Malaria

Quartan malaria; Falciparum malaria; Biduoterian fever; Blackwater fever; Tertian malaria; Plasmodium
Last reviewed: June 9, 2011.

Malaria is a parasitic disease that involves high fevers, shaking chills, flu-like symptoms, and anemia.

Causes, incidence, and risk factors

Malaria is caused by a parasite that is passed from one human to another by the bite of infected Anopheles mosquitoes. After infection, the parasites (called sporozoites) travel through the bloodstream to the liver, where they mature and release another form, the merozoites. The parasites enter the bloodstream and infect red blood cells. The parasites multiply inside the red blood cells, which then break open within 48 to 72 hours, infecting more red blood cells. The first symptoms usually occur 10 days to 4 weeks after infection, though they can appear as early as 8 days or as long as a year after infection. The symptoms occur in cycles of 48 to 72 hours. Most symptoms are caused by: The release of merozoites into the bloodstream Anemia resulting from the destruction of the red blood cells Large amounts of free hemoglobin being released into circulation after red blood cells break open Malaria can also be transmitted from a mother to her unborn baby (congenitally) and by blood transfusions. Malaria can be carried by mosquitoes in temperate climates, but the parasite disappears over the winter. The disease is a major health problem in much of the tropics and subtropics. The CDC estimates that there are 300500 million cases of malaria each year, and more than 1 million people die from it. It presents a major disease hazard for travelers to warm climates. In some areas of the world, mosquitoes that carry malaria have developed resistance to insecticides. In addition, the parasites have developed resistance to some antibiotics. These conditions have led to difficulty in controlling both the rate of infection and spread of this disease. There are four types of common malaria parasites. Recently, a fifth type, Plasmodium knowlesi, has been causing malaria in Malaysia and areas of southeast Asia. Another type, falciparum malaria, affects more red blood cells than the other types and is much more serious. It can be fatal within a few hours of the first symptoms.

Symptoms

Anemia Bloody stools Chills Coma Convulsion Fever Headache Jaundice Muscle pain Nausea Sweating

 Vomiting

Signs and tests

During a physical examination, the doctor may find an enlarged liver or enlarged spleen. Malaria blood smears taken at 6 to 12 hour intervals confirm the diagnosis. A complete blood count (CBC) will identify anemia if it is present.

Treatment
Malaria, especially Falciparum malaria, is a medical emergency that requires a hospital stay. Chloroquine is often used as an anti-malarial medication. However, chloroquine-resistant infections are common in some parts of the world. Possible treatments for chloroquine-resistant infections include: The combination of quinidine or quinine plus doxycycline, tetracycline, or clindamycin Atovaquone plus proguanil (Malarone) Mefloquine or artesunate The combination of pyrimethamine and sulfadoxine (Fansidar) The choice of medication depends in part on where you were when you were infected. Medical care, including fluids through a vein (IV) and other medications and breathing (respiratory) support may be needed.

Expectations (prognosis)
The outcome is expected to be good in most cases of malaria with treatment, but poor in Falciparum infection with complications.

Complications
Brain infection (cerebritis) Destruction of blood cells (hemolytic anemia) Kidney failure Liver failure Meningitis Respiratory failure from fluid in the lungs (pulmonary edema) Rupture of the spleen leading to massive internal bleeding (hemorrhage)

Calling your health care provider

Call your health care provider if you develop fever and headache after visiting the tropics.

Prevention
Most people who live in areas where malaria is common have gotten some immunity to the disease. Visitors will not have immunity, and should take preventive medications. It is important to see your health care provider well before your trip, because treatment may need to begin as long as 2 weeks before travel to the area, and continue for a month after you leave the area. In 2006, the CDC reported that most travelers from the U.S. who contracted malaria failed to take the right precautions. The types of anti-malarial medications prescribed will depend on the area you visit. According to the CDC, travelers to South America, Africa, the Indian subcontinent, Asia, and the South Pacific should take one of the following

drugs: mefloquine, doxycycline, chloroquine, hydroxychloroquine, or Malarone. Even pregnant women should take preventive medications because the risk to the fetus from the medication is less than the risk of catching this infection. People who are taking anti-malarial medications may still become infected. Avoid mosquito bites by wearing protective clothing over the arms and legs, using screens on windows, and using insect repellent. Chloroquine has been the drug of choice for protecting against malaria. But because of resistance, it is now only suggested for use in areas where Plasmodium vivax, P. oval, and P. malariae are present. Falciparum malaria is becoming increasingly resistant to anti-malarial medications. For travelers going to areas where Falciparum malaria is known to occur, there are several options for malaria prevention, including mefloquine, atovaquone/proguanil (Malarone), and doxycycline. Travelers can call the CDC for information on types of malaria in a certain area, preventive drugs, and times of the year to avoid travel. See: www.cdc.gov

Malaria, microscopic view of cellular parasites

Mosquito, adult feeding on the skin

There are many different species of mosquito, which can carry some of the world's most common and significant infectious diseases, including West Nile, Malaria, yellow fever, viral encephalitis, and dengue fever. (Image courtesy of the Centers for Disease Control and Prevention.)

Mosquito, egg raft

Mosquitoes of the Culex species lay their eggs in the form of egg rafts that float in still or stagnant water. The mosquito lays the eggs one at a time sticking them together in the shape of a raft. An egg raft can contain from 100 to 400 eggs. The eggs go through larval and pupal stages and feed on micro-organisms before developing into flying mosquitoes. (Image courtesy of the Centers for Disease Control and Prevention.)

Malaria, photomicrograph of cellular parasites

Malaria is a disease caused by parasites. This picture shows dark orange-stained malaria parasites inside red blood cells (a) and outside the cells (b). Note the large cells that look like targets; it is unknown how these target cells are related to this disease.

