MALARIA

A
Project Report

Submitted to
Faculty Of Pharmacy
BHUPAL NOBLES’ UNIVERSITY,UDAIPUR
B.N. INSTITUTE OF PHARMACEUTICAL
SCIENCES

SESSION – 2023-24

SUPERVISED BY:- SUBMITTED

BY:-
Dr. Chetan Singh Chauhan Nishant Saxena
Asso. Professor, B. PHARM 7’th SEMESTER
Pharmaceutical Analysis Roll No.:- 2149458
BNIPS, Udaipur Enrollment No.:-20/9458
Session – 2023-24
 FORWARDING CERTIFICATE

This is to certify that NISHANT SAXENA student of B.Pharm

Seventh Semester of this college has worked on the project entitled
“MALARIA” under my guidance and supervision.

He has worked hard meticulously and methodically. I wish every

success in future endeavours and recommend that this project work to
be forwarded for evaluation.

I wish every success in his life.

Place: Udaipur Dr. Chetan Singh Chauhan

Date:
 DEDICATED

to

My Beloved Parents

for this uncompromising principles

that guides my life

My Loving Brother and Sister

for always motivating me for all in my life

My Honourable Teachers

for all that I am today and

shall be through my life

And

My Profession
 ACKNOWLEDGEMENT
“Success is the sweetest flower in the garden of hard work”

First of all I would like to thank Dr. Chetan Singh Chauhan, Principal, B.N. Institute Of
Pharmaceutical Sciences, Udaipur for his immense support and encouragement.

I would also like to express my sincere gratitude to my guide Dr. Chetan Singh Chauhan,
B.N. Institute Of Pharmaceutical Sciences, Udaipur for this encouragement, constant
inspiration, creative and constructive criticism, whole hearted support and extending all
the possible help. His expert guidance, advice, timely suggestions, explicit decision and
deep personal interest has been privilege for me. He has been a perennial source of
inspiration for this project.

Words would be limited in expressing my heartful veneration to my Father and Mother

for their emotional support, motivation, inspiration in boosting my moral without which I
have been in vain.

Sky is the limit to express a deep sense of gratitude to all my friends who have made
more interesting that it could have been.

Last but not the least I would like to thank to my entire colleagues for their recent useful
matters, ideas and discussion over the period of time that helped me to broad my
concept to complete this project work.

Place: Udaipur Nishant Saxena

Date:
 CONTENT
Sr. No. Particulars Page No.
Chapter 1 INTRODUCTION 1-12
Defination of malaria 2
Background 3
Causes of malaria 3
Types of malaria 4-8
Symptoms of malaria 9
Risk Factors and Complications of malaria 10-12
Chapter 2 HISTORY 13-15
Chapter 3 EPIDEMIOLOGY 16-21
Epidemiologic measures 17-18
Geography of modern disease burden 18-19
Species-Specefic Epidemiology 20
Cases of malaria in India 21
Chapter 4 PATHOPHYSIOLOGY 22-26
Etiology of malaria 23-24
Malaria Pathogenesis 25-26
Chapter 5 DIAGNOSIS 27-36
Clinical diagnosis of malaria 29
Laboratory diagnosis of malaria 29-33
Molecular Diagnostic Method 34-36
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CHAPTER-1

INTRODUCTION

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 DEFINATION OF MALARIA:-
Malaria is one of the most common infectious diseases and a great public health problem
worldwide, particularly in sub- Saharan Africa, Latin America and South Asia. About
three billion people are at risk of infection in 109 countries. Each year, there are an
estimated 250 million cases of malaria leading to approximately one million deaths,
mostly in children under five years of age. The organism that causes the most dangerous
form of malaria is a microscopic parasite
called Plasmodium falciparum.

Malaria is an ancient and continuously

unmatched parasite cause of human
suffering throughout the world.

Historically, it has crushed societies,

devastated militaries, and hampered
economic growth. It continues to wreak
havoc, targeting and killing the most
vulnerable in our global society.

This parasite is transmitted by mosquito species belonging to the Anopheles genus and
only by females of those species.

The mosquito bite introduces the parasites from the mosquito's saliva into a person's
blood. The parasites travel to the liver where they mature and reproduce. A characteristic
malarial fever has ‘hot', ‘wet', and ‘cold' phases and appears 10 to 15 days after
the mosquito bites.

If not treated properly or if not treated on time malaria can turn into a life threatening
disease or may cause very serious complications in human beings. That it is why it proper
and timely treatment is necessary.

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 Background:-
In 2022 the World Health Organization’s “World Malaria Report” indicated that between
2000-2019 deaths per year from the parasitic disease had declined from 897,000 to
568,000 with overall cases declining from 245 million to 232 million.

Concurrent with the COVID-19 pandemic, malaria’s death toll and case count
unfortunately increased to 619,000 and 247 million in 2021 respectively – 76% of whom
were children and 52% of whom occurred in just 4 countries: Nigeria, the Democratic
Republic of Congo, the Republic of Niger, and the United Republic of Tanzania. [1] The
present-day devastation caused by malaria sadly is nothing new to the world.

 Causes of malaria:-
Malaria is caused when an infectious female anopheles mosquito bites a human being. It
can also be transmitted from pregnant mother to her child.

Malaria is an infectious disease that is caused by plasmodium parasite which infects the
red blood cells and is characterised by fever, body ache, chills and sweating. Of the four
species that cause malaria (Plasmodium vivax, Plasmodium falciparum, Plasmodium
ovale, Plasmodium malariae).

Plasmodium falciparum is the most serious and can cause serious complications. There is
a fifth species in Southeast Asia that can rarely infect humans and cause severe disease,
known as Plasmodium knowlesi.

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 TYPES OF MALARIA:-
Four kinds of malaria parasites infect humans that are:Plasmodium falciparum,
Plasmodium vivax, Plasmodium ovale and Plasmodium malariae.

1. Plasmodium falciparum:-
 Common in Tropical and Sub-tropical parts of Central and South America and
Africa.

 Causes- Malignant Tertian malaria (synonym-Pernicious malaria).

 Quite lethal in nature.

 Prefers to infect young RBCs but can infect RBC of all ages.

 Duration of erythrocytic schizogony- 48 hrs.

 Forms of parasite in peripheral blood-Only ring and

crescents (Gametocytes).

 Incubation period- 12 days.

 Duration of first attack (untreated)- 10-20 days.

 Relapse period- Recrudescence.

 Duration of sporogony in mosquitoes at 25°C- 10-12 days.

 No. of merozoites- 18-24, arranged in grape-like clusters.

 Ring form in RBC – Delicate, small, 1.5 pm. Double chromatin and multiple rings
common. Accole forms found.

 Late Trophozoite-Compact, seldom seen in blood smear.

 Schizont-4-5 pm fills 2/3rds of RBC which is not enlarged.

 Usually not seen in blood smear.

 Gametocytes-Crescentic. Larger than a RBC. Male-9-1 pm.

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 Female-12-14 um.

 Host cell-hardly recognizable. Normal size, Maurer’s dots (large red spots)
sometimes basophilic stippling.

 Malarial pigment-Dark brown or blackish, one or two solid blocks

.
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2. Plasmodium vivax:-
 Synonym-P. multinucleatumP. Hybernans

 Common in Tropical and Sub-tropical regions.

 Prefers to infect on Reticulocytes (young RBCs) .

 Causes - Benign Tertian malaria- relatively less dangerous. Recurs after every
48hrs or 3' day.

 Duration of erythrocytic schizogony-48 hrs

 Forms of parasite in peripheral blood- Trophozoite, Schizonts and Gametocutes.

 Incubation period- 14 days.

 Duration of first attack (untreated)- 18-20vrs.

