MALARIA

BY:
Nr. FA’IZA TIJJANI TASHI
INTRODUCTION.
Definition: Malaria is a vector-borne disease
caused by a single-celled protozoan
parasite called Plasmodium, and
transmitted by female mosquitoes.
Malaria is a common and life-threatening
disease in many tropical and subtropical
areas and it is currently endemic in 99
countries.
INCUBATION PERIOD.
P. falciparum : 9 to 14 days
P. vivax : 12 to 18 days, but some strains
may have an incubation period of 8 to 10
months or longer
P. ovale : 12 to 18 days
P. malariae : 18 to 40 days
P. knowlesi : 9 to 12 days
EPIDEMIOLOGY.
 Malaria is endemic throughout most of the tropics, ongoing
transmission occurs in 85 countries and territories.
 WHO reported 241 million cases and 627 thousand death
from malaria in 2020, these is an increased from an
estimated 227 million cases and 558 thousand death
recorded in 2019
 With the revised WHO calculation malaria accounts for 7.8%
of the global disease burden
 Over 95% of the burden occurs in the African region of the
WHO, followed by 2% each in the South east Asian and
eastern Mediterranean regions, with America and western
pacific regions contributing the remainder
 Children under 5 accounted for about 80% of all malaria
death in the region
VULNERABILITY/AT RISK
GROUP.
Pregnant women and children under the age of
five are most vulnerable to malaria infections
because they have a lower natural immunity to
the disease compared to others in the community.
Adults can also be affected by malaria, however if
they have lived in the same area for long period
of time they are likely to build up some immunity
to the parasite. This does not mean that they are
not infected but have less severe symptoms.
People who travel from malaria free areas to
malaria endemic areas are also at risk of
contracting the disease.
CAUSES.
The four species of Plasmodium which are
known to cause disease in man are:
Plasmodium vivax
Plasmodium ovale
Plasmodium malariae
Plasmodium falciparum
Plasmodium knowlesi ( its usually found in
primates, it only occasionally affect
humans)
CONT…
Plasmodium vivax: It is the most common
species in the World. It is the largest of the malaria
parasites found in humans. The length of its
asexual cycle is 48 hours. Relapses are common in
vivax malaria due to emergence of new blood
forms from maturing secondary liver schizonts. In
tropical areas, relapses may arise within three to
four months of primary attack, while in subtropical
areas relapses occur only after nine months or
more. However, it has been estimated that more
people worldwide live at risk from Plasmodium
vivax than Plasmodium falciparum and as a result
suffer increased morbidity from Plasmodium vivax.
CONT…
Plasmodium ovale: It is a relatively a rare
species with a frequency of less than 5%. It
may sometimes be confused with P. vivax.
The length of its asexual cycle is 48 hours.
Relapses occur as in P. vivax but the
disease tends to be more chronic.
Plasmodium malariae: It is a less
common species whose length of its
asexual cycle is 72 hours. P. malariae is
associated with quartan malaria.
CONT…
 Plasmodium falciparum: It is the commonest species in
Africa and it accounts for 95 - 98% of all malaria infections. It is
responsible for severe illness, cerebral malaria and other
complications and may cause death. The length of asexual
cycle is about 48 hours. Fever is produced when the schizonts
are mature i.e. at 48 hours interval. Sub-tertian means that
diurnal periodicity is common. The liver stage of development
take about 14 days. In our environment, you may have noticed
that many malaria laboratory tests report the presence of P.
falciparum. This is because it is the most common cause of
malaria in our environment. Indeed in Africa, Plasmodium
falciparum is the most common type of malaria parasite
transmitted in Africa, south of the Sahara, accounting in large
part for the extremely high mortality in this region. Plasmodium
falciparum, the dominant species in Africa, is the deadliest and
is responsible for approximately 90% of malaria deaths per
year, (White, 2011).
MALARIA LIFE CYCLE.
 The Malaria parasite lifecycle begins when an infected adult
female Anopheles mosquito bites a human being to feed on
his or her blood. As it feeds on this blood, it releases
sporozoites (which are found in the salivary gland of the
female anopheles mosquito) into the blood stream of the host
(human being). This is the infective bite.
 Once the parasites enter the human blood stream they move
quickly to the liver cells where they develop and multiply
(schizogony) through asexual reproduction.
 The infected liver cells damage and release numerous
merozoites into the blood, which invade red blood cells
(RBCs). This stage takes 9-14 days. Within the RBCs the
parasites develop from “rings” into trophozoites, then to
blood schizonts (but incases of p.ovale and p.vivax few
parasites remains dormant as hypnozoites which can be
reactivated anytime causing a relapse infection).
CONT…
 The schizonts then develop in to new merozoites and
eventually ruptures the RBCs releasing numerous new
merozoites which invade new RBCs. When the infected
red blood cells damage this process initiates the chills
and fever which are characteristic of Malaria.
