Malaria

dr Putra Hendra SpPD

UNIBA
MALARIA
• Penyakit infeksi parasit yang disebabkan
oleh plasmodium yang menyerang eritrosit
dan ditandai dengan ditemukannya bentuk
aseksual di dalam darah.

• Etiologi
Penyebab infeksi malaria adalah plasmodium.
 ■ Definition
▲ A parasitic diseases caused by plasmodium
species.
▲ Transmitted by the bite of infected female
anopheline mosquitoes.
▲ Characterized by periodic paroxysm with
shaking chills, high fever, heavy sweating.
▲ Anemia and splenomegaly in cases suffering
from several attack of paroxysm.
3
 MALARIA DI INDONESIA
• 80% Kabupaten adalah PETA ENDEMIS MALARIA DI INDONESIA
endemis malaria TAHUN 2008

• 45% penduduk tinggal #

#
#

#
#
#

#
#
#
#
#

#
#

#
#
# #
#

#
#

#
#
##
#
##
#

di daerah beresiko
##

# #
#

#
##
#
# #
#
#
# #
#
## #
#
#
#
#
#
# #
#
#
#
# # # # ## #
# # #
# # # ##
# # # #
### #
# # # # #
# #
# # # ## #
# # ## # # # ## # # # #
# # # # # # # # # # # ## # # #
# # # # ## # # # # # # # # #
# # #
# # # # # # #
# # # #
## # # # # # # # # #
# # # ##
## # # # # #
# # # # #
#
# #
# #
# #
# # #
# # # # # # # # #
#

malaria
# # # # # # # # # #
# # # # #
# # # # # # ##
# # # # #
# # # # # # # #
## # # # # #
# #
# # # # # # ### ## # # # #
# # # # # # # ## # ## # # ## # ### # #
# # ## # # # ### # ## #
# # # # # # # # # # # ## # # # # ## ## #### #
# # # # # ## # # # ## # ## #######
#### # # # # # # ## # ## # ### # # # # ## ## ## # ### ### # # #
# # # # ## # # # # # # # # # ## # ## # # # # ## # #
# # # # # # # # ## # ##
### ## ## # # # # ### # ## # ## ## ## ## ### ## # # ## ## ## # ### ## ## #### #
# # ## # # ## ## ## # # ## # # ## # # # # # # # # ## # # #
# # # # # # # # # ## # # # # ## ## ## # ## ## ## #
# ## # ## # # # ## # # # # # # # # # # ### # # # # # ## ## ## # # ## # # ##
# # # # # # # # # # # # # # # ## ## # # # #
# # # # # ## # ## # ## # ## # # # # # ## # ## ## # # # # # ## # # ## # # # #
# ## # # # # # ## # ##
# # # # # # # # # # # # # # # # #
# # # # ## # # # # # # # # # # # ## # # # # # # # # ## # ### # # # # # # #
# ## # # # # # # ## # # # # # # # ## # #
# # # # # ## # # # # # # # # ## # # # # # # # ## # # ## # # ## ## # # # ## # # # # # ##
# #### # ## ## #### # ## # # # # ##
# # # # # # # # # # # ## # # # # # # # ## # ## # # # #
# # # ## # # # # # ## # # # # # ## ## # # ## # # ## # # ## ## ## ##### #### # # # # # # # # #
# # # # # # # # # ## ## # ## # # # # # # # #
# # #
# # # # # ## # # # # #
# # # # # # ## # # #
# # # # ## # # # # # # # # # # # # ##
# # #
# # ## # # # # # #
# # # # # # # ## ##
# # # # # # # # ## ### # # ##
# # # # ## # # # ## ## ## # # # # ## #
# # # # ## # # # # ## ## # # ## ## # # #
# # ## # ## # # # ## # # # ### ## #### ## ## ## #### #### ### ## ## ## #### #### ## ## ## #####
# # # # # # # ## # ## # # # ## ## ## # # ## # ## ## # # ## ### #
# # # ## # # # # #### ### ## ## # # ## # ## # # # # # # #### ## #### ## ## ## #### #### #### ## ## # ## ## # ## ## ###### ##
# # # # # ## # # # # # ## # ## # # # ## ## ## # # #
# # # # # # # # # # # # # # # ## # # ## # ## # # # ## ## ## # # # ##
# # # # ## # # # # ## ## ## ### ## # ## # # # # ## ## # ### # #### ## #### ## ## ## #### #### #### ## # # ##
## # # # # # ## # # # ## ## # ## # # # ## ## ## #
# ## ## ## ## ## ## # # # # ## ## # # # # # # # # # # # ## #### ## #### ## ## ## #### #### #### # # # #
# # # # # ## # # # # # # ## # ## # # # ## ## ##
# ### # # # # # # ## ### # # # # # ## # # # ## # ## ## #### ## #### ## ## ## #### ###
### #### ## # ###
# # # # ## ## # # # # # # ## # ## # # # # ## ## # # # #
# # # # # ## # # # # # # ## # ## # # # ## # ## # # # # #
# # # # # # # # # ## # # # # # # # ## # ## # # # ## ## ## # # # # #
# # # # # # ## # # # # # # # ## # # ## # ## #### ## #### ## ## ## #### #### ### ## #
# # # # # # # ## # # # # ## ## # # ## # ### ## ## ## #### #### ## # # # ###
## ## # # # # # # ## # # ## # # ## # # # # # # ### #### ### ## # # # # ### #
# ## # # # # # # # ## ## # # #
## # # # # # # # # # #
# # # # # # # ## ## #
## # # # ## # # # ## # ## ### # # # # ##
# ## ## #
# ## # # #
# # ## # # # ## # # # # ##
# ## ## # ## # ## # ## ## # # # # ## # #
# # ## ## # # ## # # # # #