 Relapse period- 2-5 yrs.

 Duration of sporogony in mosquitoes at 25°C- 9-10days.

 No. of merozoites- 12-24 arranged in irregular grape-like clusters.

 Does not exhibit any drug resistance.

 Ring form in RBC- Large 2.5 um single, prominent chromatin.

 Late Trophozoite- large, irregular with prominent vacuole.

 Actively amoeboid.

 Schizont 9-10 pm, large, fills entire cell

 Gametocutes- spherical or globular.

 Size-much larger than a RBC. Male- 9 um.

 Female-10-11 um

 Host cell-enlarges with Schmuffer's dots. Fine golden brown pigments present.

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 Maximal parasitaemia- 25,000/L.
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3. Plasmodium malariae:-
 Common in Tropical Africa.

 Causes- Benign Quartan malaria- occurring every 72 hrs or 4rth day.

 Prefers to infect old (senile) RBCs.

 Duration of erythrocutic schizogony- 72 hrs.

 Forms of parasite in peripheral blood- Trophozoites, Schizonts and Gametocutes.

 Incubation period- 30 days.

 Duration of first attack (untreated) - 6 months.

 Relapse period- 10-40 yrs.

 Duration of sporogony in mosquitoes at 25°C-25-

28 days.

 No. of merozoites-6-12, daisy head or rosette

pattern.

 Does not exhibit any drug resistance.

 Ring form in RBC-Large 2.5 pm, single, thick, prominent chromatin.

 Late Trophozoite-Band-like, slightly amoeboid.

 Schizont-6-7 um, almost fills a normal sized RBC.

 Gametocytes-Spherical or globular. Size-7 um.

 Host cell-Normal, occasionally Ziemann's stippling.

 Malarial pigment-Dark brown coarse granules.

 Maximal parasitaemia-10,000/ p L.

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4. Plasmodium ovale:-
 Common in West Africa.

 Causes-Benign Tertian malaria (Ovale Tertian malaria-because of its tertian

periodicity and irregular ovale shape of infected RBCs) .

 Prefers to infect Reticulocytes.

 Duration of erythrocytic schizogony-48 hrs.

 Forms of parasite in peripheral blood-Trophozoites, Schizonts and Gametocutes.

 Incubation period-14 days.

 Duration of first attack (untreated)-18-20 days.

 Relapse period-Recrudescence very rare.

 Duration of sporogony in mosquitoes at 25°C-14-16 daus.

 No. of merozoites-6-12, irregularly arranged.

 Does not exhibit any drug resistance.

 Ring form in RBC- Large-2.5 um , single, compact, prominent chromatin.

 Late Trophozoite- compact, coarse pigment, vacuole inconspicuous and not

amoeboid.

 Schizont- 6.2 um, fills ¾ of RBC.

 Gametocytes- Spherical or globular. Size- much larger than RBC, 9 um.

 Host cell- slightly enlarged, Schuffner's dots prominent.

 Malarial pigment- Dark yellowish brown, coarse granules.

 Maximal parasitaemia- 25,000/ MI.

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5. Plasmodium knowlesi:-
Typical incubation period: 9-12 days.

Classic fever periodicity: 24-27 hours

Unique syndromes and mechanisms:

P knowlesi is a simian malaria that has been found to cross into humans in Southeast Asia
– particularly on the island of Borneo. It resembles P falciparum in early erythrocytic
stages and as it matures it resembles P malariae on microscopy; this unfortunately puts the
patient at risk of being diagnosed with a less severe infection. In contrast to P malariae, P
knowlesi infections progress to severe disease at a high rate (~8%); therefore, if a patient
is diagnosed with high parasitemia malaria identified as P malariae by microscopy, it
should be assumed that the patient has a severe P knowlesi infection until
proven otherwise.

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 SYMPTOMS OF MALARIA:-
The malaria fever symptoms usually appear within two weeks (10–14 days) from the
day of infection by a Plasmodium-infected mosquito (malaria vector). The early
symptoms of malaria include a cold, headache, and a high temperature with chills.
Some people, especially those who have previously been infected with malaria, may
experience only minor symptoms.

The following are the malaria fever symptoms:

 Feeling very tired

 Difficulty in breathing

 Nausea and vomiting

 Increased bowel moments

 Cough

 Abdominal pain

 Joint pain

 Bloody urine (dark-coloured)

 Seizures

 Yellow discolouration of eyes and skin (Jaundice)

These are some common malaria symptoms during pregnancy:

 Increase in body temperature

 Headache

 Nausea
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 Vomiting

 Muscle pain
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RISK FACTOR AND COMPLICATIONS OF MALARIA-

 RISK FACTORS:-
The greatest risk factor for developing malaria is to live in or to visit areas where the
disease is common. These include the tropical and subtropical regions of:

 Sub-Saharan Africa

 South and Southeast Asia

 Pacific Islands

 Central America and northern South America

The degree of risk depends on local malaria control, seasonal changes in malaria rates
and the precautions you take to prevent mosquito bites.

Risks of more-severe disease-

 People at increased risk of serious disease include:

 Young children and infants

 Older adults

 Travelers coming from areas with no malaria

 Pregnant women and their unborn children

In many countries with high malaria rates, the problem is worsened by lack of access to
preventive measures, medical care and information.

Immunity can wane-

Residents of a malaria region may be exposed to the disease enough to acquire a partial
immunity, which can lessen the severity of malaria symptoms. However, this partial
immunity can disappear if you move to a place where you're no longer frequently
exposed to the parasite.

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 COMPLICATIONS:-
Malaria can be fatal, particularly when caused by the plasmodium species common in
Africa. The World Health Organization estimates that about 94% of all malaria deaths
occur in Africa — most commonly in children under the age of 5.

Malaria deaths are usually related to one or more serious complications, including:

 Cerebral malaria: If parasite-filled blood cells block small blood vessels to

your brain (cerebral malaria), swelling of your brain or brain damage may occur.
Cerebral malaria may cause seizures and coma.

 Breathing problems: Accumulated fluid in your lungs (pulmonary edema) can

make it difficult to breathe.

 Organ failure: Malaria can damage the kidneys or liver or cause the spleen to
rupture. Any of these conditions can be life-threatening.

 Anemia: Malaria may result in not having enough red blood cells for an
adequate supply of oxygen to your body's tissues (anemia).

 Low blood sugar: Severe forms of malaria can cause low blood sugar
(hypoglycemia), as can quinine — a common medication used to combat
malaria. Very low blood sugar can result in coma or death.

 Malaria may recur: Some varieties of the malaria parasite, which typically
cause milder forms of the disease, can persist for years and cause relapses.

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 Complications of Malaria in Pregnancy:-

Malaria complications in pregnancy include low birth weight (LBW) due to
intrauterine growth restriction, premature labour, or both, which has been linked to
increased infant mortality. In addition to LBW, the following are the complications of
malaria:

 Maternal anaemia

 Miscarriage

 Stillbirths

 Congenital malaria

Pregnant women are particularly vulnerable to malaria's devastating effects on anaemia,

which might lead to the following:

 Congestive heart failure

 Foetal death

 Maternal mortality from haemorrhage during delivery.

Complications of Malaria in Pediatrics:-

Children with pre-existing health conditions, such as anaemia, malnutrition, and
immunocompromised states, have a higher risk of death. Malaria with severe or complex
symptoms includes

 Breathing problems

 Decrease in blood sugar levels

 Increase aminotransferases levels

 Severe anaemia (less than 5mg/dL)

 Increase parasitaemia (more than 5%–10% infected erythrocytes).