 Indeed, the peaks of fever experienced during malaria
coincide with the release into blood circulation of malaria
parasites (merozoites) from damage RBCs.
 These process is referred to as erythrocytic
schizogony or erythrocytic asexual reproduction.
 Few of the merozoites will not develop into
trophozoites but, rather they will develop into
gametocytes which is not going to be released by the
RBC until they are taken up by another feeding mosquito.
CONT…
The mosquito that take up the gametocyte
is now infected and the gametocyte reach
the gut of the mosquito where it under
goes sexual reproduction.
The fusion of gametocytes result in zygote
formation which will ultimately develop into
an oocyst.
The oocyst will now rupture releasing a
sporozoites that will reside in the
mosquito salivary gland.
PATHOPHYSIOLOGY.
 This is related to haemolytic anaemia (due to
destruction of RBC)
 RBC being destroyed will lead to release of cytokines
 In P. Falciparum, infected RBC adheres to the lining of
capillaries i.e vascular endothelium, obstructing the
vessels and resulting in decreased blood supply to the
organs
 Infected RBC ruptures and releases toxins and more
cytokines inducing the inflammatory response
( leading to fever, rigor), which leads to the wide
spread organ damage and even organ failure including
the brain, kidney, liver, and other organs. Therefore,
most malarial death are due to P. Falciparum infection.
SIGN AND SYMPTOMS.
 Fever
 Chills
 Profuse sweating
 Malaise
 Muscle and joint pain
 Headache
 Confusion
 Nausea
 Loss of appetite
 Diarrhoea
 Abdominal pain
 Cough
 anaemia
MODE OF TRANSMISSION.
The transmission of malaria depends on interaction
of the following factors: Presence of the infective
vector, susceptible human host and suitable
environment for complete saprogenic cycle.
 Malaria is transmitted by the female Anopheles
mosquito which requires blood for the development
of its eggs. These eggs are laid on stagnant water or
slow flowing water where they stay for 2-3 days
before they hatch to release mosquito larvae. The
larvae grow beneath the water surface and become
pupa. After a few days the pupa develops into adult
mosquitoes and flies away.
CONT…
The development of mosquitoes from egg to
larvae to adults takes 7-14 days at a temperature
of 31 or 20 days at 20oC. The sporozoites are the
infective stages of malaria parasites in the
mosquito. This process called sporogonic cycle
takes about 10-14days depending on
environmental temperature. When a mosquito
carrying sporozoites bites a person, it passes the
parasites into the blood of that person, thereby
infecting that person with malaria.
Malaria parasites can also be transmitted by
blood transfusions, although this is rare, (Owusu-
Ofori, Parry & Bates, 2010).
CONT…
Only female mosquitoes feed on blood;
male mosquitoes feed on plant nectar and
do not transmit the disease. Females of the
mosquito genus Anopheles prefer to feed at
night. They usually start searching for a
meal at dusk, and continue through the
night until they succeed, (Arrow, Panosian
& Gelband, 2004).
CLASSIFICATION OF MALARIA.
 Malaria is classified into either “Severe or Complicated" or
“Uncomplicated" by the World Health Organisation (WHO). It
is deemed severe when any of the following criteria are
present, otherwise it is considered uncomplicated, (World
Malaria Report, 2017)
 Decreased consciousness ,Significant weakness such that the
person is unable to walk, Inability to feed, Two or more
convulsions, Low blood pressure (less than 70 mmHg in adults
and 50 mmHg in children), Breathing problems, Circulatory
shock, Kidney failure or hemoglobin in the urine, Bleeding
problems, or hemoglobin less than 50 g/L (5 g/dL), Pulmonary
oedema, Blood glucose less than 2.2 mmol/L (40 mg/dL),
Acidosis or lactate levels of greater than 5 mmol/L, A parasite
level in the blood of greater than 100,000 per microlitre (µL) in
low-intensity transmission areas, or 250,000 per µL in high-
intensity transmission areas
CONT…
Cerebral malaria is defined as a severe P.
falciparum-malaria presenting with
neurological symptoms, including coma
(with a Glasgow coma scale less than 11, or
a Blantyre coma scale less than 3), or with
a coma that lasts longer than 30 minutes
after a seizure (World Malaria Report, 2017)
CONT…
UNCOMPLICATED MALARIA
The classical but rarely observed malaria
attacks last 6-10 hours and it consist of
A cold stage (sensation of cold, shivering)
A hot stage (fever, headache, vomiting)
Finally a sweating stage (sweat returns to
normal temperature, tiredness)
DIAGNOSTIC PROCEDURES.
Blood microscopy ( widely considered the
gold standard for laboratory confirmation of
malaria)
Rapid diagnostic tests (RDTs) : these test
can provide results quickly but they may
not be as accurate as microscopic diagnosis
Molecular diagnosis : this process involves
using polymerase chain reaction (PCR)
tests to detect parasite nucleic acid and
diagnose the species of malaria. The result
usually takes long time
MANAGEMENT.
