Dr.J.Nuchin. M.D.,M.B.A.,D.C.A.
Epidemiologist
16-03-2011
By the end of session, you would be
expected to be able to describe:
vProblem statement
vLife cycle of parasite
vType of vector
vClinical features
v8 important CFs of severe
complicated malaria
vTreatment
vDiagnosis
vControl measures
v
Sir Ronald Ross (1857-1932)
•
• 1897: role of
the mosquito.
•
•
• Nobel prize:
1902
Introduction…
Ø A protozoan disease caused by a parasite
plasmodium
Ø A major parasitic cause of death in man
Ø One of the oldest recorded diseases
Ø Egyptian mummies with enlarged spleens (1000
BC).
Ø Hippocrates (460-370 B.C.)-Clear discussion of
quartan and tertian fevers made by in his Book of
Epidemics, Noted relationship between enlarged
spleens and marshes.
Ø Region between Tigris and Euphrates was
malarious (2000 BC).
Ø Malaria was well known to the Ancient Greeks and
Romans.
Problem statement-World
§ Has been a scourge of
mankind for the
centuries
§ Total death toll due to
malaria is more than
that due to any
other diseases or
even wars
§ Endemic in 109 (in
2006) countries
covering about 45%
of global population
§ Burden – 300-500
million cases and 2-3
million deaths
• Kills a child every 15 to 20 seconds or 8000
children per day
• Nine of 10 deaths globally are among sub-
Saharan children under age 5.
• Responsible for 25% total child mortality in
Africa
• 90 percent of global incidence of malaria
occurs in 13 countries of Africa.
• Out of this more than 50% of cases are from
Nigeria, Congo, Ethiopia, Tanzania and
Kenya.
• In pregnant women, it causes abortion, still
births, LBWs and neonatal deaths globally.
•
•
•
Indian scenario
§ Has always been a home ground for
malaria
§ Before 1947 (preDDT era)- malaria was a
major cause of death
§ In 1908, an outbreak in UP and Punjab
killed more than 3 lakh people in just a
span of 2 months
§ In 1947, India had about 75 million cases
and >50% of total deaths were due to
Malaria alone
• All the aspects of life were affected
directly or indirectly
In 1950s, India used to report about
75 million every year with around 7.5
million deaths
Major malaria ecotypes found in
India
• Rural malaria-
• Urban malaria-
• Forest malaria
• Irrigation malaria
• Project malaria
• Migration malaria
• Border malaria
•
Factors responsible for the
increase in VBDs
ü
ü Poverty and rapid population growth
ü Irrigation
ü Urbanization and improper sanitation
ü Industrialization
ü Migration and rapid population movement
ü Natural disasters
ü Resistance
ü Global warming
ü Political instability
ü Inadequate health infrastructure
1.1 billion people live on
less than $1 a day.
91.02
80
78.12
Million Hectares
60
56.81
52.02
40
41.21
37.1
29.12 30.57
20 22.6
26.25
0
P re 1st IInd IIIrd Annual IVth Vth Annual VIth VIIth
1951-56 1956-61 1961-66 1966-69 1969-74 1974-78 1978-80 1985-90 1990-95
Karnataka
§ A major CMD in the state.
§ 7 districts namely DK,G,R,K,T,Bijapur and
Bagalkot together contributed >65% of
the total burden in the state in 2010
§ The P.f cases are being decreased in
Karnataka and not so in other parts of
the country.
§ Double resistance has been recorded
§
MALARIA CASES IN Karnataka
since 2006 to 2010
Karnataka in 2006- 62864 cases
Dakshina
kannada
21%
Others
32%
Kolar
13%
Belgaum
7%
Raichur
Tumkur Gulbarga 12%
7% 8%
85% of the cases in the state were due to these 11
districts with 2 deaths in the year 2008
85
% o
ft
he c
a
se
si
n t
hes
t
at
e w
e
re
d
ue
to
th
es
e1
1d
i
str
i
cts
wi
th2
de
at
hs
Contribution of malaria cases in the year 2009 in 10
districts of Karnataka- Total no of cases-36859.