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CHAPTER-2

HISTORY

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HISTORY OF MALARIA:-
Implications on civilization include the following:

Malaria has affected the development of human civilization for millennia. Likely accounts
of the disease have been found in most developed ancient societies such as Mesopotamia,
India, China, Egypt, Greece, and Rome; these accounts have been covered extensively by
both modern popular and scientific writings. Malaria even has been postulated to have
protected against invaders while simultaneously accelerating the demise of ancient Rome
via its presence in the Pontine Marshes. The presence of Plasmodium falciparum on the
Apennine peninsula may have led to the many reports of outbreaks of deadly fevers
between the 1 st and 2 nd centuries AD.

The efficient Anopheles mosquito vector enabled malaria to suppress economic

productivity and development in the subtropical regions around the globe, especially
within sub-Saharan Africa. Plasmodium falciparum’s deadly course
repelled European traders for centuries and was powerful and persistent
enough to potentially select for different genetic profiles such as “sickle-
cell trait” in African natives.

At the turn of the 20 th century, Colonel William Gorgas and the United
States military led the charge in malaria prevention, proving efficacy of
environmental vector control for the Panama Canal Commission. Through
swamp drainage, oil spraying, employing “mosquito swatters,” installing
screens in living quarters, and instituting the use of anti-malarial prophylaxis with quinine,
malaria case incidence was reduced from 800 per 1,000 workers to 16 per 1,000 in a
matter of 3 years. Malaria eventually was eradicated from the United States in 1951, yet
the Anopheles vector persists. Granting that treatment advanced over the first half of the
century, malaria has continued to wreak havoc on a global scale. It exposed itself in the
Second World War as the US Navy and Marine Corps alone suffered over 100,000 cases
and 3.3 million “sick-days” due to malaria. Most intensely, in the South Pacific on the
island of Guadalcanal there was an astonishing case incidence of 1,781 per 1,000 per year
in November 1942 amongst US and Allied forces. Lower incidence rates and case
numbers occurred in the Korean and Vietnam conflicts; however, malaria remains a major
issue for forward deployed forces globally, with many modern cases requiring
telemedicine consultation from infectious disease specialists in the states.

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 Discovery-
The following were significant in the discovery of
malaria:

In 1880, while stationed in Algeria, the French Army

physician Charles Louis Alphonse Laveran discovered the
protozoal cause of malaria using a microscope with dry
objective at 400x magnification. [9] As this discovery
refuted the miasma theory as well as the leading germ
theory of the time that espoused a bacterial cause of the
disease, it took the better part of a decade to convince other
leading researchers in the field that a protozoa was the
pathogenic agent. In 1907, Laveran received the Nobel prize
in medicine for his discoveries.

Using the English Army physician Ronald Ross’ work with avian
malaria as a foundation, a series of Italian physician scientists -
notably Giovanni Grassi, Amico Bignami, and Giuseppe
Bastianelli incriminated the Anopheles mosquito as the vector for
human malaria and further elucidated the protozoan’s life cycle.

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CHAPTER-3

Epidemiology

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As per the WHO, as of 2021 malaria was endemic in 84 countries, placing nearly half the
world’s population at risk of contracting the disease. Modern US travelers acquire almost
90% of malaria by traveling to Africa; almost 9% of the disease is acquired in Asia,
whereas South and Central America/ the Caribbean make up the remainder. In these
patients, there is a 14% risk for severe disease, and 13% of the cases initially are
misdiagnosed.

Epidemiologic measures-
 Entomologic inoculation rate: sporozoite-positive mosquito bites per unit time
 Annual parasite incidence: number of new parasite-confirmed cases per 1000
population
 Spleen rate: proportion of individuals of a given age with enlarged spleens

Transmission-
 The female Anopheles mosquito requires the protein from a blood meal to produce its
eggs. This genus serves as the vector for human malaria; there are more than 400
species of Anopheles. However, only 40 species of Anopheles transmit malaria to
humans.Varying amongst species-specific preferences, the mosquitos lay their eggs in
water ranging from large open bodies such as ponds to much smaller collections like
puddles from footprints. The eggs hatch into larvae, then molt several times to become
pupal stages of adults. When protein for egg production is required, the adult female is
attracted to many chemical indicators of human activity: CO 2, lactic acid, odors, and
moisture. Typically, they feed at night or in the late evening or early morning, and
after feeding, the mosquitos display different preferences in where and how long they
rest before biting again. All these differences in species-specific preferences are of
importance when it comes to vector control.
 Transmission intensity typically is measured by parasite incidence. The varying
degrees are characterized as follows:
o High transmission: >450 cases per 1,000 people annually and P
falciparum prevalence >35%
o Moderate transmission: 250-450 cases per 1,000 people annually and P
falciparum/ vivax prevalence 10-35%
o Low transmission: 100-250 cases per 1,000 people annually and P falciparum/
vivax prevalence 1-10%
o Very low transmission: < 100 cases per 1,000 people annually and P falciparum/
vivax prevalence 0-1%
 Epidemiology of clinical cases is affected by the background of acquired protective
immunity to the parasite. In areas with continuously moderate to high transmission,
repeated exposure to the parasite reduces the risk of adolescents and adults contracting
severe disease. If environmental control measures effectively limit transmission in a
given area, the population’s acquired immunity decreases over time; this necessitates
sustainment of the transmission-control efforts to prevent a subsequent increased risk
for epidemic severe malaria. The same premise applies to previously immune people
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 who have traveled away from the endemic for an extended period of time (ie, 1 year or
more).
Geography of modern disease burden
 Several geographic traits influence transmission levels and burden of disease: altitude,
humidity, annual rainfall, proximity to bodies of water, land use, and temperature.
The maps below were generated using data obtained from the WHO 2022 World Malaria
Report.

North America-
North American Presumed and Confirmed Malaria Cases 2021.
Gray indicates that there were either no data available or there
were zero endemic cases. Map created using data adapted from
WHO 2022 World Malaria Report

South America-
South American Presumed and Confirmed Malaria Cases
2021. Gray indicates that there were either no data
available or there were zero endemic cases. Map created
using data adapted from WHO 2022 World Malaria Report

Europe-
Per the WHO 2022 World Malaria Report, no 2021 case data exists for the European
region. Malaria was eradicated from Europe in the 1970s through insecticide spraying,
drug therapy, and environmental engineering; however, climatic conditions are becoming
more conducive to malaria transmission and the large influx of migrant populations may
serve as an adequate parasite reservoir.

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Africa-
African Presumed and Confirmed Malaria Cases 2021.
Gray indicates that there were either no data available or
there were zero endemic cases. Map created using data
adapted from WHO 2022 World Malaria Report
[https://www.who.int/teams/global-malaria-programme/reports/world-malaria-report-
2022].

Asia & South Pacific-

Asian and Oceanic Presumed and Confirmed Malaria
Cases 2021. Gray indicates that there were either no data
available or there were zero endemic cases. Map created
using data adapted from WHO 2022 World Malaria Report

South Pacific Presumed and Confirmed Malaria Cases

2021. Gray indicates that there were either no data
available or there were zero endemic cases. Map created
using data adapted from WHO 2022 World Malaria
Report.

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Species-Specific Epidemiology-
P falciparum and vivax are the most common species of malaria that cause disease in
humans – see the map below for proportional comparison of the cases caused by the 2
species from 2021.
 Americas – P vivax (76%), P falciparum & mixed (24%)
 Eastern Mediterranean – P vivax (24%), P falciparum & mixed (74%), other (2%)
 South-East Asia – P vivax (44%), P falciparum & mixed (55%), other (1%)
 Western Pacific – P vivax (32%), P falciparum & mixed (68%)
 High transmission countries in East & Southern Africa – P vivax (< 1%), P
falciparum (>99%)
 Low transmission countries in East & Southern Africa – P vivax (8%), P falciparum &
mixed (92%)
 Central Africa – P falciparum (100%)
 West Africa – P falciparum (>99%), other (< 1%)
 P vivax infects reticulocytes preferentially via the Duffy antigen present on red blood
cells.Incidentally, most Africans are Duffy-negative, and there is a low prevalence
of P vivax on that continent. Note that Ethiopia, India, Indonesia, and Pakistan account
for more than 75% of all P vivax cases. As previously mentioned, P ovale is endemic
to West Africa, and P knowlesi has been identified in South-East Asia. P malariae is
found throughout the tropics; however, most cases seen in US travelers are mixed
infections in returning travelers from Africa.