 NURSING MANAGEMENT
 Monitor vital signs
 Record and observe input and output
 Monitor therapeutic response
 Tepid sponging
 Rehydration
 Patient and family education
 When using chloroquine for management you need to
perform baseline and periodic ophthalmic examination
 Serve primaquine and pyrimethamine with meals to prevent
GI discomfort
 Encourage bed rest
 If a patient is in coma, change position frequently and
perform passive range of motion exercise every 3 to 4 hours
CONT…
Emotional support and reassurance
CONT…
 MEDICAL MANAGEMENT.
 UNCOMPLICATED MALARIA
 For P. Falciparum infections acquired in areas with
chloroquine resistance four treatment options are
available, these include;
 Artemether-lumefantrine (coartem), which is
preferred option if readily available.
 Atovaquones-proguanil (malarone)
 Quinine sulphate + doxycycline or tetracycline or
clindamycin
 Mefloquine ; which is in the case of severe
neuropsychiatric reactions. These can be used only
when other above options cannot be used
CONT…
SEVERE MALARIA
All patient with severe malaria regardless
of the infecting specie should be treated
with intravenous artesunate which is given
at 0, 12 and 24 hours at a dose of 2.4mg/kg
(which is applied to both adult and
children).
NURSING DIAGNOSIS.
Activity intolerance
Acute pain
Anxiety
Hyperthermia
Deficient fluid volume
Deficient cardiac output
Impaired gas exchange
Fatigue
PREVENTION AND CONTROL.
Methods used to prevent malaria include
medications, mosquito elimination and the
prevention of bites. The presence of malaria in an
area requires a combination of high human
population density, high anopheles mosquito
population density and high rates of transmission
from humans to mosquitoes and from mosquitoes to
humans. If any of these is lowered sufficiently, the
parasite eventually disappears from that area, as
happened in North America, Europe, and parts of the
Middle East. However, unless the parasite is
eliminated from the whole world, it could re-establish
if conditions revert to a combination that favors the
parasite's reproduce.
CONT…
 Prevention of malaria may be more cost-effective than
treatment of the disease in the long run, but the initial
costs required are out of reach of many of the world's
poorest people. There is a wide difference in the costs of
control (i.e. maintenance of low endemicity) and
elimination programs between countries. For example, in
China—whose government in 2010 announced a strategy
to pursue malaria elimination in the Chinese provinces—
the required investment is a small proportion of public
expenditure on health. In contrast, a similar program in
Tanzania would cost an estimated one-fifth of the public
health budget, (Sabot, Cohen, Hsiang, Kahn, Basu, Tang,
Zheng, Gao, Zou, Tatarsky, Aboobakar, Usas, Barrett,
Cohen, Jamison &Feachem, 2010).
CONT…
 In areas where malaria is common, children under five years
old often have anemia, which is sometimes due to malaria.
Giving children with anemia in these areas preventive
antimalarial medication improves red blood cell levels slightly
but does not affect the risk of death or need for hospitalisation,
(Athuman, Kabanywanyi &Rohwer, 2015).
 Vector control refers to methods used to decrease malaria by
reducing the levels of transmission by mosquitoes. For
individual protection, the most effective insect repellents are
based on DEET or picaridin, (Kajfasz, 2009). Insecticide-treated
mosquito nets (ITNs) and indoor residual spraying (IRS) have
been shown highly effective in preventing malaria among
children in areas where malaria is common, (Tanser, Lengeler&
Sharp, 2010). Prompt treatment of confirmed cases with
artemisinin-based combination therapies (ACTs) may also
reduce transmission, (Palmer, 2012).
CONT…
 Mosquito nets help keep mosquitoes away from people and
reduce infection rates and transmission of malaria. Nets
are not a perfect barrier and are often treated with an
insecticide designed to kill the mosquito before it has time
to find a way past the net. Insecticide-treated nets are
estimated to be twice as effective as untreated nets, and
offer greater than 70% protection compared with no net,
(Miller, Korenromp, Nahlen&Steketee, 2007).
 Indoor residual spraying is the spraying of insecticides on
the walls inside a home. After feeding, many mosquitoes
rest on a nearby surface while digesting the blood meal, so
if the walls of houses have been coated with insecticides,
the resting mosquitoes can be killed before they can bite
another person and transfer the malaria parasite,
(Enayati& Hemingway, 2010).
COMPLICATION.
Organ dysfunction
Cerebral malaria
Hypoglycemia
Metabolic acidosis
Pulmonary oedema
Acute respiratory distress syndrome
Hyperparasitemia
Severe anaemia
DIC
Seizures
THANK YOU FOR LISTENING…………
QUESTIONS!!!