Soundatti Bailhongal
10% 5%
Ramdurg
13%
Gokak
68%
Ta
luk
w is
eMa
lariain
cid
enc
e -2
008
B
ailhonngal
4%
Sav
d atti B
elgaum
18% 4%
R
amdurg
13 %
Gok
ak
59%
M a la ria c a s-2e s0 0 6m o n th w is-To
e ta l C a s -e s
4149
678
246 237
160
93
80
Ja n to D ec
M o n t h w is e n o . o f M a-2l 0a 0r i7a c a
Note the 2nd
560 peak of
disease
421 429
401419
299 305
279
250
210
181
154
2000 1849
1500
1498 1483 1 3 51 83 3 4
1 0 7 29 6 0
1000 776 836
643
408373
500
J a n u a r y to D e c e m b e r
Monthwise Malaria Cases-2007
560
421 429
401 419
299 305
279
250
210
181
154
Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec
355
332
242
208 208
183 175
127 139 124
76 57
Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec
What’s the Good News?
contnd…
Plasmodium Sporozoite
Different species
P.vivax- all over 60-70% BTM Mild
world-less Anaemia, splenic
common in rupture rarely
Africa
(depending upon
the species) they
become hepatic
schizonts
•
Hepatic schizoint- The actively dividing,
multinucleated, parasite form in hepatocytes; produces
no inflammatory response.
Pre-erythrocytic schizoints
Ø
Ø These hepatic schizoints eventually rupture, Contnd…
releasing showers of merozoites which attack
RBCs.
gametocytes
Erythrocytic forms (signet)
Ø Some of the
erythrocytic forms
do not divide but
become male
(smaller) and
female (longer)
gametocytes
Ø These are infective to
mosquitoes
Ø Gametocytes always
circulate in the
subcutaneous
capillaries
Characteristics of different species
Species Duration of Incubation Number of Red cells
tissue period (days) merozoites / invaded
phase (days) cell
Complete
Metamorphosis 6–8
Total = 10 – 12 Days
days
2 Days
65
Sl. Common Malaria vector Features
No. geographical area
Disease Potential is high in An. Minimus, An. Dirus, An. Fluviatilis, medium in
An. stephensi
An. sundaicus and low in An. culicifacies
An.culicifacies Breeding Sites
Host factors
Ø Malaria affects all ages, but rare in newborn
due to presence of foetal haemoglobin and
maternal immunity
Ø Common in males because of outdoor activities
and clothing pattern (816 F -45% and 1014
M-55% out of 1830 in Belgaum till JAN 1998 to
August 2008)
Ø Duffy negative people are resistant to P.v. Most
of the Africans are Duffy negative, this
explains why P.v is not so common in Africa
Ø Patients of SC trait ( Hb AS), G6PD and
thalasseamia are less likely to be affected by
High risk group
Pregnant mothers- have an increased risk of severe
malaria especially in primigravidae, as the immunity to
the malaria is impaired in pregnancy.
Pregnant women attract twice the number of mosquitoes
than non-pregnant women
There is a greater susceptibility to P. falciparum than P.
vivax during pregnancy
•
Children - Malaria affects cognitive development and
learning abilities of children.
• Malaria is a risk factor of neuro-sensory and behavioral
development in children
•
Immigrants from Europe- as they lack natural
immunity
Immunity
Prepatent period
This is the length of time between the bite
•
• This is usually seen in older children and adults
who have acquired natural immunity to
clinical disease as a consequence of living in
areas with high malaria endemicity.
• There are malaria parasites in the peripheral
blood but no symptoms.
• These individuals may be important reservoirs
for disease transmission.
•
• Some individuals may even develop anti-
parasite immunity so that they do not
develop parasitaemia following infection.
Simple, uncomplicated malaria
Hot stage
Ø The fever raises so high so the
patient feels burning hot and takes off
the clothes
Ø The patient feels intense headache with
nausea and vomiting
Ø Pulse is of bounding type, patient feels
Sweat stage
Ø Fever comes down with profuse sweating
Ø He goes usually into deep sleep
Ø Lasts for 2-4 hours
Ø Febrile herpes is very common
Malaria- one clinical febrile
episode of malaria consumes 5,000 k
Cal.
Ø
Note how the frequency of spikes of fever differ
according to the Plasmodium species.
In practice, spikes of fever in P. falciparum, occur
irregularly - probably because of the presence of
parasites at various stages of development.
Other features of simple,
uncomplicated malaria include:
v Anorexia
v Cough
v Headache
v Malaise
v Muscle aches
v Splenomegaly
v Tender hepatomegaly
•
• Increases the risk of mortality and sequelae in
children with cerebral malaria; may present
with convulsions or a deterioration in level of
consciousness.