Global P falciparum to P vivax Case Ratios

2021. Gray indicates that there were either no
data available or there were zero endemic
cases. Red indicates higher proportion of P
vivax cases, whereas blue indicates higher
proportion of P falciparum cases. Map created
using data adapted from WHO 2022 World Malaria Report.

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Cases Of Malaria In India:-

Year Total cases of P. falciparum cases No. of deaths in

malaria (in million) (in million) India
2022 0.045 0.07 50
2021 0.16 0.10 90
2020 0.19 0.12 93
2019 0.34 0.16 77
2018 0.44 0.21 96
2017 0.84 0.53 194
2016 1.09 0.71 331
2015 1.17 0.78 384
2014 1.10 0.72 562
2012 0.88 0.46 440
2011 1.06 0.53 519
2010 1.31 0.67 754
2009 1.60 0.83 1018
2008 1.56 0.84 1144
2007 1.53 0.77 1055
2006 1.51 0.74 1311
2005 1.79 0.84 1707
2004 1.82 0.81 963
2003 1.92 0.89 949
2002 1.87 0.86 1006
2002 1.84 0.90 973
2001 2.09 1.01 1005
2000 2.03 1.05 932
1999 2.28 1.14 1048
1998 2.22 1.03 664
1997 2.66 1.01 879
1996 3.04 1.18 1010
1995 2.93 1.14 1151

The case load, though steady around 2 million cases annually in the late nineties, has
shown a declining trend since 2002.

The reported Pf cases declined from 1.14 million in 1995 to 0.07 million cases in 2022.
The Pf % has gradually increased from 39% in 1995 to 64.84% in 2020.

Number of reported deaths has been levelling around 1000 per year. The mortality peak in
2006 was related to severe malaria epidemics affecting Assam caused by population
movements.
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CHAPTER-4

PATHOPHYSIOLOGY

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All the manifestations of malarial illness are caused by the infection of the red blood cells
by the asexual forms of the malaria parasite and the involvement of the red cells makes
malaria a potentially multisystem disease, as every organ of the body is reached by the
blood.All types of malaria manifest with common symptoms such as fever, some patients
may progress into severe malaria. Although severe malaria is more often seen in cases
of P. falciparum infection, complications and even deaths have been reported in non-
falciparum malaria as well.

 Etiology of Malaria:-
There are 4 common Plasmodium species of concern to humans. There is
a fifth in Southeast Asia that rarely can infect humans and cause severe
disease, Plasmodium knowlesi; however, this species typically causes
simian malaria. The overwhelming majority of worldwide morbidity from
malaria is caused by P falciparum and to a lesser degree, P vivax.

Life cycle:-

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Stages of Infection-

Infection-
Infection occurs during the mosquito’s blood meal as the female Anopheles inserts her
proboscis into human skin and injects up to 100 sporozoites (sporo- meaning “spores,” -
zoite meaning “animal”) per bite with her saliva, each of them gliding at speeds up to 2
micrometers per second. After waiting 1 to 3 hours in the dermis, the successful
sporozoites reach the bloodstream and are swiftly carried off through the blood to the
liver, where they must cross the sinusoidal barrier to access and invade their target
hepatocytes.

Exoerythrocytic Schizogeny – “Liver Stage”-

Once they have transitioned from migratory to invasive phenotypes, the sporozoites
mature into spherical multinuclear schizonts (schiz- meaning “divided,” -ont meaning
“type”). After 5-21 days depending on species, each liver schizont ruptures into 2,000 to
40,000 uninucleate merozoites (mero- meaning “part,” -zoite meaning “animal”).

Erythrocytic Schizogeny - “Blood Stage”-

At this point, each merozoite may infect a red blood cell; differences between the species
at specific stages are noted below. The parasites begin to feed off hemoglobin within the
erythrocytes, with the parasites first appearing as ring forms, then forming trophozoites
(tropho- meaning “nourishment,” -zoite meaning “animal”). Hemozoin is the brown
pigment biocrystal waste product generated from the parasite’s hemoglobin meal; this
results in safe disposal of the free-radical-generating heme molecule that otherwise would
be toxic to the Plasmodium. Trophozoites again mature into schizonts, which rupture into
merozoites, thus continuing the erythrocytic or “blood” stage. Some trophozoites mature
into sexual stage gametocytes rather than schizonts. These male and female gametocytes
then may be ingested by another feeding Anophelese mosquito.

Sporogony - “Mosquito Stage”-

Male and female gametocytes ingested by a mosquito undergo sexual reproduction in
the gut of the mosquito, producing motile ookinetes (oo- meaning “egg,” -kinete
meaning “relating to motion”), which invade the wall of the mosquito midgut, forming
oocysts. The oocysts subsequently rupture, releasing sporozoites that invade their way to
the mosquito’s salivary glands and await a new human host.

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Malaria Pathogenesis-

Despite the many morphologies of the parasite in its life cycle, only a few stages cause
clinical disease in humans, the most severe of which are typically P falciparum and P
vivax. The initial schizont broods rupture out of the liver phase, release thousands of
merozoites into the bloodstream, and attempt to establish periodicity within the
erythrocytic phase (time periods vary per species) where level of parasitemia increases
exponentially.

 Fever-
o Once the parasite concentration is high enough, a fever is mounted (pyrogenic
threshold). This pyrogenic threshold may be anywhere from 0.05 to 1.25
parasites/1,000 red blood cells (0.005 - 0.125% parasitemia) – immune patients may
require 0.2% parasitemia to experience fever. The most theorized mechanism for the
cyclic fevers is the human immune response to the hemozoin (waste product
generated from Plasmodium’s diet of hemoglobin) that bursts into the bloodstream
during each cycle of asexual erythrocytic schizogony. Hemozoin is known to be
a Plasmodium pathogen associated molecular pattern (PAMP) recognized by toll-
like receptors (TLRs) that induces intense immune response. Other malarial toxins
such as malaria glycophosphatidylinositol (GPI) likely are culpable through similar
mechanisms. The temperature fluctuation with the human febrile response is
expected to play a role in guiding the broods of parasites toward the classic
paroxysmal fever-associated periodicity of schizont rupture.

 Anemia-
o Severe malaria-associated anemia typically is seen in the young in areas of the
world with poor health infrastructure and diets poor in essential vitamins. Schizont
rupture from erythrocytes is an obvious mechanism of anemia; however, the more
profound loss of red blood cell mass is seen in the population of uninfected
erythrocytes. Their decline is thought to occur via oxidative damage of the
erythrocyte membranes, eventually leading to hemolysis. Another mechanism of
anemia lies within bone marrow; both insufficient production and function of
erythropoietin as well as possible apoptosis induction of erythrocyte precursors lead
to dyserythropoiesis.

 Splenomegaly-
o During acute malaria infection, the spleen serves as the main driver of infected
erythrocyte clearance, immune cell activation, and extramedullary
hematopoiesis. The extraordinary burden on the spleen causes the red pulp to
become congested with infected and uninfected red blood cells, but splenomegaly
also occurs by massive cellular expansion in both the red and white pulp.