Malaria Situation in SEAR Countries

Bangladesh
Bangladesh Bhutan Malaria Situation Malaria has been a major public health problem in Bangladesh. Approximately 33.6% of the total population are at risk of malaria Majority of malaria cases are reported from 13 out of the total 64 districts in the country. About 4 million populations living in 34 upazillas of eight of the thirteen districts live in the epidemic-prone border areas. Focal outbreaks occur every year, and the response to control the epidemic is inadequate. Malaria cases are grossly under-reported due to shortcomings in surveillance and information. Country is reporting on average 50,000 confirmed malaria cases with around 70% of Pf cases (killer malaria) and 450 malaria deaths annually. The case finding is very poor and <2% population at risk of malaria screened every year. In 2008-09, with the help of Global funds enhanced surveillance and case finding activities including vector control through bednets and treatment through ACTs resulted in a increase in lab confirmed cases and significant decrease in malaria deaths (Fig1 & Fig.3). Country did not reaport any probable malaria case in 2009. Programme is promoting LLINs & ITNs amongst the community as a vector control measure in these areas which has increased tremendously in last few years (Fig2). Total 2.57 million bednets (LLINS + ITNs) were distributed and 6.42 million people are covered by it. However, its coverage in high endemic districts ranges between 40% to 63%. Fig 1: Trends of confirmed malaria cases in Bangladesh, 1970-2009 DPR Korea India Indonesia Maldives Myanmar Nepal Sri lanka Thailand TimorLeste

Malaria Situation 2009 : At a Glance Total population Population in malarious areas Number of confirmedmalaria cases Number of probablemalaria cases P. falciparum Proportion (Including RDT Positives) Number of deathsdue to malaria No. of Ist line treatment courses including ACTs Delivered No. of ACT courses delivered No of LLINs Distributed No. of effective LLINs+ITNs (cumulative) availability Population protected with LLINs + ITNs Population protected with IRS : 47 (Reporte d) : 161.6 million : 50.6 million : 63,87 1

89%

: N.A.

: :

0 0

: 2.35 million

: 5.86 million : Not done

Vectors: An. dirus, An. minimus, An. Philppinensis, An. aconitus, An. annularis, and An. Sundaicus Most (80%) cases derived from forest related areas along the border with Myanmar and India where malaria is highly endemic. No epidemics reported in 2008.

Supported by Global Funds

Click on the image to enlarge Fig.2 Cumulative availability of effective LLINs & ITNs in Bangladesh, 2005-2009 Fig3 : Distribution of ACT and Number of malaria deaths in Bangladesh, 2005-2009

Total financing for malaria in 2009 was approximately US$ 9.5 million, the main sources being the Government (US$ 555 000), the Global Fund (US$ 7.7 million), the World Bank (US$ 890 000) and WHO (US$ 230 000) (Fig. 4). Fig.4 : Availability of funds by Source in Bangladesh, 2006-2009

Pogramme Goals and Targets: To reduce malaria morbidity and mortality until the disease is no longer a public health problem in the country. Targets Baseline data in 2005 40% 2010

To provide early diagnosis and prompt treatment (EDPT) with effective drugs to 80% of malaria patients To provide effective malaria prevention to 80% of population at risk To strengthen malaria epidemiological surveillance system

80%

24% 60%

80% 100%

To establish Rapid Response Team (RRT) at national and district levels and increase preparedness and response capacity for containment of outbreaks To promote community participation, and strengthen partnership with private sector and NGOs for malaria control

80%

100%

25%

80%

Control strategy: Malaria control activities are integrated with the general health services Active Case Detection (ACD) and Passive Case Detection (PCD) with laboratory diagnosis Prompt treatment Case management of severe malaria and complicated cases in hospital. Vector control minimal, no IRS with DDT since 1993. SEAR working group recommendation on revised control strategy has been adopted Due to spread of chloroquine resistance, drug regimen has been revised and COARTEM has been introduced by programme Strengthening programme management is of high priority

Best practices and success stories Establishment of partnership with NGO consortium. Promotion and use of ITNs/LLINs Quality diagnosis using RDT and effective treatment using ACTs

Issues and Challenges: Inadequate access to treatment and diagnostic facilities especially in the remote areas Inadequate programme management capacity at various level and management of severe malaria in hospitals Poor coverage of prevention and control methods (IRS, ITN/LLIN coverage still low) in the community Referral system is weak and pre-referral treatment provisions are limited; Optimum treatment of cases of severe malaria in different categories of hospitals are inadequate Cross-border malaria at the Bangladesh India and Ban- Myanmar border

Partners and donors WHO World Bank Global fund BRAC and 14 member NGO Consortium 4 Local NGOs in Chittagong Hill Tract (CHT)

Johns Hopkins Malaria Research Institute

Every year malaria afflicts 225 million people with acute disease and kills nearly 800,000. In 2001 an anonymous donor gave $100 million to the Bloomberg School to fund a state-of-the-art research facility that would mount a broad program of basic-science research to treat and control malaria, develop a vaccine and find new drug targets to prevent and cure this deadly disease. The Johns Hopkins Malaria Research Institute (JHMRI) started operations in the Bloomberg Schools W. Harry Feinstone Department of Molecular Microbiology and Immunology in May 2001. The JHMRI was soon able to attract a critical mass of malaria experts from around the world. Together they are taking a multidisciplinary approach to understanding the Plasmodium parasite, the mosquito and the genes and proteins involved in the transmission of malaria.

Malaria is one of the major public health problems in Bangladesh. Out of the total 64 districts 13 districts are in the high endemic areas of malaria transmissions.

In these 13 endemic districts there are 70 endemic Upazilas covering 620 unions with the total population of 10.9 million. Over 98% of the total cases in the country are reported from these areas