• Results from a combination of factors:
– reduced glycogen stores because of
reduced food intake
– increased metabolism due to fever and
repeated convulsions
– glucose consumption by malaria parasites
– cytokine or quinine-stimulated
4. Metabolic acidosis
• Lactic acidosis is a major contributor and
probably results from tissue anoxia and
anaerobic glycolysis
Presents with deep, rapid respirations (as in
diabetic ketoacidosis)
Acidaemia (arterial pH < 7.25) or Acidosis
P. Malariae
quarten nephrosis
6. Acute pulmonary oedema
This is a grave and usually
fatal manifestation of severe
falciparum malaria and
occurs mainly in adults.
Hyperparasitaemia (>5% of
RBCs are parasitized), renal
failure and pregnancy are
recognised predisposing
factors and the condition is
commonly associated with
hypoglycaemia and
metabolic acidosis.
7. Circulatory collapse, shock,
“algid malaria”
Systolic BP < 50 mmHg in children and < 80 mmHg in
adults defines hypotension/shock.
Patient with severe malaria can develop sudden
hypotension & become shocked. This is “Algid
Malaria”.
Features of circulatory collapse-
cold/clammy skin, weak/ thready pulses,
hypotension, peripheral cyanosis, peripheral
vasoconstriction, and rapid feeble pulse with core/skin
temperature difference of ≥ 10° C.
“Algid malaria” is characterised by
hypotension, vomiting, diarrhoea, rapid
respiration and oliguria. This condition is
associated with a poor prognosis.
8. Haemoglobinuria or
“Blackwater Fever”
Characterized by rapid, severe, massive
intravascular haemolysis.
It is associated with infection by P.f, most
commonly seen in a non-immune person
who has resided in the endemic country
for the last 6 months to 1 year and
inadequately treated by quinine.
In these cases, quinine is a precipitating
factor.
It is triggered by exposure to cold, sun,
fatigue, trauma, pregnancy, X-rays etc,.
The condition presents with severe pallor,
A 3 year old boy with
severe anaemia (Hb%
3.3 g/dl) and dark
urine (shown in the
container)
practice.
a)Antigen capture kits. Uses a dipstick and a
finger prick blood sample. Rapid test - results are
available in 10-15 minutes. Expensive and
sensitivity drops with decreasing parasitaemia.
b)
c)PCR based techniques. Detects DNA or
mRNA sequences specific to Plasmodium.
Sensitivity and specificity high but test is
expensive, takes several hours and requires
technical expertise.
d)
c) Fluorescent techniques- Relatively low
specificity and sensitivity. Cannot identify the parasite
species. Expensive and requires skilled personnel.
The treatment of
0-1 75 75 75 37.5 -
1-4 150 150 150 75 7.5
4-8 300 300 300 150 15
8-14 450 450 450 225 30
>14 600 600 600 300 45
RADICAL TREATMENT- After microscopic
confirmation
No Primaquine to infants and pregnant women. Each
Chloroquine tab available as 150 mg and Primaquine
tab as 2.5 mg
Age (Yr) P.vivax P.falciparum
Chloroqui Primaquin Chloroquine(mg) Primaquin
ne e e
(mg) (mg) (mg)
14 days Day1 Day2 Day3
0-1 75 - 75 75 37.5 -
1-4 150 2.5 150 150 75 7.5
4-8 300 5 300 300 150 15
8-14 450 10 450 450 225 30
>14 600 15 600 600 300 45
Site of Action
Primaquine
Chloroquine
Quinine, SP
Artemisinin
Quinine &
Chloroquine in P.V.
and Primaquine in
P.F.
Drug Drugs
Class
Blood Chloroquine, Quinine, Quinidine, Mefloquine, Halofantrine,
Schizon Sulfonamides, Tetracyclines, Atovaquone, Artemisinin
tocidal compounds
Gametoc Primaquine
idal
Hypnozo Primaquine
itocida
l
109
Drug Sporozoites Primary Asexual Gametocyte Hypnozoite
tissue phase parasite
Quinine NA NA A A-P.v NA
Chloroquine NA NA A A-P.v NA
Primaquine A A A A A
in toxic dose
SP Less A Little A on Incomplete NA NA
P.f
Mefloquine NA NA A NA NA
- Recommended for
1.Travellers from non endemic areas
2.As a short measure for soldiers,
police and labours serving in highly
endemic areas
3.All ANCs in HRAs- initiated in II
semester
•
MALARIA TREATMENT COST OF
AN ADULT IN INDIA
Drugs Cost (Rs.)
