Malaria Diagnosis, Treatment, Prevention

Malaria Diagnosis, Malaria Diagnosis, Treatment, Treatment, PreventionPrevention

Welcome to Malaria WorldWelcome to Malaria World

StatisticsStatistics

300-500 million people infected worldwide300-500 million people infected worldwide 1-2 million deaths annually1-2 million deaths annually Kills over 3,000 children DAILYKills over 3,000 children DAILY 40% of the world’s population lives in 40% of the world’s population lives in

malarious areasmalarious areas Major military importance for deployed US Major military importance for deployed US

forces forces 1993, Operation Restore Hope, Somalia, Marines 1993, Operation Restore Hope, Somalia, Marines

fell ill due to non-compliance and bad med intel fell ill due to non-compliance and bad med intel as to plasmodium species in the areaas to plasmodium species in the area

2003, Liberia, Marines and AF Ravens2003, Liberia, Marines and AF Ravens

Infectious Parasitic AgentInfectious Parasitic Agent

Plasmodium ssp.Plasmodium ssp. P. falciparumP. falciparum

most lethal, infects all ages of RBC’smost lethal, infects all ages of RBC’s may cause hemolysis of 30% of RBC’s at a may cause hemolysis of 30% of RBC’s at a

timetime P. malariaeP. malariae

infects mature RBC’sinfects mature RBC’s P. vivaxP. vivax and and P. ovaleP. ovale

relapsing stage in liverrelapsing stage in liver infect immature RBC’sinfect immature RBC’s

Transmission:Transmission:

Dusk to DawnDusk to Dawn transmission transmission Transfer of sporozoites from Transfer of sporozoites from

mosquito saliva to human bloodmosquito saliva to human blood Migrate to liver, infect cells and Migrate to liver, infect cells and

mulitiplymulitiply Liver cells rupture and release Liver cells rupture and release

merozoites, which infect and cause merozoites, which infect and cause rupture of RBC’srupture of RBC’s

Clinical SignsClinical Signs

High fever, headache, chills High fever, headache, chills Anemia, splenomegaly, icterusAnemia, splenomegaly, icterus GI symptoms: nausea, vomiting, GI symptoms: nausea, vomiting,

diarrheadiarrhea Periodicity of fever depends on Periodicity of fever depends on

species; almost continuous with P. species; almost continuous with P. falciparumfalciparum

Clinically severe signs with Clinically severe signs with P. falciparumP. falciparum

Cerebral malaria: headache Cerebral malaria: headache progressing to seizures, impaired progressing to seizures, impaired consciousness, deathconsciousness, death

Renal tubular necrosisRenal tubular necrosis Pulmonary edema due to tissue Pulmonary edema due to tissue

necrosis factor release necrosis factor release

Patient HistoryPatient History

Travel to endemic area: Check the CDC Travel to endemic area: Check the CDC “yellow book” for quick reference“yellow book” for quick reference

““Airport malaria” is rare but possible; Airport malaria” is rare but possible; patient has not been to malarious areapatient has not been to malarious area

Not on prophlyaxis or not compliantNot on prophlyaxis or not compliant Flu like symptoms may start in country, Flu like symptoms may start in country,

or weeks, months, or years after leaving or weeks, months, or years after leaving area with relapsing forms ( P.vivax and area with relapsing forms ( P.vivax and ovale )ovale )

DiagnosisDiagnosis

Gold Standard: Examine multiple blood Gold Standard: Examine multiple blood smears, thick and thin, taken when fever smears, thick and thin, taken when fever is risingis rising Speciation is possible this waySpeciation is possible this way

““Dipstick” methods based on detecting P. Dipstick” methods based on detecting P. falciparum proteins are used for field falciparum proteins are used for field screening or confirmatory tests but do screening or confirmatory tests but do not replace the smears. not replace the smears. Expensive; malarious countries can rarely Expensive; malarious countries can rarely

afford afford

P. falciparumP. falciparum

Delicate rings, multiples, marginalized, double chromatin

P. malariaeP. malariae

“Broad band” gametocyte form present, RBC’s not enlarged

P. vivaxP. vivax

Thick signet rings, enlarged RBC’s, developing forms

P. ovaleP. ovale

“Comet” shaped cells, enlarged RBC’s

ProphylaxisProphylaxis

Chloroquine (non-resistant strains)Chloroquine (non-resistant strains) 300 mg base once weekly, begun 2 300 mg base once weekly, begun 2

weeks before travel and continued until weeks before travel and continued until 4 weeks after leaving malarious area4 weeks after leaving malarious area

Safe for pregnant women; however Safe for pregnant women; however pregnant women are discouraged from pregnant women are discouraged from travel to malarious areas! Mosquitoes travel to malarious areas! Mosquitoes prefer pregnant women due to skin prefer pregnant women due to skin temp and increased CO2 production.temp and increased CO2 production.

