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MALARIA

MALARIA. PRESENTED BY CAPT SMITI JUYAL. MODERATOR MAJ DHEERAJ N GD SPL MEDICINE. Historical perspective. Waicherian Expedition of British Army in 1809…

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MALARIA

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  1. MALARIA PRESENTED BY CAPT SMITI JUYAL MODERATOR MAJ DHEERAJ N GD SPL MEDICINE

  2. Historical perspective Waicherian Expedition of British Army in 1809… 70,000 men who landed on 01 Aug, 35,000 men contracted Malaria and 10,000 died by 10 Oct. 1826: a force of British & Indian troops landed in Arakan...Within few weeks 5000 were struck down by Malaria, of the total British troops 3/4 died. In East African Campaign in 1916, 51,000 cases occurred in force of 58,000. In Macedonian campaign during WWI 1,70,000 cas caused by Malaria as opposed to 24,000 battle cas.

  3. etiology • Vector for transmission :- Anopheles mosquito • Causative agent :- Plasmodium species • P. vivax – Beningn Tertian • P . Falciparum – Malignant Tertian • P . Malariae – Beningn Tertian • P . Ovale - Quartian

  4. Malaria transmission cycle • Sexual reproductive phase in mosquito known as sporogony Infective stage – sporozoite • Asexual reproductive phase in humans known as schizogony • Human cycle has • Pre-erythrocytic phase • Erythrocytic phase

  5. Oocyst Sporozoites Mosquito Salivary Gland Zygote Hypnozoites (for P. vivax and P. ovale) Gametocytes Erythrocytic Cycle Malaria Life Cycle Sporogony Exo- erythrocytic (hepatic) cycle Schizogony

  6. Malaria Transmission Cycle Exo-erythrocytic (hepatic) Cycle: Sporozoites infect liver cells and develop into schizonts, which release merozoites into the blood Sporozoites injected into human host during blood meal Parasites mature in mosquito midgut and migrate to salivary glands Dormant liver stages (hypnozoites) of P. vivax and P. ovale HUMAN MOSQUITO Erythrocytic Cycle: Merozoites infect red blood cells to form schizonts and later relaeasing daughter merozoites Some merozoites differentiate into male or female gametocyctes Parasite undergoes sexual reproduction in the mosquito

  7. EPIDEMIOLOGY • Major cause of mortality & morbidity • Resurgence due to Chloroquin resistance and vector resistance to insecticides. • All deaths mainly due to falciparum malaria 100 countries malarious, 1/2 in sub-Saharan Africa 300-500 million clinical cases / yr • 1.1 to 2.7 million killed / yr • 1 million are children <5yrs (cerebral malaria)

  8. epidemiology • P .vivax predominates in Central America • P .falciparum predominates in Africa • Prevalence of these two species is almost equal in Indian subcontinent, South America ,East Asia • P. malariae and P.ovale found in Africa

  9. EPIDEMIOLOGY • Malaria indirectly responsible deaths due to diarrhoea, anaemia, malnutrition • Delay in diagnosis sp in high risk gp children and pregnant women. • Due to global deployment of army and new drug resistance strains

  10. CLINICAL FEATURES

  11. CLINICAL FEATURES Initial features nonspecific. • Loss of sense of well being • headache • Fatigue • Abdominal discomfort • Muscle ache • Fever • Nausea, vomiting & hypotension

  12. CLINICAL FEATURES • Classic paroxysm of fever, chills & rigor are relatively unusual now a days • Palpable spleen • Anemia • Mild jaundice

  13. Complicated malaria • Cerebral Malaria • Hypoglycemia • Acidosis • Non cardiogenic pulmonary edema • Renal failure • Severe jaundice seen with falciparum malaria • Septicemia common in children

  14. Chronic complication • Tropical splenomegaly • Quartan malaria nephropathy

  15. Diagnosis • High index of clinical suspicion • Diagnosis confirmed by demonstration of parasite in blood smear • Thick smear for detecting level of parasitaemia • Thin smear for identification of parasite, may be negative in severe falciparum or in patients on anti malarial drugs.