Chloroquine 3.50-10.00
Chloroquine injection + fluids 200.00
Sulfadoxine Pyrimethamine 7.00-30.00
Mefloquine 240.00-300.00
Artemether injections 390.00-1000.00
Arteether injections 275.00
Artesunate injections 1120.00
Quinine tables + Tetracycline 270.00-210.00
Quinine injections+IV fluid+Tetracycline 800-910
*Antipyretics @ Rs. 5.00-10.00 per treatment
I/V fluid may be required during Artemisinin treatment
HIV,Pregnant women and their
fetus/newborn
• HIV does make malaria in pregnancy
worse
– More and higher density malaria, more
illness, more anemia, more low birth
weight
• Malaria may make HIV worse
– Higher HIV viral load
– ? impact on Mother-to-Child Transmission
(MTCT)
The Worlds Priorities? Annual Expenditure
Global Reduction in Malaria $ 1 billion
Basic education for all $ 6 billion
Cosmetics in the US $ 8 billion
Safe water and sanitation $ 9 billion
Ice cream in Europe $ 11 billion
Reproductive health for all women $ 12 billion
Perfumes in Europe and the US $ 12 billion
Basic health and nutrition $ 13 billion
Pet food in Europe and the US $ 17 billion
Business entertainment in Japan $ 35 billion
Cigarettes in Europe $ 50 billion
Alcoholic drinks in Europe $ 105 billion
Narcotic drugs in the world $ 400 billion
Military spending in the world $ 780 billion
Laboratory Pre-clinical
Phase 1a, 2a
Phase 1b
Phase 2b
Phase 3
Environmental
management
AL
I V C or
IC
OG
OL
BI
IDVC
IEC, community
CHEMICAL
participation,
Intersectoral
cooperation ,etc
Integrated vector control
programme
vOne of the main strategy is to reduce the
man-mosquito contact.
vThere are many methods to curb the
mosquito nuisance
vNo single method of control is likely to
provide a solution in all situations.
vIntegrated approach is the present trend
to obtain maximum results with the
minimum effort and to avoid the
excessive use of any one method,
implement in an effective manner
simultaneously.
Mosquito control measures
vVarious methods are classified as bellow
v
v
I.Anti-larval methods
II.Anti-adult measures
III.Protection against
mosquito bites
I. Anti-larval
methods
i) Environmental control
ii) Chemical control
III) Biological control
i) Environmental control
• Source reduction - elimination of
breeding sites by minor
engineering methods- yield
permanent results
a.Filling and levelling-the filling of
depressions holding water and the
levelling of ground
b.Drainage -Designed to remove and
dispose off excess or unwanted
water.
Contd…
If anopheles are a problem
• filling and drainage
If Mansonia are a problem
• Removal of aquatic plants to which
larvae attach themselves
•
•
Contnd…
If Culex are a problem
• Abolish domestic and peri domestic
sources such as cesspools and open
ditches
• Adequate collection, removal and disposal
of sewage and waste water
If Aedes are a problem
• Remove the water holding containers such
as discarded tins, empty pots, broken
bottles, coconut shells and similar other
artificial collections of water
•
ii) Chemical control
The commonly used larvicides are
§ Mineral oils
§ Paris green and
§ Synthetic insecticides
Dosage
Larvicide Dosage
Chloropyrifos 10-15gm/ha
Use and limitations
• Useful in control of urban mosquitoes
& in the presence of other
refractory situations .
• Important limitations :
Ø Larvae not killed develop into adult
mosquitoes.
Ø Repeated every 7 to 10 days
Ø Thorough knowledge about the
habitats and ecology of the target
species.
Ø Environmental contamination.
III. Biological control
• Control of mosquito breeding by
application of biological control systems.
• An innovative approach to the problem of
mosquitoes and the diseases they
transmit.
• Cost effective, non-polluting, resistance
does not develop.
• Mosquitoes can be controlled by
employing their natural enemies viz.,
fishes, bugs, nematodes, bacteria and
fungi.
A female western
mosquitofish, Gambusia
affinis
Guppy fish
i.
Insecticidal dosage for IRS
Insecticide preparation Per sq. Rounds/ Area to be
mtr yr covered
In and out door fogging
Dragonfly &
Damselfly larvae
Backswimmers
Water Striders
Thank you
Any ????