Introduction 1

1
Introduction 1
Malaria

• Welcome to the malaria module!
• Malaria is a major public health problem in warm
  climates especially in developing countries.
• It is a leading cause of disease and death among
  children under five years, pregnant women and
  non-immune travellers/immigrants.

Children under 5 are the major at risk group in
malarious regions. Inset An Anopheles mosquito
taking a blood meal Sources http//www.ifnc.org/p
ictures.html http//phil.cdc.gov/phil/quicksearch
.asp
For more information about the authors and
reviewers of this module, click here
2
How to use this module

• This self-directed learning (SDL) module has been
  designed for medical and other health care
  students
• We suggest that start with the learning
  objectives and try to keep these in mind as you
  go through the module slide by slide, in order
  and at your own pace.
• Print-out the malaria SDL answer sheet. Write
  your answers to the questions on the mark sheet
  as best you can before looking at the answers.
• Repeat the module until you have achieved a mark
  of 22/27 (80).
• You should research any issues that you are
  unsure about. Look in your textbooks, access the
  on-line resources indicated at the end of the
  module and discuss with your peers and teachers.
• Finally, enjoy your learning! We hope that this
  module will be enjoyable to study and complement
  your learning about malaria from other sources.

3
Introduction 2
Learning Outcomes

• By the end of the module, you would be expected
  to be able to describe
• How P. falciparum malaria is a major killer of
  people in warm climates and that children years, pregnant women and non-immune
  visitors/immigrants are at greatest risk
• The 4 species of malaria, their geographical
  distribution and the major stages of the life
  cycle
• How malaria is transmitted by the female
  anopheles mosquito and how levels of endemicity
  vary according to climate and mosquito ecology
• How parasite and host factors determine disease
  severity
• The clinical features of simple, uncomplicated
  disease and 8 important severe manifestations of
  malaria
• How malaria is diagnosed by blood film
  examination, antigen detection and molecular
  methods
• The role of chloroquine, quinine, artemesin and
  other drugs in treatment
• How malaria can be prevented by reducing
  man-mosquito contact, chemoprophylaxis and
  intermittent presumptive treatment

4
What is malaria ?
Malaria is a disease caused by the protozoan
parasites of the genus Plasmodium. The 4 species
that commonly infect man are
5
The burden of malaria

• The direct burden of malaria
• morbidity and mortality
• Every year, there are about 500 million clinical
  attacks of malaria. Of these, 2-3 million are
  severe and about 1 million people die (about 3000
  deaths every day).
• Malaria in pregnancy accounts for about 25 of
  cases of severe maternal anaemia and 10-20 of
  low birthweight. Low birthweight due to malaria
  accounts for about 5-10 of neonatal and infants
  deaths.
• 80 of all malaria cases occur in tropical Africa
  where the disease
• accounts for 10-30 of all hospital admissions
• is responsible for 15-25 of deaths in children
  aged
  year.
• kills an African child every 30 seconds

• The indirect burden of malaria
• Human development Impaired intellectual
  development, developmental abnormalities
  (especially following cerebral malaria), lost
  school attendance and productivity at work
• Economics Malaria retards economic development
  in the developing world. The cost of a single
  bout of malaria is equivalent to over 10 working
  days in Africa. The cost of treatment is between
  US0.08 and US5.30, depending on the type of
  drugs prescribed as required by the local pattern
  of drug resistance.
• The total cost of malaria in Africa in terms
  of healthcare, treatment and lost productivity,
  is currently estimated to be US12 billion
  every year.