ProphylaxisProphylaxis

Mefloquine (non-resistant strains)Mefloquine (non-resistant strains) 250 mg weekly, 2 weeks prior, during, 250 mg weekly, 2 weeks prior, during,

and 4 weeks after leaving malarious and 4 weeks after leaving malarious areaarea

Can be given on days 1,2,3, and 7, Can be given on days 1,2,3, and 7, then weekly, if time does not permit then weekly, if time does not permit patient to start regimen 2 weeks prior.patient to start regimen 2 weeks prior.

Cannot be given to flyersCannot be given to flyers Side effects: nausea, dizziness, sleep Side effects: nausea, dizziness, sleep

disturbancesdisturbances

ProphylaxisProphylaxis

Doxycycline Doxycycline 100 mg SID, 1-2 days prior continuing 100 mg SID, 1-2 days prior continuing

through 4 weeks after. through 4 weeks after. OK for flyers with ground testOK for flyers with ground test GI upset and sun sensitivity; yeast GI upset and sun sensitivity; yeast

infections in womeninfections in women

Terminal prophylaxis:Terminal prophylaxis:

Primaquine is only drug that kills Primaquine is only drug that kills the relapsing stage (hypnozoite) of the relapsing stage (hypnozoite) of P. vivax and P. ovale in the liverP. vivax and P. ovale in the liver 23 mg daily for 14 days, upon leaving 23 mg daily for 14 days, upon leaving

malarious area.malarious area. Not necessary to take it exactly upon Not necessary to take it exactly upon

leaving area; if it is missed, make sure leaving area; if it is missed, make sure it is taken at some point after it is taken at some point after deploymentdeployment

ProphylaxisProphylaxis

Flyers need ground test of doxycyclineFlyers need ground test of doxycycline All personnel should have known G6PD All personnel should have known G6PD

status before being given Primaquine. status before being given Primaquine. G6PD deficiency can lead to G6PD deficiency can lead to hemolysis.hemolysis.

If primaquine use is needed for If primaquine use is needed for treatment of malaria infection in G6PD treatment of malaria infection in G6PD deficiency, use once weekly, 30-45 mg deficiency, use once weekly, 30-45 mg for 8 weeksfor 8 weeks

Malaria TreatmentMalaria Treatment

Drug regimen depends on species Drug regimen depends on species of Plasmodium and severity of of Plasmodium and severity of infectioninfection Quinine (sulfate or dihydrochloride)Quinine (sulfate or dihydrochloride) Malarone (atovaquone plus proguanil)Malarone (atovaquone plus proguanil) MefloquineMefloquine Artemisinins (Chinese traditional tx)Artemisinins (Chinese traditional tx) Primaquine for relapsing speciesPrimaquine for relapsing species

PREVENTIONPREVENTION

DEET used on skinDEET used on skin Permethrin treated bednets and Permethrin treated bednets and

uniformsuniforms Avoid activity dusk to dawn Avoid activity dusk to dawn

(showering, etc.)(showering, etc.) Malaria control depends on direct Malaria control depends on direct

discipline by those in commanddiscipline by those in command

Good references:Good references:

Centers for Disease Control and Prevention (CDC)Centers for Disease Control and Prevention (CDC)

Control of Communicable Disease ManualControl of Communicable Disease Manual Located with Public HealthLocated with Public Health

National Center for Medical Intelligence (NCMI)National Center for Medical Intelligence (NCMI) https://www.intelink.gov/ncmi/index.phphttps://www.intelink.gov/ncmi/index.php

Air Force Reporting Instructions Tool (AFRIT)Air Force Reporting Instructions Tool (AFRIT) https://aef.afpc.randolph.af.mil/AFRIT/Afrit.aspxhttps://aef.afpc.randolph.af.mil/AFRIT/Afrit.aspx