• Tahun 2009 : terdapat

# # ## ### ## ## # # #### # # # # # # # # # #### # #
# ## # # # # # # # #
## ## # # # # ## # ## # # # # # #
# ### # ## # # # # # # # # # ##
# # # # ## ## # # # # ## # ##
# # ## # ## #
### # ## # # # # ## #
# # # ## # # #
# # # ## # # ## # #
#
# # # # #
# #
# # # # ## # #
# # # # # # # # # #
# # # # # # ## # # # # #
# # ### ## ## # # # ## # # #
# # ## # # # # # #
# # # # # # #
# # # # #
# #
# # #
# # #
# # #
# # # # ###
#
# # # # # # #
# # ##
#
# #
# # #
# #
# # # ## # # # #
# # # #
# # # # ## # #
# #
# # # # # # #
# # # ## ##
# #
# # #
# #
# # # # #
# #
#
# #
#
# # # # # # # ## # #
# ## # #
# # ## ## # ## # # ##
# # ## # # # #
# # # #
# # # # # # #
# #
# # # # # #
# ### # # #
## # # # # # # ## # # # # # ## # #### # # ## # # # # ### # #
# ## # # # ## # # # # # # # # # # #
# ## ## # ## # # # # ### # # # # ## # ## # # ## ##### # #### ## # # # ## ## # ###
######## # # # # ## # ## # # # #
## # # # # # # # #### ##
## # # # # # ### # ## # ## # # # # ## # # # ## ##
## ## # # #
# # # # # ## # # ## #### # ### # # # ## # ## # # # ## # ## # ## ## # ## # # # # ## # # # # ##
# # # # ## ## # # ## # # ## ## ## # # ## ## ## ## ## ## # # # ## ## ## # # # # ## ## #### # ### #### ## ## ## # ### ## ### # ## ## # ## #
# # ## # # # # # # # # # # ## # #
# # # ## # # ## # ### # ## # # # # # ## ##
# # # ## # # # # # # ### # ## # # ## # ## ## # ### # # # # ## ######## # ## # ### #### ## ##### ## #### ### # ## ##
## #### ##
### # # ## ## # # # # # ## # # # ### # # ### # # ## # ## ### # # # #
# ## # # # ## # # #
# # ## # ### ### # #
# # # ## # ## #