6
Geographical Distribution of Malaria
Although previously widespread, today malaria is
confined mainly to Africa, Asia and Latin
America. About 40 of the worlds population is
at risk of malaria. It is endemic in 91
countries, with small pockets of transmission
occurring in a further 8 countries.
Malaria is transmitted by the female anopheles
mosquito. Factors which affect mosquito ecology,
such as temperature and rainfall, are key
determinants of malaria transmission. Mosquitoes
breed in hot, humid areas and below altitudes of
2000 meters. Development of the malaria parasite
occurs optimally between 25-30oC and stops below
16oC. Indigenous malaria has been recorded as far
as 64oN and 32oS. Malaria has actually increased
in sub-Saharan Africa in recent years. The major
factor has been the spread of drug-resistant
parasites. Other important factors include the
persistence of poverty, HIV/AIDS, mosquito
resistance to insecticides, weak health services,
conflict and population migration.
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Endemicity and immunity to malaria

• Endemicity refers to the amount or severity of
  malaria in an area or community. Malaria is said
  to be endemic when there is a constant incidence
  of cases over a period of many successive years.
  
• Endemic malaria may be present in various
  degrees. Recognised categories of endemicity
  include
• A. Hypoendemicity - little transmission and
  the disease has little effect on the population.
• B. Mesoendemicity - varying intensity of
  transmission typically found in the small, rural
  communities of the sub-tropics.
• C. Hyperendemicity - intense but seasonal
  transmission immunity is insufficient to prevent
  the effects of malaria on all age groups.
• D. Holoendemicity - intense transmission
  occurs throughout the year. As people are
  continuously exposed to malaria parasites, they
  gradually develop immunity to the disease. In
  these areas, severe malaria is mainly a disease
  of children from the first few months of life to
  age 5 years. Pregnant women are also highly
  susceptible because the natural immune defence
  mechanisms are impaired during pregnancy.
• Depending on the intensity of transmission,
  malaria can be stable or unstable, reflecting
  different epidemic scenarios.
• Stable malaria Sustained incidence over
  several years. Seasonal fluctuations in
  transmission may occur but epidemics are
  unlikely.
• Unstable malaria- Marked variations in the
  incidence of malaria over time. Population does
  not develop immunity and people of all ages are
  susceptible to severe disease when transmission
  increases.

8
End of Section 1

• Well done!
• You have come to the end of the first section.

,

• We suggest that you answer Question 1 to assess
  your learning so far. Please remember to write
  your answers on the mark sheet before looking at
  the correct answers!

Click to Reveal Answers
9
Question 1Write T or F on the answer sheet.
When you have completed all 5 questions, click on
the box and mark your answers.
Click for the correct answer

• P. ovale occurs mainly in West Africa
• P. falciparum is the most important species of
  malaria
• The largest burden of malaria occurs in South
  East Asia
• Malaria epidemics are likely to occur in a
  holoendemic area
• e) Environmental factors which affect mosquito
  breeding are closely related to the intensity of
  malaria transmission

a
b
c
d
e
10
How is malaria transmitted?

• Malaria parasites are transmitted from one person
  to another by the bite of a female anopheles
  mosquito.
• The female mosquito bites during dusk and dawn
  and needs a blood meal to feed her eggs.
• Male mosquitoes do not transmit malaria as they
  feed on plant juices and not blood.
• There are about 380 species of anopheles mosquito
  but only about 60 are able to transmit malaria.
• Like all mosquitoes, anopheles breed in water -
  hence accumulation of water favours the spread of
  the disease.

Female Anopheles mosquito taking a blood
meal Sourcehttp//phil.cdc.gov/phil/quicksearch.
asp
11
How does infection develop ?

• Plasmodium infects the human and insect host
  alternatively and several phases of the parasite
  life cycle are described.
• During feeding, saliva from the mosquito is
  injected into the human blood stream. If the
  mosquito is carrying malaria, the saliva contains
  primitive stages of malaria parasites called
  sporozoites.
• Hepatic, tissue or pre-erythrocytic phase
  Sporozoites invade and develop in liver cells.
  The infected hepatocyte ruptures to release
  merozoites.
• Erythrocytic phase Merozoites then invade red
  blood cells. The red cells lyse and this causes
  bouts of fever and the other symptoms of the
  disease. This cycle repeats as merozoites invade
  other red cells.
• Sexual phase Sexual forms of the parasites
  develop and are ingested when another female
  anopheles mosquito feeds. These develop into
  sporozoites in the gut of the insect host and
  travel to its salivary glands. Then the cycle
  starts again
• The life cycle of the malaria parasite is shown
  on the next slide

