Contents:

1. Introduction.
2. Life cycle.
3. Causes, incidence, and risk factors.
4. Symptoms.
5. Diagnosis and tests.
6. Complications.
7. Malaria Situation in Bangladesh.
8. Treatments.
9. References.

Introduction:
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Malaria is a mosquito-borne infectious disease of humans and other animals

caused by eukaryotic protists of the genus Plasmodium. The disease results from
the multiplication of Plasmodium parasites within red blood cells, causing symptoms
that typically include fever and headache, in severe cases progressing to coma or
death. It is widespread in tropical and subtropical regions, including much of SubSaharan Africa, Asia, and the Americas.
Five species of Plasmodium can infect and be transmitted by humans. Severe
disease is largely caused by Plasmodium falciparum while the disease caused by
Plasmodium vivax, Plasmodium ovale, and Plasmodium malariae is generally a
milder disease that is rarely fatal. Plasmodium knowlesi is a zoonosis that causes
malaria in macaques but can also infect humans.
Malaria transmission can be reduced by preventing mosquito bites by distribution of
mosquito nets and insect repellents, or by mosquito-control measures such as
spraying insecticides and draining standing water (where mosquitoes breed). The
challenge of producing a widely available vaccine that provides a high level of
protection for a sustained period is still to be met, although several are under
development. A number of medications are also available to prevent malaria in
travelers to malaria-endemic countries (prophylaxis).
A variety of antimalarial medications are available. Severe malaria is treated with
intravenous or intramuscular quinine or, since the mid-2000s, the artemisinin
derivative artesunate, which is superior to quinine in both children and adults.
Resistance has developed to several antimalarial drugs, most notably chloroquine.
There were an estimated 225 million cases of malaria worldwide in 2009. An
estimated 781,000 people died from malaria in 2009 according to the World Health
Organization's 2010 World Malaria Report, accounting for 2.23% of deaths
worldwide.[9] Ninety percent of malaria-related deaths occur in sub-Saharan Africa,
with the majority of deaths being young children. Plasmodium falciparum, the most
severe form of malaria, is responsible for the vast majority of deaths associated
with the disease. Malaria is commonly associated with poverty, and can indeed be a
cause of poverty and a major hindrance to economic development.

Life Cycle:
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A female Anopheles mosquito carrying malaria-causing parasites feeds on a human

and injects the parasites in the form of sporozoites into the bloodstream. The
sporozoites travel to the liver and invade liver cells.
Over 5-16 days, the sporozoites grow, divide, and
produce tens of thousands of haploid
forms, called merozoites, per liver cell.
Some malaria parasite species remain
dormant for extended periods in the liver,
causing relapses weeks or months later.
The merozoites exit the liver cells and reenter the bloodstream, beginning a cycle of
invasion of red blood cells, asexual
replication, and release of newly formed
merozoites from the red blood cells
repeatedly
over
1-3
days.
This
multiplication can result in thousands of
parasite-infected
cells
in
the
host
bloodstream, leading to illness and
complications of malaria that can last for
months if not treated.
Some of the merozoite-infected blood cells
leave the cycle of asexual multiplication. Figure 1: Life cycle of the Malaria Parasite.
Instead of replicating, the merozoites in
these cells develop into sexual forms of the parasite, called male and female
gametocytes, that circulate in the bloodstream.
When a mosquito bites an infected human, it ingests the gametocytes. In the
mosquito gut, the infected human blood cells burst, releasing the gametocytes,
which develop further into mature sex cells called gametes. Male and female
gametes fuse to form diploid zygotes, which develop into actively moving ookinetes
that burrow into the mosquito midgut wall and form oocysts.
Growth and division of each oocyst produces thousands of active haploid forms
called sporozoites. After 8-15 days, the oocyst bursts, releasing sporozoites into the
body cavity of the mosquito, from which they travel to and invade the mosquito
salivary glands. The cycle of human infection re-starts when the mosquito takes a
blood meal, injecting the sporozoites from its salivary glands into the human
bloodstream

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Causes, incidents, and risk factors:

Malaria is caused by a parasite that is passed from one human to another by
the bite of infected Anopheles mosquitoes. After infection, the parasites
(called sporozoites) travel through the bloodstream to the liver, where they
mature and release another form, the merozoites. The parasites enter the
bloodstream and infect red blood cells.
The parasites multiply inside the red blood cells, which then break open
within 48 to 72 hours, infecting more red blood cells. The first symptoms
usually occur 10 days to 4 weeks after infection, though they can appear as
early as 8 days or as long as a year after infection. The symptoms occur in
cycles of 48 to 72 hours.
Most symptoms are caused by:
1. The release of merozoites into the bloodstream
2. Anemia resulting from the destruction of the red blood cells
3. Large amounts of free hemoglobin being released into circulation after red
blood cells break open
Malaria can also be transmitted from a mother to her unborn baby
(congenitally) and by blood transfusions. Malaria can be carried by
mosquitoes in temperate climates, but the parasite disappears over the
winter.
The disease is a major health problem in much of the tropics and subtropics.
The CDC estimates that there are 300-500 million cases of malaria each
year, and more than 1 million people die from it. It presents a major disease
hazard for travelers to warm climates.
In some areas of the world, mosquitoes that carry malaria have developed
resistance to insecticides. In addition, the parasites have developed
resistance to some antibiotics. These conditions have led to difficulty in
controlling both the rate of infection and spread of this disease.
There are four types of common malaria parasites. Recently, a fifth type,
Plasmodium knowlesi, has been causing malaria in Malaysia and areas of
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southeast Asia. Another type, falciparum malaria, affects more red blood
cells than the other types and is much more serious. It can be fatal within a
few hours of the first symptoms.

Symptoms:

Anemia
Bloody stools

Figure 2: Symptoms of Malaria

Chills
Coma
Convulsion
Fever

Figure 3: Transfusing a child with

severe anaemia due to Malaria

Headache
Jaundice
Muscle pain
Nausea
Sweating
Vomiting

Figure 4: A patient suffering from

jaundice due to severe malaria.

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Diagnosis and tests:

In order to make a malaria diagnosis, the healthcare provider may ask a

number of questions concerning:

Current symptoms

Medical conditions

Family medical history

Current medications

Recent travel history.

The healthcare provider will also likely perform a physical exam, looking for
signs or symptoms of malaria. He or she may also order certain tests to help
in diagnosing malaria or another condition.
The doctor may suspect malaria based on the patient's symptoms, and the physical findings
at examination; however, to make a definitive diagnosis of malaria, laboratory tests must
demonstrate the malaria parasites, or their components.

The best test available to diagnose malaria is called a blood

smear. In this test, malaria parasites can be identified by
examining a drop of the patient's blood under the microscope,
spread out as a "blood smear" on a microscope slide. Prior to
examination, the specimen (blood) is stained to give to the
parasites a distinctive appearance.
There are other blood tests available that may be used along
with a blood smear to confirm a malaria diagnosis.

Figure 5: Blood smear test

A malaria diagnosis can be difficult to make, especially in areas where

malaria is not very common. A number of other conditions share similar
symptoms with malaria. Some of these conditions the healthcare provider
will consider before diagnosing malaria include:
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The flu (influenza)

Common cold

Meningitis

Typhoid fever

Dengue fever

Acute schistosomiasis (disease caused by worms)

Bacteremia/septicemia (infection in blood)

Hepatitis

Viral gastroenteritis (stomach flu)

Yellow fever (disease typically transmitted by mosquitoes).

Complications:
Malaria can be fatal, particularly the variety that's common in tropical parts
of Africa. The Centers for Disease Control and Prevention estimate that 90
percent of all malaria deaths occur in Africa most commonly in children
under the age of 5.
In most cases, malaria deaths are related to one or more of these serious
complications:

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.

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Breathing problems. Accumulated fluid in your lungs (pulmonary

edema) can make it difficult to breathe.

Organ failure. Malaria can cause your kidneys or liver to fail, or your
spleen to rupture. Any of these conditions can be life-threatening.

Severe anemia. Malaria damages red blood cells, which can result in
severe anemia.

Low blood sugar. Severe forms of malaria itself can cause low blood
sugar, as can quinine one of the most common medications used to
combat malaria. Very low blood sugar can result in coma or death.
Recurrence may occur
Some varieties of the malaria parasite, which typically cause milder forms of
the disease, can persist for years and cause relapses.