114 juta kasus malaria

# # ## # # # #
# # # # ### ## #
# # # # # ## ## ## #
# # ### # # # ## # #
## ## # # # ## ### ## ## ### # ## #
# # # # # ## # # # # #
## ## # # # # # # # # # ## ## ### ##
## # # # # # # ## ### ## # # ## #
# ## ## # # ## ## #
# # # # # ##
# ### # ## ## ## #
# # # # # ## # # # # # #
# # # # ## #
# # ## # # ## ##
# # # ## # # #
## ## # ## #
# ## # # # # ## #
#

##
###
### ##
# #
# # ## #
# # ### ### #
##
#

dan yang positif

sebanyak 199 ribu kasus
Pos 0 0-1 1-5 5-49 50-100 > 100
0/00 Free Low Moderate High 1 dot = 100 Kasus
pddk
 Malaria Kepri 2005
Natuna
Batam Bintan AMI :53
AP I: 0.94 API : 7.92
P : 564 P : 4.782
P : 942

Tg.pinang
Karimun
API : 0.92
API : 2.6 P : 147
P : 520 Tambelan

Lingga
AMI : 86
P : 6932

API < 1‰

API 1 - 5 ‰
API : Annual Parasites Incidence API > 5 ‰
STRATIFIKASI MALARIA MENURUT API DI PROVINSI
KEPULAUAN RIAU TAHUN 2009

Anambas
API 0,88

Karimun
API 1,91 Batam
API 0.65

Bintan
API 5,73

Natuna
API 2,30

Tanjungpinang
API 3,13

Lingga
API 10,31
 What is malaria ?
Malaria is a disease caused by the protozoan parasites of the genus Plasmodium.
The 4 species that commonly infect man are:

Species Major features

P. falciparum  The most important species as it is responsible for 50% of all malaria cases
worldwide and nearly all morbidity and mortality from severe malaria
 Found in the tropics & sub-tropics
P. vivax  The malaria parasite with the widest geographical distribution
 Seen in tropical and sub-tropical areas but rare in Africa
 Estimated to cause 43% of all malaria cases in the world
P. ovale  This species is relatively rarely encountered
 Primarily seen in tropical Africa, especially, the west coast, but has been reported
in South America and Asia

P. malariae  Responsible for only 7% of malaria cases

 Occurs mainly in sub-tropical climates
Recognizing Erythrocytic Stages:
Schematic Morphology

Blue
Cytoplasm

RING Red TROPHOZOITE

Chromatin

Brown
Pigment

SCHIZONT GAMETOCYTE
 Species Differentiation on Thin Films
P. falciparum P. vivax P. ovale P. malariae

Rings

Trophozoites

Schizonts

Gametocytes
Malaria Parasite Erythrocytic Stages

Ring form

Trophozoite
Schizont

Gametocytes
 Parasitemia and clinical correlates
Parasitemia Parasites/l Remarks
2-5% 100,000- Hyperparasitemia/severe
250,00 malaria*, increased
mortality
10% 500,000 Exchange transfusion may
be considered/ high
mortality
*WHO criteria for severe malaria are parasitemia > 10,000 /l and
severe anaemia (haemaglobin < 5 g/l).
Prognosis is poor if > 20% parasites are pigment containing
trophozoites and schizonts (more mature forms) and/or if > 5% of
neutrophils contain visible pigment.
Hänscheid T. (1999) Diagnosis of malaria: a review of alternatives to conventional
microscopy. Clin Lab. Haem. 21, 235-245.
Life Cycle of Plasmodium
Pathogenesis
 Extra-erythrocytair LIVER
LIVER

Takisporozoit

Plasmodium
Plasmodium vivax
vivax
(malaria
(malaria tertiana)
tertiana)
Hypnozoite ini yang
HYPNOZOITE
HYPNOZOITE menimbulkan kambuh, walau
tidak digigit nyamuk lagi.
Bradisporozoit
Extra-erythrocytair LIVER
LIVER