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The Malaria Parasite Life Cycle
Click on the diagram to explore different areas
of the life cycle
Show Me
13
The Malaria Parasite Life Cycle
Back
14
The Malaria Parasite Life Cycle
1. Transmission Female anopheles mosquito bites
and releases sporozoites into the blood stream.
These circulate for about 30 mins and then invade
the liver.
15
The Malaria Parasite Life Cycle
2. Pre-erythrocytic phase Also called the
tissue or hepatic phase Takes place in
hepatocytes. The sporozoites mature into
schizonts which rupture to release merozoites.
Duration of this phase depends on the species.
In P. vivax and P. ovale, the schizont may also
differentiate into hypnozoites. These are dormant
forms of the parasite which may remain in the
liver for several months or years and cause
relapse in the human host.
16
The Malaria Parasite Life Cycle
3a. Asexual phase (Erythrocytic
schizogony) Merozoites invade red blood cells.
Here they grow and mature into trophozoites which
appear as ring forms. The trophozoites develop
into schizonts. The infected red blood cells then
rupture to release numerous merozoites from the
schizont to infect other red cells. Merozoite
release results in fever, chills, rigours and
other symptoms of malaria infection.
17
The Malaria Parasite Life Cycle
3b. Sexual phase Some merozoites differentiate
into male and female gametocytes, the forms of
Plasmodia infective to mosquitoes. These are
taken up by a mosquito during another blood meal.
These fuse to form an ookinette in the gut lumen
of the mosquito. The ookinette invades the
stomach wall to form the oocyst. This in turn
develops and releases sporozoites which migrate
to the salivary gland of the mosquito. This
mosquito then goes on to infect another human
host.
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Severity of disease and host factors

• In addition to parasite factors, several host
  factors determine the outcome of exposure to
  malaria
• Naturally-acquired immunity. People who are
  constantly exposed to malaria gradually acquire
  immunity, firstly against clinical disease and
  later against parasite infection. Clinical
  manifestations of malaria are most severe in the
  non-immune. In holoendemic areas, these are
  children aged (especially primagravidae). People of any age
  from areas that are free from malaria, or have
  limited malaria transmission, are at risk when
  they are exposed to malaria.
• Red cell and haemoglobin variants. Well known
  examples of inherited factors that protect
  against malaria are Haemoglobin S carrier state,
  the thalassaemias and Glucose-6-phosphate
  dehydrogenase (G6PD) deficiency. Malaria provides
  the best known example whereby an environmental
  factor (malaria) has selected human genes because
  of their survival advantage.
• Foetal haemoglobin (HbF) High levels of HbF
  occur in neonates, and in some people with
  inherited haemoglobin variants, protect against
  severe forms of P. falciparum malaria.
• Duffy blood group P. vivax requires the Duffy
  blood receptor to enter red blood cells.
  Therefore, people who do not carry the Duffy
  blood group are resistant to this malaria
  species. This explains the rarity of P. vivax in
  Africa, as most Africans are Duffy blood group
  negative.

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End of Section 2

• Well done!
• This is the end of the second section.

• We suggest that you proceed to answer questions 2
  and 3 to assess your learning further. Do
  remember to write your answers on the mark sheet
  before looking at the right answer!