  16. Diagnosis • Newer tests • PFHRP II (Plasmodium Falciparum Histidine Rich Protien II) dipstick test • P LDH dipstick test • PCR (Polymerase Chain Reaction)

  17. Managementofmalaria • General Guidelines • When patient in or from malarious area presents thick & thin smear made • If any doubt regarding resistance parasite considered resistant • Despite high resistance rates in Southeast Asia Chloroquine remains drug of choice • For treatment of falciparum malaria WHO recommends artimissin- based combination as 1st line

  18. Uncomplicatedmalaria P .vivax, P.malariae, P. ovale, P.falciparum ( known chloroquine sensitivity ) • Chloroquine 10mg/kg stat followed by 5mg/kg at 12, 24 & 36 hr OR • Chloroquine 10 mg/kg stat followed by 10mg/kg at 24 hr & 5mg/kg at 48 hr OR • Amodiaquine 10-12 mg/kg OD * 3 days

  19. UNCOMPLICATEDMALARIA Sensitive P. falciparum malaria • Artesunate 4mg /kg * 3 days plus sulfadoxime 25mg /kg – pyrimethamine 1.25 mg /kg as single dose OR • Artesunate 4mg/ kg * 3 days plus amodiaquine 10 mg /kg * 3 days

  20. UNCOMPLICATEDMALARIA • Multidrug resistant P .falciparum • Artimether – lumefantrine (1.5/9 mg/kg BD * 3 days) or artesunate (4mg/kg OD * 3 days) PLUS • Mefloquine 25mg/kg (either 8mg/kg OD * 3days or 15 mg/kg on day 2 and 10 mg/kg on day 3)

  21. UNCOMPLICATEDMALARIA • 2nd line treatment • Artesunate (2mg/kg OD * 7day) or Quinine (10mg/kg TDS * 7 days) PLUS 1 0F THE FOLLOWING • 1. Tetracycline(4mg/kg qiD * 7 days) • 2. doxycycline(3mg/kg od * 7 days) • 3. clindamycin(2mg/kg bd * 7 days)

  22. Radical treatment • Needed in P .vivax & P. ovale infection Primaquine ( 0.25mg/kg OD * 14 days)

  23. Severe p falciparum MALARIA • Artesunate (2.4 mg/kg iv stat followed by 2.4 mg/kg at 12 & 24 h & then daily if necessary) OR • Artemether (3.2mg/kg im stat followed by 1.6 mg/kg) OR • Quinine (20mg/kg infused over 4h followed by 10mg/kg infused over 2-8 h) OR • Quinidine (10mg/kg infused over 1-2 h followed 1.2mg/kg/h )

  24. Resistance • Sensitive : Asexual forms completely clear in 7 days & don’t recur in 10,14, 17, 21, 24, 28 days • R1: Parasitaemia clears up but recur in 7 days in early type and in 14 days in delayed type • RII :Marked decline up to 25% or less in 48 hr but no clearance of parasites • RIII: Reduction <75% during 48 hr or even increase with preliminary decrease

  25. Principles of Malaria Control • Awareness of risk to tps and families • Avoidance of mosquito bite • Early diagnosis & treatment • Chemoprophylaxis

  26. Avoidance of mosquito bite • Avoidance of mosquito bite • Remain indoors in dusk & dawn • Use of repellent every 3-4 hours • Use of mosquito-net with pyrethroid impregnation • Spray indoors, coils, mats, vaporisers

  27. Avoidance of mosquito bite • ANTIADULT MEASURES • RESIDUAL SPRAY • MALATHION • DDT • BAYGON • SYNTH PYRETHRIODS • FOGGING • SPACESPRAY • BED NET IMPREGNATION

  28. Avoidance of mosquito bite • ANTI LARVAL ACTIVITY • ENGR PLANNING • DISCARDED TINS • WATER COLLECTION • OHT • SEPTIC TANK • FILLING • DRAINAGE • MT DISP • DRY DAY • BAYTEX GRALUNES • BAYTEX CONC • ABATE • GAMBUSIA

  29. Early diagnosis & treatment • Survival depends upon prompt recognition of disease, its complication, prevent transmission, and minimise drug resistance. • Uncomplicated malaria, rigor may not be there or may not have tertian or quartan pattern • High index of clinical suspicion is must for diagnosis and early treatment

  30. Chemoprophylaxis • Use of anti-malarial drugs to prevent the development of malaria • Supplement to protective measure • Should start a week before entering area malarious area and continued 4 wks after return • Suppresses shizogony doesn't effect pre-erythrocytic cycle (proguanil and primaquine)

  31. Chemoprophylaxis • Primary chemoprophylaxis • Causal prophylaxis: Prevents establishment of infection in the liver . Primaquine and proguanil • Suppressive prophylaxis: Suppresses blood forms of malaria parasite • Terminal Prophylaxis Administration of primaquine for two weeks after returning from travel to tackle the hypnozoites of P. vivax and P. ovale that can cause relapses of malaria.