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infection (at least in mice). Because of P vivax’ tropism for reticulocytes (prevalent
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in the spleen), splenic rupture is a characteristic severe complication of P vivax, and
there is evidence to suggest a separate splenic life cycle for this species.

 Acidosis-
o End-organ damage from microvascular sequestration, respiratory depression, and
production of Plasmodium lactate dehydrogenase (pLDH) by the malaria parasite
all lower the pH of the blood.

 Renal Injury-
o Cytoadherence with thrombi formation in glomeruli is a common mechanism of
acute kidney injury. If anuria or hemoglobinuria (“blackwater fever”) occur, it likely
is secondary to an abundance of cell-free hemoglobin that results in reduced renal
perfusion. Although contributing to morbidity of the acute illness, most patients do
not require long-term dialysis.

 Cerebral malaria-
o After infecting a red blood cell, P falciparum can insert adhesive proteins into the
erythrocyte membrane, thus creating a cytoadherant phenotype (further described
below in ‘species specific nuances’).The ability to stick to endothelium, uninfected
blood cells, and platelets causes more than 20% of brain capillaries to be filled
with P falciparum parasites, resulting in vascular congestion, retinopathy, capillary
leakage, thrombi, hemorrhage, axonal injury, coma, and death from cerebral malaria
within 48 hours (especially in children).

 Placental malaria-
o Occurring with highest incidence in Africa secondary to P falciparum due to its
ability to form the cytoadherent phenotype, placental malaria is characterized by the
accumulation of infected red blood cells within the intervillous space and ensuing
infiltration of maternal macrophages. In severe cases, the resulting chronic
intravillositis leads to decreased transplacental nutrient transport, fetal growth
restriction and low birth weight babies, as well as increased risk for preterm birth
and preeclampsia for the mother.

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CHAPTER-5

DIAGNOSIS

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DIAGNOSIS OF MALARIA:-
Prompt and accurate diagnosis is critical to the effective management of malaria. The
global impact of malaria has spurred interest in developing effective diagnostic strategies
not only for resource-limited areas where malaria is a substantial burden on society, but
also in developed countries, where malaria diagnostic expertise is often lacking. Malaria
diagnosis involves identifying malaria parasites or antigens/products in patient blood.
Although this may seem simple, the diagnostic efficacy is subject to many factors. The
different forms of the 5 malaria species; the different stages of erythrocytic schizogony,
the endemicity of different species, the interrelation between levels of transmission,
population movement, parasitemia, immunity, and signs and symptoms; drug resistance,
the problems of recurrent malaria, persisting viable or non-viable parasitemia, and
sequestration of the parasites in the deeper tissues, and the use of chemoprophylaxis or
even presumptive treatment on the basis of clinical diagnosis, can all influence the
identification and interpretation of malaria parasitemia in a diagnostic test.

Malaria is a potential medical emergency and should be treated accordingly. Delays in

diagnosis and treatment are leading causes of death in many countries. Diagnosis can be
difficult where malaria is no longer endemic for healthcare providers unfamiliar with the
disease. Clinicians may forget to consider malaria among the potential diagnoses for some
patients and not order the necessary diagnostic tests. Technicians may be unfamiliar with,
or lack experience with, malaria, and fail to detect parasites when examining blood smears
under a microscope. In some areas, malaria transmission is so intense that a large
proportion of the population is infected but remains asymptomatic, e.g., in Africa. Such
carriers have developed sufficient immunity to protect them from malarial illness, but not
infection. In such situations, finding malaria parasites in an ill person does not necessarily
mean that the illness is caused by the parasites. In many malaria-endemic countries, the
lack of resources is a major barrier to reliable and timely diagnosis. Health personnel are
undertrained, underequipped, and underpaid. They often face excessive patient loads, and
must divide their attention between malaria and other equally severe infectious diseases,
such as tuberculosis or HIV/AIDS.

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Clinical Diagnosis Of Malaria:-

A clinical diagnosis of malaria is traditional among medical

doctors. This method is least expensive and most widely
practiced. Clinical diagnosis is based on the patients' signs and
symptoms, and on physical findings at examination. The earliest
symptoms of malaria are very nonspecific and variable, and include fever, headache,
weakness, myalgia, chills, dizziness, abdominal pain, diarrhoea, nausea, vomiting and
anorexia . A clinical diagnosis of malaria is still challenging because of the non-specific
nature of the signs and symptoms, which overlap considerably with other common, as well
as potentially life-threatening diseases, e.g. common viral or bacterial infections, and other
febrile illnesses. The overlapping of malaria symptoms with other tropical diseases impairs
diagnostic specificity, which can promote the indiscriminate use of antimalarials and
compromise the quality of care for patients with non-malarial fevers in endemic areas. The
Integrated Management of Children Illness (IMCI) has provided clinical algorithms for
managing and diagnosing common childhood illnesses by minimally trained healthcare
providers in the developing world having inappropriate equipment for laboratory
diagnosis. A widely utilized clinical algorithm for malaria diagnosis, compared with a
fully trained pediatrician with access to laboratory support, showed very low specificity
(0-9%) but 100% sensitivity in African settings . This lack of specificity reveals the perils
of distinguishing malaria from other causes of fever in children on clinical grounds alone.
Recently, another study showed that use of the IMCI clinical algorithm resulted in 30%
over-diagnosis of malaria. Therefore, the accuracy of malaria diagnosis can be greatly
enhanced by combining clinical-and parasite-based findings.

LABORATORY DIAGNOSIS OF MALARIA-

Rapid and effective malaria diagnosis not only alleviates suffering, but also decreases
community transmission. The nonspecific nature of the clinical signs and symptoms of
malaria may result in over-treatment of malaria or non-treatment of other diseases in
malaria-endemic areas, and misdiagnosis in non-endemic areas. In the laboratory, malaria
is diagnosed using different techniques, e.g. conventional microscopic diagnosis by
staining thin and thick peripheral blood smears, other concentration techniques, e.g.
quantitative buffy coat (QBC) method, rapid diagnostic tests e.g., OptiMAL , ICT, Para-
HIT-f , ParaScreen, SD Bioline, Paracheck , and molecular diagnostic methods, such as
polymerase chain reaction (PCR). Some advantages and shortcomings of these methods
have also been described, related to sensitivity, specificity, accuracy, precision, time
consumed, cost-effectiveness, labor intensiveness, the need for skilled microscopists, and
the problem of inexperienced technicians.
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Microscopic diagnosis using stained thin and thick peripheral blood smears (PBS)

Malaria is conventionally diagnosed by microscopic examination of stained blood films

using Giemsa, Wright's, or Field's stains. This method has changed very little since
Laverran's original discovery of the malaria parasite, and improvements in staining
techniques by Romanowsky in the late 1,800s. More than a century later, microscopic
detection and identification of Plasmodium species in Giemsa-stained thick blood films
(for screening the presenting malaria parasite), and thin blood films (for species'
confirmation) remains the gold standard for laboratory diagnosis. Malaria is diagnosed
microscopically by staining thick and thin blood films on a glass slide, to visualize malaria
parasites. Briefly, the patient's finger is cleaned with 70% ethyl alcohol, allowed to dry
and then the side of fingertip is picked with a sharp
sterile lancet and two drops of blood are placed on a
glass slide. To prepare a thick blood film, a blood spot
is stirred in a circular motion with the corner of the
slide, taking care not make the preparation too thick,
and allowed to dry without fixative. After drying, the
spot is stained with diluted Giemsa (1 : 20, vol/vol) for
20 min, and washed by placing the film in buffered
water for 3 min. The slide is allowed to air-dry in a
vertical position and examination using a light microscope. As they are unfixed, the red
cells lyse when a water-based stain is applied. A thin blood film is prepared by
immediately placing the smooth edge of a spreader slide in a drop of blood, adjusting the
angle between slide and spreader to 45° and then smearing the blood with a swift and
steady sweep along the surface. The film is then allowed to air-dry and is fixed with
absolute methanol. After drying, the sample is stained with diluted Giemsa (1 : 20,
vol/vol) for 20 min and washed by briefly dipping the slide in and out of a jar of buffered
water (excessive washing will decolorize the film). The slide is then allowed to air-dry in a
vertical position and examined under a light microscope. The wide acceptance of this
technique by laboratories all around the world can be attributed to its simplicity, low cost,
its ability to identify the presence of parasites, the infecting species, and assess parasite
density-all parameters useful for the management of malaria. Recently, a study showed
that conventional malaria microscopic diagnosis at primary healthcare facilities in
Tanzania could reduce the prescription of antimalarial drugs, and also appeared to improve
the appropriate management of non-malarial fevers. However, the staining and
interpretation processes are labor intensive, time consuming, and require considerable