20
Question 2 Parasite factors and disease
severity. Study the table below. Write down on
your answer sheet 2 features of the biology of P.
falciparum which contribute to it being
responsible for nearly all severe malaria. Then
click on the box and mark your answers.
Click here for the answers
Incubation period is the number of days from
exposure (injection of sporozoites) to the onset
of clinical symptoms.
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Question 3 The following people are at risk of
severe malariaWrite T or F on the answer
sheet. When you have completed all 7 questions,
click on the box and mark your answers.
Click for the correct answer
a

• Pregnant women
• Neonates
• Immigrants from Europe
• A 20 year old man who has lived all of his life
  in Nigeria
• A 3 year old girl resident in an area holoendemic
  for malaria
• A 10 year old child with sickle cell disease
• A 3 year old boy with Duffy negative blood group

b
c
d
e
f
g
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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
• Asymptomatic parasitaemia (clinical immunity)
• Acute, uncomplicated malaria
• Severe malaria

23
A. Asymptomatic parasitaemia
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.
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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.
25
The periodicity of malaria fever

• Erythrocytic schizogony is the time taken for
  trophozoites to mature into merozoites before
  release when the cell ruptures.
• It is shortest in P. falciparum (36 hours),
  intermediate in P. vivax and P. ovale (48 hours)
  and longest in P. malariae (76 hours).
• Typical paroxysms thus occur every
• 2nd day or more frequently in P. falciparum
  (sub-tertian malaria)
• 3rd day in P. vivax and P. ovale (tertian
  malaria)
• 4th day in P. malariae infections, (quartan
  malaria)

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.
26
Other features of simple, uncomplicated malaria
include

• Vomiting
• Diarrhoea more commonly seen in young children
  and, when vomiting also occurs, may be
  misdiagnosed as viral gastroenteritis
• Convulsions commonly seen in young children.
  Malaria is the leading cause of convulsions with
  fever in African children.
• Pallor resulting mainly from the lysis of red
  blood cells. Malaria also reduces the synthesis
  of red blood cells in the bone marrow.
• Jaundice mainly due to haemolysis.
• Malaria is a multisystem disease. Other common
  clinical features are
• Anorexia
• Cough
• Headache
• Malaise
• Muscle aches
• Splenomegaly
• Tender hepatomegaly
• These clinical features occur in mild malaria.
  However, the infection requires urgent diagnosis
  and management to prevent progression to severe
  disease.

27
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

• Acute renal failure
• Pulmonary oedema
• Circulatory collapse, shock or algid malaria
• Blackwater fever

• Cerebral malaria
• Severe malaria anaemia
• Hypoglycaemia
• Metabolic acidosis

Note It is common for an individual patient to
have more than one severe manifestation of
malaria!
28
Summary of differences in the clinical features
of severe malaria in adults and children
Frequency of occurrence
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End of Section 3

• You have made tremendous progress!
• This is the end of the third section.

• You should now be able to answer Question 4 to
  assess what you have learnt. You are to remember
  to write your answers on the mark sheet before
  looking at the right answer!

30
Question 4 Clinical malariaWrite T or F on
the answer sheet. When you have completed all 7
questions, click on the box and mark your
answers.
Click for the correct answer

• Asymptomatic parasitaemia signifies acquired
  immunity to malaria
• Symptoms typically occur during the hepatic phase
  of infection
• Young children with mild malaria require urgent
  assessment and treatment
• A single convulsion signifies severe disease
• The clinical signs of acidosis are rapid
  respirations with deep breathing
• Acute renal failure occurs in older children and
  adults
• A patient with malaria and dark urine is unlikely
  to be anaemic

a
b
c
d
e
f
g
31
Diagnosis

• Malaria is a multisystem disease. It presents
  with a wide variety of non-specific clinical
  features there are no pathognomonic symptoms or
  signs. Many patients have fever, general aches
  and pains and malaise and are initially
  misdiagnosed as having flu.
• P. falciparum malaria can be rapidly progressive
  and fatal. Prompt diagnosis saves lives and
  relies on astute clinical assessment
• A good history
• Residence or a recent visit (in the preceding 3
  months) to a malaria endemic area
• History of fever (may be paroxysmal in nature)
• Recognise significance of non-specific clinical
  features such as vomiting, diarrhoea, headache,
  malaise
• Physical examination
• Identify signs consistent with malaria fever,
  pallor, jaundice, splenomegaly
• Exclude other possible causes of fever (e.g.
  signs of viral and bacterial infections)
• The diagnosis of malaria should be considered in
  any unwell person who has been in a malarious
  area recently