  32. Chemoprophylaxis • Chloroquine 5 mg/kg weekly (300mg/wk) start 2wk before travel & continued for 4 wk post travel • Proguanil 3mg/kg daily 2 tab per week • Mefloquine 5mg/kg 1 tab per week • Doxycycline 100mg daily

  33. Chemoprophylaxis • On return from area one time Radical treatment is given 600 mg chloroquine and 45 mg primaquine • Chemoprophylaxis in arm • Sanctioned by the GOC in C • Adv by DDMS comd • Not in perm loc • On move for ex/trg

  34. Malariameasurement • Spleen Rate : % of children (2-10yr) showing spleen enlargement • Parasite Rate : % of children showing MP in PBS • Infant Parasite rate : % of infants showing MP in slide. most sensitive, most recent index • Proportional case rate : No of cases dx as clinical malariafor every 100 cases attending hospital

  35. Malaria measurement • API = No of blood smears found positive for MP X 1000 • Total popn under suveillance • Indicates malaria endemicity • Impact of control activities, API 2 -indoor residual spray • ABER = No of blood smears collected during yr X 100 Popn under surveillance • WHO recommends 1% in a month, in MPOmin 10% in a yr • ABER is index of op efficiency

  36. Malaria measurement • SPR = No of blood smears positive for MP X 100 • No of blood smears examined • Indicates distribution of malaria in popn • SPR trends used in epidemic forecasting • Epidemic if monthly SPR > 2.5 times of SD of SPR of last • 3 yr / preceding 3m of same yr

  37. Importance for Indian Army Endemic areas in North-EastSoldiers from non-endemic areasLack of basic amenitiesTps operate in close proximity to local popnPrevention is the only effective tool Conventional methods can not be used

  38. Anti Malaria Org in Armed Forces • In cantt or stn stn cdr on advise of SEMO Generally based on current orders. • Stn health commitee CO MH, all CO,OC of unit • Assess the progress of, reviews the 1 mth prior to onset of season and 1 mth prior to peak incidence of mth

  39. Anti Malaria Org in Armed Forces • In Op area fmn cdr and unit CO with tech advise of DADH or ADH/ OC FHO, rep of engr services. DADH also asst cdr in plg cont measures • Stn, and its periphery 1 km depth is divided into No of circles depending upon area, each is further divided into six zones, each capable being covered in one day for anti larval operations.

  40. Anti Malaria Org in Armed Forces • OCs are responsible for anti malaria activity within unit and adjoining area under the charge. • Anti malaria Squads and anti malaria offrs

  41. Following records to be maintained • Principle events in malaria season, initiation & formulation of anti larval, residual spray campaign, spleen rate, parasite rate, initial & periodic check, state of equipment. • Weekly met record max, min temp, incidence unit wise.

  42. Following records to be maintained • Record of insecticide spray, No of house, hut, tents sprayed. • Spot map, breeding area, temp or perm, potential or actual • Malaria register • No, rank, unit, sub unit, date onset of fever, dt of adm, dt of +ve m/c, species, relapse/ fresh, movement during last 3 moths, pers precautions taken, chemoprophylaxis, dt of discharge

  43. MALARIA “ MORE SERIOUS THAN THE MONSOON WAS THE INCIDENCE OF TROPICAL DISEASE” ADM MOUNTBATTEN “FEVER COST ME AS MANY MEN AS SEVEN BATTLES” PRUSSIAN GEN FEDREICK

  44. REFRENCES • HARRISONS TEXT BOOK OF INTERNAL MEDICINE 17ED • SOCIAL AND PREVENTIVE MEDICINE PARK • THE RED BOOK

  45. THANKYOU

  46. TRG FOR PREV AND CONTROL OF MALARIA SHOULD BE ESSN PART OF TRG FOR WAR TO ACHIEVE ZERO MALARIA RATE IS NOT POSSIBLE

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