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expertise and trained healthcare workers, particularly for identifying species accurately at
low parasitemia or in mixed malarial infections. The most important shortcoming of
microscopic examination is its relatively low sensitivity, particularly at low parasite levels.
Although the expert microscopist can detect up to 5 parasites/µl, the average microscopist
detects only 50-100 parasites/µl. This has probably resulted in underestimating malaria
infection rates, especially cases with low parasitemia and asymptomatic malaria. The
ability to maintain required levels of in malaria diagnostics expertise is problematic,
especially in remote medical centers in countries where the disease is rarely seen.
Microscopy is laborious and ill-suited for high-throughput use, and species determination
at low parasite density is still challenging. Therefore, in remote rural settings, e.g.
peripheral medical clinics with no electricity and no health-facility resources, microscopy
is often unavailable.

QBC technique

The QBC technique was designed to enhance

microscopic detection of parasites and simplify
malaria diagnosis. This method involves staining
parasite deoxyribonucleic acid (DNA) in micro-
hematocrit tubes with fluorescent dyes, e.g.
acridine orange, and its subsequent detection by
epi-fluorescent microscopy. Briefly, finger-prick
blood is collected in a hematocrit tube containing
acridine orange and anticoagulant. The tube is centrifuged at 12,000 g for 5 min and
immediately examined using an epi-fluorescent microscope. Parasite nuclei fluoresces
bright green, while cytoplasm appears yellow-orange. The QBC technique has been shown
to be a rapid and sensitive test for diagnosing malaria in numerous laboratories settings.
While it enhances sensitivity for P. falciparum, it reduces sensitivity for non-falciparum
species and decreases specificity due to staining of leukocyte DNA. Recently, it has been
shown that acridine orange is the preferred diagnostic method (over light microscopy and
immunochromatographic tests) in the context of epidemiologic studies in asymptomatic
populations in endemic areas, probably because of increased sensitivity at low
parasitemia . Nowadays, portable fluorescent microscopes using light emitting diode
(LED) technology, and pre-prepared glass slides with fluorescent reagent to label
parasites, are available commercially. Although the QBC technique is simple, reliable, and
user-friendly, it requires specialized instrumentation, is more costly than conventional
light microscopy, and is poor at determining species and numbers of parasites.
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Rapid diagnostic tests (RDTs)

Since the World Health Organization (WHO) recognized the urgent need for new, simple,
quick, accurate, and cost-effective diagnostic tests for determining the presence of malaria
parasites, to overcome the deficiencies of light
microscopy, numerous new malaria-diagnostic
techniques have been developed . This, in turn, has led
to an increase in the use of RDTs for malaria, which are
fast and easy to perform, and do not require electricity
or specific equipment. Currently, 86 malaria RDTs are
available from 28 different manufacturers. Unlike conventional microscopic diagnosis by
staining thin and thick peripheral blood smears, and QBC technique, RDTs are all based
on the same principle and detect malaria antigen in blood flowing along a membrane
containing specific anti-malaria antibodies; they do not require laboratory equipment.
Most products target a P. falciparum-specific protein, e.g. histidine-rich protein II (HRP-
II) or lactate dehydrogenase (LDH). Some tests detect P. falciparum specific and pan-
specific antigens (aldolase or pan-malaria pLDH), and distinguish non-P. falciparum
infections from mixed malaria infections. Although most RDT products are suitable for P.
falciparum malaria diagnosis, some also claim that they can effectively and rapidly
diagnose P. vivax malaria. Recently, a new RDT method has been developed for detecting
P. knowlesi. RDTs provide an opportunity to extend the benefits of parasite-based
diagnosis of malaria beyond the confines of light microscopy, with potentially significant
advantages in the management of febrile illnesses in remote malaria-endemic areas. RDT
performance for diagnosis of malaria has been reported as excellent; however, some
reports from remote malaria-endemic areas have shown wide variations in sensitivity.
Murray and co-authors recently discussed the reliability of RDTs in an "update on rapid
diagnostic testing for malaria" in their excellent paper. Overall, RDTs appears a highly
valuable, rapid malaria-diagnostic tool for healthcare workers; however it must currently
be used in conjunction with other methods to confirm the results, characterize infection,
and monitor treatment. In malaria-endemic areas where no light microscopy facility exists
that may benefit from RDTs, improvements are required for ease of use, sensitivity for
non-falciparum infection, stability, and affordability. The WHO is now developing
guidelines to ensure lot-to-lot quality control, which is essential for the community's
confidence in this new diagnostic tool because the simplicity and reliability of RDTs have
been improved for use in rural endemic areas, RDT diagnosis in non-endemic regions is
becoming more feasible, which may reduce time-to-treatment for cases of imported
malaria.

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Serological tests

Diagnosis of malaria using serological methods is usually based on the detection of

antibodies against asexual blood stage malaria parasites. Immunofluorescence antibody
testing (IFA) has been a reliable serologic test for malaria in recent decades. Although IFA
is time-consuming and subjective, it is highly sensitive and specific . The literature clearly
illustrates the reliability of IFA, so that it was usually regarded as the gold standard for
malarial serology testing . IFA is useful in epidemiological surveys, for screening potential
blood donors, and occasionally for providing evidence of recent infection in non-immunes.
Until recently, it was a validated method for detecting Plasmodium-specific antibodies in
various blood bank units, which was useful for screening prospective blood donors, so
avoiding transfusion-transmitted malaria. In France, for example, IFA is used as a part of a
targeted screening strategy, combined with a donor questionnaire . The principle of IFA is
that, following infection with any Plasmodium species, specific antibodies are produced
within 2 wk of initial infection, and persist for 3-6 months after parasite clearance. IFA
uses specific antigen or crude antigen prepared on a slide, coated and kept at -30 ℃ until
used, and quantifies both IgG and IgM antibodies in patient serum samples. Titers > 1 : 20
are usually deemed positive, and < 1 : 20 unconfirmed. Titers > 1 : 200 can be classified as
recent infections. In conclusion, IFA is simple and sensitive, but time-consuming. It
cannot be automated, which limits the number of sera that can be studied daily. It also
requires fluorescence microscopy and trained technicians; readings can be influenced by
the level of training of the technician, particularly for serum samples with low antibody
titers. Moreover, the lack of IFA reagent standardization makes it impractical for routine
use in blood-transfusion centers, and for harmonizing inter-laboratory results.

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MOLECULAR DIAGNOSTIC METHOD-

As mentioned above, traditional malaria diagnostic methods remain problematic. New

laboratory diagnostic techniques that display high sensitivity and high specificity, without
subjective variation, are urgently needed in various laboratories. Recent developments in
molecular biological technologies, e.g. PCR, loop-mediated isothermal amplification
(LAMP), microarray, mass spectrometry (MS), and flow cytometric (FCM) assay
techniques, have permitted extensive characterization of the malaria parasite and are
generating new strategies for malaria diagnosis.