32
Investigations
Blood Film Examination Thick and thin blood
films (or smears) have remained the gold
standard for the diagnosis of malaria. The films
are stained and examined by microscopy. Thick
blood film - Used for detecting malaria a
larger volume of blood is examined allowing
detection of even low levels of parasitaemia.
Also used for determining parasite density and
monitoring the response to treatment. Thin blood
film Gives more information about the parasite
morphology and, therefore, is used to identify
the particular infecting species of Plasmodium.
Show Me
Source- SOM 208 Microbiology Syllabus
Show Me
33
Thick blood film

• A drop of blood is spread over a small area.
  When dry, the slide is stained with Fields or
  Giemsa stains. The red cells lyse leaving behind
  the parasites.
• Used to detect parasites, even if parasitaemia is
  low
• Less useful for speciation

Back
34

• A small drop of blood is spread across a
  microscope slide, fixed in methanol and stained
  with Giemsa stain.
• The microscopist finds the area of the film where
  red cells are lying next to each other. The fine
  details of the parasites can be examined to
  determine the species.
• Used for speciation
• Does not detect low parasitaemia

Thin blood film
Back
35
Appearance of P. falciparum in thin blood films
Ring forms or trophozoites many red cells
infected some with more than one parasite
Gametocytes (sexual stages) After a blood meal,
these forms will develop in the mosquito gut
http//phil.cdc.gov/phil/quicksearch.asp
36
Other methods of diagnosis of malaria

• These are not routinely used in clinical
  practice. They include
• 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.
• 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.
• Fluorescent techniques. Relatively low
  specificity and sensitivity. Cannot identify the
  parasite species. Expensive and requires skilled
  personnel.
• Serologic tests. Based on immunofluorescence
  detection of antibodies against Plasmodium
  species. Useful for epidemiologic and not
  diagnostic purposes.

37
Treatment

• The treatment of malaria depends on a number of
  factors which include
• severity of the infection whether simple,
  uncomplicated or severe, complicated malaria.
• parasite factors species, drug sensitivity
  (usually inferred from the known sensitivity
  pattern in the geographical location where the
  infection was acquired)
• patient factors age, pregnancy, prior
  chemoprophylaxis, known allergies, likelihood of
  drug compliance.
• In the absence of reliable diagnosis, clinical
  assessment alone can not differentiate malaria
  from other common febrile illnesses. Therefore,
  in this situation, anti-malarial treatment should
  be given routinely for people with fever.

38
Treatment of simple, uncomplicated malaria
single agents

• 4-aminoquinolines Chloroquine, Amodiaquine.
• Chloroquine is cheap and widely available and has
  been the most widely used antimalarial drug. It
  is a blood schizonticide - it kills the
  erythrocyte stages but has no effect on the
  exo-erythrocytic (liver) stages or gametocytes.
  Use is now severely limited because of widespread
  resistance of P. falciparum to chloroquine in
  South East Asia, East Africa and other parts of
  Africa. Most cases of P. vivax are still
  sensitive to chloroquine, although resistance is
  emerging.
• Amodiaquine is an alternative for
  chloroquine-resistant falciparum malaria.
• Sulphadoxine/pyrimethamine Fansidar has
  replaced choloroquine as first line treatment for
  P. falciparum malaria in many countries, although
  resistance to this drug has also developed
  rapidly
• Mefloquine useful in areas of chloroquine
  resistance. Blood schizonticide. Use limited by
  adverse effects, especially neuropsychiatric
  disturbances.
• Artemisinins artemether, artesunate, artheether
  based on the Chinese herb quinhaosu. Rapidly
  acting and effective against gametocytes as well
  as erythrocytic stages (therefore, may reduce
  transmission).
• Halofantrine Useful in cases of multi-drug
  resistant malaria. Blood schizonticide. May cause
  cardiac arrhythmias and sudden death.
• 8- aminoquinolines Primaquine is active against
  the exo-erythrocytic forms of P. vivax and P.
  ovale. Primaquine is usually added to the
  treatment to prevent relapses.