Erythrocytair
Extra-erythrocytair LIVER
LIVER

P.vivax : eritrosit muda (2 %)

Menimbulkan anaemi (KD

: kurang darah)

Erythrocytair P.Falciparum : eritrosit muda dan tua (10 – 40 %)

 P.vivax : eritrosit muda (2 %)

Menimbulkan anaemi (KD

: kurang darah)

P.Falciparum : eritrosit muda dan tua (10 – 40 %)

Extra-erythrocytair LIVER
LIVER

Plasmodium
Plasmodium falsiparum
falsiparum
(malaria
(malaria tropika)
tropika)
DEMAM
Pecahnya parasit di darah yang
mengeluarkan zat tertentu, memicu
Inang untuk mengeluarkan sitokin
yang mempengaruhi
thermoregulator
Thermoregulator

TNF Titik set suhu

(Tumor berubah
Necrosis
Factor)

Sel Inang

Hypothalamus
endothelium

 Produktifitas kerja tidak optimal

 Absensi anak sekolah tinggi
Diagnosis
 The clinical course of P. falciparum

Following a bite by an infected mosquito, many people do not

develop any signs of infection. If infection does progress,
the outcome is one of three depending on the host and
parasite factors enumerated in the previous slides:

A. Asymptomatic parasitaemia (“clinical immunity”)

B. Acute, uncomplicated malaria
C. Severe malaria
 B. Simple, uncomplicated malaria
This can occur at any age but
it is more likely to be seen in
individuals with some degree
of immunity to malaria. The
affected person, though ill,
does not manifest life-
threatening disease.

Fever is the most constant

symptom of malaria. It may
occur in paroxysms when lysis
of red cells releases
merozoites resulting in fever,
chills and rigors
(uncontrollable shivering).
Children with malaria waiting to be seen at a
malaria clinic in the south western part of
Nigeria. Identifying children with severe malaria,
and giving them prompt treatment, is a major
challenge when large numbers attend clinics.
 Other features of simple,
uncomplicated malaria include:
o Vomiting
o Diarrhoea – more commonly seen in young children and, when vomiting also occurs, may be
misdiagnosed as viral gastroenteritis
o Convulsions – commonly seen in young children. Malaria is the leading cause of convulsions with
fever in African children.
o Pallor – resulting mainly from the lysis of red blood cells. Malaria also reduces the synthesis of red
blood cells in the bone marrow.
o Jaundice – mainly due to haemolysis.

Malaria is a multisystem disease. Other common clinical features are:

o Anorexia
o Cough
o Headache
o Malaise
o Muscle aches
o Splenomegaly
o Tender hepatomegaly

These clinical features occur in “mild” malaria. However, the infection requires urgent
diagnosis and management to prevent progression to severe disease.
 Demam
• DHF : pelana

• Demam tifoid

• Malaria
 Differential Diagnostic
• Typhoid fever
• Dengue Haemorrhagic Fever
• Respiratory Tract Infection
• In tropical countries, mixed infections of
malaria along with other microorganism
should be considered
Rapid Diagnostic Test (RDT)
 Diagnostik parasitologis malaria
• Idealnya darah diambil akhir stadium demam,
memasuki stad berkeringat.
• Sediaan darah tebal :  10 µl darah (3 tts)
• Sediaan darah tipis : 2 µl (1 tts)
reventing Transfusion-Transmitted Malaria (TTM
Detection of Parasites/Parasite Products
PCR (0.05 to 0.1 parasites/l)
Microscopy (5 parasites/l)

Antigen detection
(10 to 100 parasites/ l)

10-5 10-3 10-1 10 103

Parasite densities (parasites/l)

 The Malaria Transmission Cycle
Sites of Action for Antimalarial
Drugs
TISSUE SCHIZONTOCIDES:
primaquine
pyrimethamine
proguanil
tetracyclines