PCR technique

PCR-based techniques are a recent development in

the molecular diagnosis of malaria, and have proven
to be one of the most specific and sensitive
diagnostic methods, particularly for malaria cases
with low parasitemia or mixed infection. The PCR
technique continues to be used extensively to
confirm malaria infection, follow-up therapeutic
response, and identify drug resistance. It was found to be more sensitive than QBC and
some RDTs. Concerning with the gold standard method for malaria diagnosis, PCR has
shown higher sensitivity and specificity than conventional microscopic examination of
stained peripheral blood smears, and now seems the best method for malaria diagnosis.
PCR can detect as few as 1-5 parasites/µl of blood (≤ 0.0001% of infected red blood cells)
compared with around 50-100 parasites/µl of blood by microscopy or RDT. Moreover,
PCR can help detect drug-resistant parasites, mixed infections, and may be automated to
process large numbers of samples. Some modified PCR methods are proving reliable, e.g.,
nested PCR, real-time PCR, and reverse transcription PCR, and appear to be useful
second-line techniques when the 96 Korean J Parasitol. Vol. 47, No. 2: 93-102, June 2009
results of traditional diagnostic methods are unclear for patients presenting with signs and
symptoms of malaria; they also allow accurate species determination. Recently, the PCR
method has become widely accepted for identifying P. knowlesi infections. Although PCR
appears to have overcome the two major problems of malaria diagnosis-sensitivity and
specificity- the utility of PCR is limited by complex methodologies, high cost, and the
need for specially trained technicians. PCR, therefore, is not routinely implemented in
developing countries because of the complexity of the testing and the lack of resources to
perform these tests adequately and routinely. Quality control and equipment maintenance
are also essential for the PCR technique, so that it may not be suitable for malaria
diagnosis in remote rural areas or even in routine clinical diagnostic settings.

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LAMP technique

The LAMP technique is claimed to be a simple and

inexpensive molecular malaria-diagnostic test that
detects the conserved 18S ribosome RNA gene of P. falciparum. Other studies have
shown high sensitivity and specificity, not only for P. falciparum, but also P. vivax, P.
ovale and P. malariae. These observations suggest that LAMP is more reliable and useful
for routine screening for malaria parasites in regions where vector-borne diseases, such as
malaria, are endemic. LAMP appears to be easy, sensitive, quick and lower in cost than
PCR. However, reagents require cold storage, and further clinical trials are needed to
validate the feasibility and clinical utility of LAMP.

Microarrays

Publication of the Plasmodium genome offers many malaria-diagnostic opportunities.

Microarrays may play an important role in the future diagnosis of infectious diseases. The
principle of the microarrays technique parallels traditional Southern hybridization.
Hybridization of labeled targets divided from nucleic acids in the test sample to probes on
the array enables the probing of multiple gene targets in a single experiment. Ideally, this
technique would be miniaturized and automated for point-of-care diagnostics. A pan-
microbial oligonucleotide microarray has been developed for infectious disease diagnosis
and has identified P. falciparum accurately in clinical specimens. This diagnostic
technique, however, is still in the early stages of development.

FCM assay

Flow cytometry has reportedly been used for malaria diagnosis. Briefly, the principle of
this technique is based on detection of hemozoin, which is produced when the intra-
erythrocytic malaria parasites digest host hemoglobin and crystallize the released toxic
heme into hemozoin in the acidic food vacuole. Hemozoin within phagocytotes can be
detected by depolarization of laser light, as cells pass through a flow-cytometer channel.
This method may provide a sensitivity of 49-98%, and a specificity of 82-97%, for
malarial diagnosis, and is potentially useful for diagnosing clinically unsuspected malaria.
The disadvantages are its labor intensiveness, the need for trained technicians, costly
diagnostic equipment, and that false-positives may occur with other bacterial or viral
infections. Therefore, this method should be considered a screening tool for malaria.

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Automated blood cell counters (ACC)

An ACC is a practical tool for malaria diagnosis, with 3 reported

approaches. The first used a Cell-Dyn® 3500 apparatus to detect
malaria pigment (hemozoin) in monocytes, and showed a sensitivity of
95% and specificity of 88%, compared with the gold-standard blood
smear. The second method also used a Cell-Dyn® 3500, and analyzed
depolarized laser light (DLL) to detect malaria infection, with an overall sensitivity of
72% and specificity of 96%. The third technique used a Beckman Coulter ACC to detect
increases in activated monocytes by volume, conductivity, and scatter (VCS), with 98%
sensitivity and 94% specificity. Although promising, none of the 3 techniques is routinely
available in the clinical laboratory; further studies are required to improve and validate the
instrument and its software. The accuracy these methods promise, for detecting malaria
parasites, mean ACC could become a valuable and routine malaria-diagnostic laboratory
method.

Mass spectrophotometry

A novel method for in vitro detection of malaria parasites,

with a sensitivity of 10 parasites/µl of blood, has been
reported recently. It comprises a protocol for cleanup of
whole blood samples, followed by direct ultraviolet laser
desorption mass spectrometry (LDMS). For malaria
diagnosis, the principle of LDMS is to identify a specific biomarker in clinical samples. In
malaria, heme from hemozoin is the parasite-specific biomarker of interest. LDMS is
rapid, high throughput, and automated. Compared with the microscopic method, which
requires a skilled microscopist and up to 30-60 min to examine each peripheral blood
smear, LDMS can analyze a sample in < 1 min. However, the remote rural areas without
electricity are inhospitable for existing high-tech mass spectrometers. Future
improvements in equipment and techniques should make this method more
practicable.Recently, other reliable malaria-diagnostic tests have been developed and
introduced, and some tests are commercially available, for example, enzyme linked
immunosorbent assay (ELISA)/enzyme immunoassay (EIA), latex agglutination assay ,
and cultivation of live malaria parasites. Post-mortem organ diagnoses, by investigating
malaria parasites in tissue autopsy, e.g. liver and spleen, kidney and brain, have also been
described. However, parasite culture, molecular techniques, serology techniques and
pathobiological diagnostic techniques, although sometimes useful in research laboratories,
are not practical or appropriate for the routine clinical diagnosis of malaria.

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CHAPTER-6

MANAGEMENT AND
PREVENTION OF
MALARIA

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MANAGEMENT OF MALARIA:-
Management of Malaria includes Following Measures:-

1. Early Detection & Early Treatment-

 Early Detection of Fever Cases in the Community by

House to House Visit by the Health Workers in Every
15 Days.
 Early Administration of Chloroquine (CHQ) to All
Fevers.
 Collection of Blood Films(Thick & Thin) from Fever.
 Cases & Laboratory Examinations for Malaria Parasite.
 Administration of Medical Treatment to All Positive Cases of Malaria.

2. Mosquito Measure-

 Anti Adult Measure ( DDT Spraying)

 Anti Larval Measures (Larvicidal Operations)
 Protection Against Mosquito Bites e.g.-Mosquito Nets, Repellent Creams etc.

3. National Malaria Eradication Programme-

 Gov of India Launch this Programme in 1953.

 The National Eradication Programme consists various Meausres.
 Administering Anti Malarial Drugs.
 Chloroquine 10mg/kg for 3 days.
 Ancodiaquine with 500 mg Sulfamethopyrazine (5 mg).
 25 mg Pyrimethamine with 500 mg Sulfadoxine.
 The Programme Achived Good Success.

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PREVENTION OF MALARIA:-
Malaria can often be prevented by the use of antimalarial drugs and use of protection
measures against mosquito bites.