39
Treatment of simple, uncomplicated malaria drug
combinations

• The rapid emergence of resistance to drugs when
  used as single agents has led to the development
  of drug combinations for first-line treatment.
• Because of rapid action and current low levels of
  resistance, many drug combinations include an
  artemisinin derivative. Examples include
• Artemether lumefantrine
• Artesunate mefloquine
• Non-artemisinin combinations include
• Chlorproguanil dapsone (Lapdap)
• Atovaquone Proguanil (Malarone)
• The choice of which combination to use depends on
  many factors, including the existing pattern of
  resistance and cost.

40
Treatment of severe, complicated malaria

• Quinine is the most widely used drug. It is
  administered by rate-controlled intravenous
  infusion. Where this is not possible, it can be
  administered by deep intramuscular injection.
  This is less desirable because of slow and
  uncertain absorption and risks such as injection
  abscess and muscle necrosis.
• Artemisinin derivatives are also used to treat
  severe malaria.
• Supportive therapy is a vital adjunct to clinical
  management. It includes the general care of the
  unconscious patient, careful fluid balance,
  control of seizures, nasogastric tube feeding,
  correction of metabolic derrangements (e.g.
  hypoglycaemia, metabolic acidosis) and blood
  transfusion for severe anaemia. Bacterial
  infection can also co-exist with severe malaria
  and require antibiotic treatment.

41
Malaria prevention and control- 1
Reducing man-mosquito contact Insecticide-treated
nets (ITNs) are relatively cheap and, if used
correctly, an effective means of preventing
malaria. The development of longlasting nets may
help to overcome the requirement to re-treat nets
with insecticide regularly. The major difficulty
remains achieving high coverage rates of ITNs in
the most at-risk populations. Historically,
indoor house-spraying with residual insecticides
(e.g. DDT) achieved many successes but was not
sustainable. However, some countries still use
this approach as part of their public health
measures against malaria. Other means to reduce
contact for individuals are wearing of protective
clothing and insect repellents at dawn and dusk.
Families are advised to prioritise the use of bed
nets for children under 5 years and pregnant
women the family members at most risk of
developing severe malaria.
42
Malaria prevention and control- 2

• Chemoprophylaxis - the administration of drugs to
  individuals likely to be exposed to malaria.
• Indicated in travellers and also pregnant women
  and people with sickle cell disease living in
  malaria endemic areas
• Effective malaria prophylaxis is challenging
  because of cost, drug resistance and adverse
  effects.
• The recommendations vary according to likely
  parasite resistance and patient characteristics
  (e.g. age, breastfeeding, pregnancy).
• Commonly-used drugs include chloroquine and
  proguanil, mefloquine and malarone.

43
Malaria prevention and control- 3

• Vaccines against P. falciparum
• Research is progressing rapidly with some recent
  successes. Vaccine development has targeted
  different stages of the parasite life cycle
• Pre-erythrocytic aimed to either prevent
  sporozoite invasion of hepatocytes or to kill
  infected hepatocytes
• Blood-stage mainly focussed on antigens involved
  in parasite invasion of red cells
• Transmission-blocking aimed at preventing
  mosquito infection during blood feeding
• Other approaches include inducing T-cell immunity
  by using different preparations of an antigen in
  a prime-boost strategy and whole-organism
  vaccines.
• The most advanced vaccine to date combines a
  circumsporozoite protein with hepatitis-B surface
  antigen (RTS,S/AS02A pre-erthrocytic) and has
  been shown to provide some degree of protection
  in recent trails of both adults and children.