MOSQUITO HUMAN
BLOOD
SCHIZONTOCIDES:
chloroquine
mefloquine
quinine/quinidine
tetracyclines
SPORONTOCIDES: halofantrine
primaquine GAMETOCYTOCIDES: sulfadoxine
pyrimethamine primaquine pyrimethamine
proguanil artemisinins
Antimalarial Mechanism
Malaria - Treatment

Artemisinin
• Andrographis paniculata
Nees, Acanthaceae class
• andrographolida,
neoandrographolida,
dehydroandrographolida
, and
deoxyandrographolida
 C. Severe and complicated malaria

Nearly all severe disease and the estimated >1 million deaths from
malaria are due to P. falciparum. Although severe malaria is both
preventable and treatable, it is frequently a fatal disease.

The following are 8 important severe manifestations of malaria:

Click on each severe manifestation for details

1. Cerebral malaria 5. Acute renal failure

2. Severe malaria anaemia 6. Pulmonary oedema
7. Circulatory collapse, shock or
3. Hypoglycaemia
“algid malaria”
4. Metabolic acidosis 8. Blackwater fever

Note: It is common for an individual patient to have more than

one severe manifestation of malaria!
 2. Severe malaria anaemia
Defined as a haematocrit of <15% or haemoglobin
concentration <5 g/dl.

Occurs commonly in young children and pregnant

women.

Anaemia in malaria results from a combination of

factors:
• Destruction of parasitised red blood cells
• Destruction of unparasitised red cells by
complement-mediated lysis
• Bone marrow suppression by cytokines produced
by malaria parasites
• Haemolysis induced by medications in individuals
with glucose-6-phosphate dehydrogenase
deficiency
Marked pallor in an African child with
severe anaemia due to P. falciparum
Many patients require urgent transfusion. The infection
condition may be rapidly fatal when blood
transfusion is delayed.

Back
Malaria - Prevention
Malaria - Vaccination
Permasalahan malaria saat ini :
• Resistensi obat
• Resistensi vektor
• Belum adanya vaksin
• KLB di daerah
endemi
Antimalarial Resistance in
Indonesia 1978 - 2005
Causes of Treatment Failure
• Hipo Endemik: bila parasit rate atau spleen
rate 0-10%
• Meso Endemik: bila parasit rate atau spleen
rate 10-50%
• Hiper Endemik: bila parasit rate atau spleen
rate 50-75%
• Holo Endemik: bila parasit rate atau spleen
rate >75%
 I. Pencegahan dan Penanggulangan Faktor Risiko
• Distribusi kelambu pada kelurahan endemis tinggi : Sambau, Galang dan Belakang
Padang, terutama diberikan pada ibu hamil dan ibu yang mempunyai anak kurang
dari 5 tahun. Disistribusikan pada bulan November, Desember tahun 2009 dan
tahun 2010.

• Penyemprotan rumah (IRS) dilaksanakan 2 siklus di wilayah Puskesmas Belakang

Padang, Sei Lekop, Sambau, dan Galang telah dimulai sejak tahun 2006. Tahun
2010 dilaksanakan di P. Terong, P. Kasu, P. Karas, P. Abang, P. Petong dan
Sambau

• Larvaciding dilaksanakan sejak tahun 2006 sampai sekarang di lokasi wilayah

kerja Belakang Padang, Sei Lekop, Sambau, dan Galang. Dilaksanakan setiap
tahun sampai sekarang

• Pembersihan Lumut dilakukan pada saat kenaikan kasus di Wilayah Puskesmas

Galang yaitu Kelurahan Petong, P. Abang pada bulan Juni 2006. Tahun 2008 dan
2009 di kelurahan Sambau ( Nongsa Pantai, Teluk Mata Ikan) serta Wilayah
Puskesmas Belakang Padang yaitu Sekanak Raya, tahu n 2010 di Kecamatan
Nongsa
 Tempat
perindukan
vektor Malaria
Batam
(Nongsa)