Medications-

When planning to travel to an area where malaria occurs, talk with your doctor well in
advance of your departure. Drugs to prevent malaria can be prescribed for travelers to
malarious areas, but travelers from different countries may receive different
recommendations, reflecting differences in treatment protocols as well as availability of
medicines in different countries. Travelers visiting only cities or rural areas where there
is no risk of malaria may not require preventive drugs, but an exact itinerary is
necessary to determine what degree of protection may be needed.

According to the Centers for Disease Control and Prevention (CDC), there are several
medications recommended for prevention of malaria in travelers. Determining which
medication is best depends on several factors, such as your medical history and the
amount of time before your scheduled departure. Strict adherence to the recommended
doses and schedules of the antimalarial drug selected is necessary for effective
protection.

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Protection from mosquitoes-

Be aware that you are still at risk for malaria even with the use of protection.

To avoid mosquito bites, the CDC recommends the following:

 Apply insect repellent to exposed skin. The recommended repellent contains 20-
35% percent N,N-Diethyl-meta-toluamide (DEET).
 Wear long-sleeved clothing and long pants if you are outdoors at night.
 Use a mosquito net over the bed if your bedroom is not air-conditioned or
screened. For additional protection, treat the mosquito net with the insecticide
permethrin.
 Spray an insecticide or repellent on clothing, as mosquitoes may bite through thin
clothing.
 Spray pyrethrin or a similar insecticide in your bedroom before going to bed.
 Maintain cleaniness at home with daily removing of dust.
 Keeping the surroundings and environment clean.
 Don’t let water to get contaminated.

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CHAPTER-7

TREATMENT OF
MALARIA

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When treating patients suspected of having malaria, it is important that treatment does
not start until there is a definitive diagnosis of malaria. To guide malaria treatment
appropriately, it is important to identify three factors: the infecting Plasmodium species,
the clinical status of the patient, and the drug susceptibility of the infecting parasites (the
geographic area from where the infection was acquired from and any previous
antimalarial medications). The obvious exception is in waiting for confirmation to treat
suspected malaria if the patient shows signs of severe malaria, and clinical suspicion for
malaria is high.

By identifying the infecting Plasmodium species, the healthcare practitioner can identify
which infections will progress to
severe manifestations and which
will not. Also, some infections can
remain dormant in the liver as
hypnozoites and can lead to a
relapse. The clinical status of a
patient can fall into two main
categories: uncomplicated malaria
or severe malaria. The main
difference in treatment is that
uncomplicated malaria is treated
with oral antimalarials, while
severe malaria gets treated with parenteral antimalarials. Last, healthcare practitioners
can select an appropriate treatment course by determining the drug susceptibility of the
infecting Plasmodium species. Practitioners can do this by looking at where the patient
was when they acquired the infection and if they have received any previous treatment
with antimalarials.

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TREATMENT OF MALARIA AT HOME:-

Treatment of malaria is necessesary as early as possible because if it is not treated on time
it can lead to serious complications and may cause death.

Malaria can be treated at home also but it is advised to visit a doctor before taking any
kind of treatment.

There are various home remedies that are readily available in everyone’s house that can be
used to treat malaria.

Here's are 9 most effective home remedies for malaria:-

1. Cinnamon-

Anti-inflammatory, antioxidant and antimicrobial properties in cinnamon help in dealing

with symptoms of malaria. Add cinnamon and black pepper powder in hot water. Add
some honey to it for enhancing taste. Drink it once or twice a day.

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2. Turmeric-

Turmeric is the super spice with amazing anti-oxidant and antimicrobial properties.
Turmeric helps in flushing out harmful toxins from the body which build up because of
plasmodium infection. Turmeric also helps in killing malaria parasite. Anti-inflammatory
properties help in reducing muscle and joint pain, which are common in malaria. Drink a
glass of turmeric milk every night to deal with malaria.

3. Orange juice

When infected with malaria, you can have orange juice in between your meals. Vitamin C
in orange juice helps in boosting immunity. Orange juice can also help in reducing fever
juice. You can have 2 to 3 glasses of fresh orange juice if you are infected with malaria.

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4. Ginger

Antimicrobial and anti-inflammatory properties ginger can provide relief from pain and
treat nausea. Add ginger in hot water. Add honey to the concoction and drink it twice a
day.

5. Sweet lime juice

Fresh juice extracted from sweet lime can be an effective home remedy for malaria. The
juice is easy to digest and also have Vitamin C.

6. Apple cider vinegar-

Apple cider vinegar can help in reducing fever caused in malaria. Dilute apple cider
vinegar with water and soak cloth in it. Place it on your forehead for 10 minutes.

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7. Mustard oil

Cooking food in mustard oil can help a person infected with malaria. It helps in fighting
infection in a more efficient way.

8. Grapefruit

Raw grapefruit can help in reducing intensity of malarial infection. To make grapefruit
juice, you can boil grapefruit in hot water and strain the pulp. Grapefruit juice has a
quinine-like substance which helps in reducing symptoms of malaria. However, do take
your doctor's advice before taking grapefruit juice.

9. Fenugreek seeds

Intermittent fever in people infected with malaria makes them feel very weak. Fenugreek
seeds are considered to be the perfect home remedy for reducing this weakness. They offer
a quick recovery from malaria by boosting immunity and fighting malaria parasites. You
can soak fenugreek seeds in water overnight and drink the water in an empty stomach.

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ANTIMALARIAL DRUGS:-
This are those drugs or agents that are used to treat malaria.

The antimalaria drugs can be categorised as under :-

1. Tissue Schizonticide for Prophylaxis : The drugs have action on the tissue in the liver.
The invasion of erythrocyte and its transmission to mosquito is stopped. The
Chloroguanide drug in plasmodium falciparum malaria fever is an example.

2. Blood Schizonticides for Clinical Cure: The clinical cure is meant for having no
attack of fever. The complete elimination of plasmodium parasite from the body is the aim
which may be called a suppressive cure. The drugs like quinine, chloroquine, mefloquine
artermisinine, artemether are weak bases, they cause rapid response and quick cure. The
resistance to these drugs develops slowly.

The drugs like pyrimethamine, sulphunamides, tetracyclines and chloroquanide are slow
acting drugs. The resistance to drugs occurs commonly.

3. Tissue Schizonticides which prevent relapse: The drug Primaquine used for Radical
cure of malaria, it acts on liver in hepatic form of Plasmodium vivax, Flasmodium ovale
and completely kills organisms and prevent relapse of malaria lever.

4. Gametocide Drugs: The drugs like chloroquine, quinine destroy sexual forms
(gametocytes) in blood and prevents transmission of plasmodium to mosquitos.
Primaquine prevents .falciparum germs gamete formation and prevent or stops
transmission to the mosquito

5. Sporontocides (Sporontocides) Drugs: The sporontocide drugs make the gametocyte

non-infective to cause malaria in the female mosquito and thus stops transmission. The
example is Chloroganide, Primaquine.

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Classification Of Antimalarial Drugs-

There are various classes of drugs that are used to treat malaria.

The drugs used in malaria are classified as under:-

S.no Class Drugs

1 4-Aminoquinolines Chloroquine
Amodiaquine
2 Quinoline Mefloquine
3 Biguanides Proguanil
Chloroquanide
4 Cinchona alkaloids Quinine
Quinidine
5 Sulphunamides Dapsone
Sulphamethoxy pyridiazine
Sulphadoxine
6 8 Aminoquinoline Primaquine
Balaquine
7 Diaminopyrimidines Pyrimethamine
8 Amino alcohols Halofantrine
9 Napthoquinone Atovaquone
10 Mannich base Pyronaridine
11 Sesquiterpine lactones Arteether
Artemether

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