44
Malaria in pregnancy

• More than 45 million women (30 million inAfrica)
  become pregnant in malaria endemic areas each
  year.
• Common adverse effects of malaria in pregnancy
  include
• Maternal anaemia
• Stillbirths
• Premature delivery and intrauterine growth
  retardation result in the delivery of low birth
  weight infants
• The WHO now recommends intermittent preventive
  treatment (IPT) the administration of
  anti-malarial drugs (e.g. sulphadoxine-pyrimethami
  ne) during antenatal care whether or not women
  show symptoms. IPT has been shown to
  substantially reduce the risk of maternal anaemia
  in the mother and low birth weight in the
  newborn.
• Previously, chemoprophylaxis (e.g. with
  chloroquine) was recommended for all women living
  in malaria endemic areas.

Source http//phil.cdc.gov/phil/quicksearch.asp
45
International initiatives

• Many international organisations are involved in
  the fight against malaria.
• The WHO in partnership with UNICEF, UNDP and the
  World Bank initiated Roll Back Malaria (RBM) in
  1998 to promote an effective control strategy to
  combat the disease. The goal of RBM is to halve
  the worlds burden of malaria by 2010. RBM was
  later joined by a broader group of partners
  including governments of countries affected by
  the disease, multi and bilateral agencies, NGOs,
  international private sector representative and
  research groups.
• RBM focuses on
• Rapid clinical case detection and provision of
  prompt access to effective malaria treatment,
  especially in the home.
• Preventing and controlling malaria during
  pregnancy.
• Promoting the use of insecticide treated bed
  nets (ITN) as a means of prevention, especially
  in young children and pregnant women.
• Dealing effectively with malaria in emergency
  and epidemic situations.

Prompt effective malaria treatment saves lives
46
End of Section 4

• You have come a long way!
• This is the last of the sections.

• For the section just ended, you should be able to
  answer Question 5 to assess what you have learnt.
  It is still required that you put down your
  answers on the mark sheet before looking at the
  right answer!

47
Question 5 Malaria diagnosis, prevention and
treatmentWrite T or F on the answer sheet.
When you have completed all 6 questions, click on
the box and mark your answers.
7. Quiz 1
Click for the correct answer

• A well-prepared and stained thick blood film is
  usually the most practical way to diagnose
  malaria
• Chloroquine prophylaxis is recommended during
  pregnancy in East Africa
• More than one anti-malarial drug should be used
  for first-line treatment
• Quinine is the drug of choice for severe malaria
• Poor compliance with antimalarial therapy favours
  the development of resistance
• Insecticide-impregnated bednets are used to
  prevent malaria mainly in travellers

a
b
c
d
e
f
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Sources of information

• Malaria. Greenwood BM, Bojang K, Whitty CJ,
  Targett GA. Review Lancet 2005 3651487-98.
• http//mosquito.who.int/cmc_upload/0/000/015/372/R
  BMInfosheet_1.htm
• These WHO fact sheets developed by the Roll Back
  Malaria Partnership cover many different aspects
  of malaria including prevention with
  insecticide-treated bed nets and treatment with
  atemesinin-based combination therapies
• http//www.cdc.gov/malaria/
• The US Centre for Disease Control and Prevention
  site for malaria
• http//www.malaria.org/
• Follow the Learn about malaria link on the
  Malaria Foundations website. This contains
  numerous useful and accessible resources.
• http//www.rph.wa.gov.au/labs/haem/malaria/
• An interactive resource from the Royal Perth
  Hospital, Western Australia. Contains useful
  self-assessment exercises in malaria diagnosis by
  microscopy that are set in the context of
  clinical cases.

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End of Module

• Well done!
• Now that you have completed the malaria module
  and attempted sectional questions, you may wish
  to take on the full quiz to assess your learning
  for the whole module. Please print out the
  questions
• The questions may differ slightly from those you
  have come across in the sectional assessment but
  are based on the material covered in this module.
• END OF MODULE QUIZ
• You will also find a link to the answers at the
  end of the quiz to measure your performance
• Please attempt this as many times as you wish.