • 3. Clindamycin (bid for 7 days)
  • or
  • Atovaquone-Proguanil
  • (qd for 3 days with food)

74
Severe Falciparum
  • Artesunatec (IV followed by at 12 and 24 h and
    then daily if necessary)
  • or, if unavailable, one of the following
  • Artemetherc (IM followed by qd)
  • or
  • Quinine dihydrochloride (infused over 4 h,
    followed infused over 28 h q8h)
  • or
  • Quinidine (infused over 12 h, followed by
    houriwith electrocardiographic monitoring)

75
  • Very few areas now have chloroquine-sensitive P.
    falciparum
  • Tetracycline and Doxycycline should not be given
    to pregnant women or to children lt8 years of age
  • Oral treatment should be substituted as soon as
    the patient recovers sufficiently to take fluids
    by mouth

76
  • WHO now recommends Artemisinin-based combinations
    as first-line treatment for uncomplicated
    Falciparum

77
  • Quinine, Quinidine
  • Common Hypoglycemia

78
Chloroquine
  • Acute Hypotensive shock (parenteral), cardiac
    arrhythmias, neuropsychiatric reactions
  • Chronic Retinopathy (cumulative dose, gt100 g),
    skeletal and cardiac myopathy

79
Primaquine
  • Massive hemolysis in subjects with severe G6PD
    deficiency

80
Severe Malaria
81
Uncomplicated Malaria
82
..
  • If there is any doubt as to the identity of the
    infecting malarial species, treatment for
    falciparum malaria should be given
  • Nonimmune patients receiving treatment ,daily
    parasite counts performed until the thick films
    are negative. If the level of parasitemia does
    not fall below 25 of the admission value in 48 h
    or if parasitemia has not cleared by 7 days (and
    adherence is assured), drug resistance is likely
    and the regimen should be changed

83
Radical Treatment
  • Primaquine (0.5 mg of base/kg, adult dose)
    should be given daily for 14 days to patients
    with P. vivax or P. ovale infections after
    laboratory tests for G6PD deficiency have proved
    negative. If the patient has a mild variant of
    G6PD deficiency, primaquine can be given in a
    dose of 0.75 mg of base/kg (45 mg maximum) once
    weekly for 6 weeks.

84
Radical Treatment
  • Pregnant women with vivax or ovale malaria should
    not be given Primaquine but should receive
    suppressive prophylaxis with Chloroquine (5 mg of
    base/kg per week) until delivery, after which
    radical treatment can be given.

85
Complications
  • Acute Renal Failure
  • Acute Pulmonary Edema
  • (Acute Respiratory Distress Syndrome)
  • Hypoglycemia
  • Spontaneous Bleeding
  • Convulsions
  • Aspiration pneumonia
  • Bacterial Sepsis

86
Prevention
  • no safe, effective, long-lasting vaccine is
    likely to be available for general use in the
    near future

87
Personal Protection Against
  • Avoidance of exposure to mosquitoes at their peak
    feeding times (usually dusk to dawn)
  • Insect repellents containing 1035 DEET (or, if
    DEET is unacceptable, 7 Picaridin),
  • Suitable Clothing
  • Insecticide-impregnated bed nets or other
    materials. Widespread use of bed nets treated
    with residual Pyrethroids reduces the incidence
    of malaria in areas where vectors bite indoors at
    night

88
Chemoprophylaxis
  • Chemoprophylaxis is never entirely reliable
  • Chloroquine phosphate
  • Atovaquone-Proguanil (Malarone)
  • Doxycycline
  • Mefloquine

89
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90
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91
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92
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93
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94
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96
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