Table 1: Indicators of severe malaria and poor prognosis [1,3-5]

Manifestation

Features

Initial World Health Organization criteria from 1990 [3]

1. Cerebral malaria:

Unarousable coma not attributable to any other

cause, with a Glasgow Coma Scale score 9; Coma
should persist for at least 30 min after a
generalized convulsion

2. Severe anemia

Hematocrit <15% or hemoglobin < 50 g/l in the

presence of parasite count >10000/l

3. Renal failure

Urine output <400 ml/24 hours in adults (<12

ml/kg/24 hours in children) and a serum creatinine
>265 mol/l (> 3.0 mg/dl) despite adequate
volume repletion

4. Metabolic (Lactic)
Acidosis/acidosis

Metabolic acidosis is defined by an arterial blood

pH of <7.35 with a plasma bicarbonate
concentration of <22 mmol/L; hyperlactatemia is
defined as a plasma lactate concentration of 2-5
mmol/L and lactic acidosis is characterized by a pH
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<7.25 and a plasma lactate >5 mmol/L.

5. Pulmonary edema or
acute respiratory
distress syndrome
(ARDS)

Breathlessness, bilateral crackles, and other

features of pulmonary oedema. The acute lung
injury score is calculated on the basis of
radiographic densities, severity of hypoxemia, and
positive end-expiratory pressure

6. Hypoglycemia

Whole blood glucose concentration of less than 2.2

mmol/l (less than 40 mg/dl).

7. Hypotension and
shock (algid malaria)

Systolic blood pressure <50 mmHg in children 1-5

years or <70 mm Hg in patients 5 years; cold and
clammy skin or a core-skin temperature difference
>100C

8. Abnormal bleeding
Spontaneous bleeding from the gums, nose,
and/or disseminated
gastrointestinal tract, retinal haemorrhages and/or
intavascular coagulation laboratory evidence of disseminated intravascular
coagulation.
9. Repeated generalised 3 generalized seizures within 24 hours
convulsions
10. Haemoglobinuria

Macroscopic black, brown or red urine; not

associated with effects of oxidant drugs or enzyme
defects (like G6PD deficiency)

Added World Health Organization criteria from 2000 [4]

11. Impaired
consciousness

Various levels of impairment may indicate severe

infection although not falling into the definition of
cerebral malaria. These patients are generally
arousable

12. Prostration

Extreme weakness, needs support

13. Hyperparasitemia

5% parasitized erythrocytes or > 250 000

parasites/l (in nonimmune individuals)

14. Hyperpyrexia

Core body temperature above 400C

15. Jaundice

Serum bilirubin of more than 43m mol/l (2.5

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(Hyperbilirubinemia)

mg/dl).

Other
16. Fluid and electrolyte Dehydration, postural hypotension, clinical
disturbances [5]
evidence of hypovolemia
17. Vomiting of oral
drugs

Patients with persistent vomiting may have to be

admitted for parenteral therapy.

18. Complicating or
associated infections

Aspiration bronchopneumonia, septicemia, urinary

tract infection etc.

19. Other indicators of

poor prognosis [5]

Leukocyte count >12,000/cumm; high CSF lactate

(>6 mmol/l)and low CSF glucose; more than 3-fold
elevation of serum enzymes (aminotransferases);
increased plasma 5'-nucleotidase; low antithrombin
III levels; peripheral schizontemia;
papilloedema/retinal oedema

20. Malarial Retinopathy A large, prospective autopsy study of children

dying with cerebral malaria in Malawi found
malarial retinopathy to be a better indicator of
malarial coma. Similar retinopathy in an adult has
also been reported.

Malaria situation in Bangladesh:

Malaria has been a major public health problem in Bangladesh.
Approximately 33.6% of the total population are at risk of malaria Majority
of malaria cases are reported from 13 out of the total 64 districts in the
country. About 4 million populations living in 34 upazillas of eight of the
thirteen districts live in the epidemic-prone border areas. Focal outbreaks
occur every year, and the response to control the epidemic is inadequate.
Malaria cases are grossly under-reported due to shortcomings in
surveillance and information.
Country is reporting on average 50,000 confirmed malaria cases with around
70% of Pf cases (killer malaria) and 450 malaria deaths annually. The case
finding is very poor and <2% population at risk of malaria screened every
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year. In 2008-09, with the help of Global funds enhanced surveillance and
case finding activities including vector control through bednets and
treatment through ACTs resulted in a increase in lab confirmed cases and
significant decrease in malaria deaths . Country did not reaport any probable
malaria case in 2009.
Programme is promoting
LLINs & ITNs amongst the
community as a vector
control measure in these
areas which has increased
tremendously in last few
years. Total 2.57 million
bednets (LLINS + ITNs) were
distributed and 6.42 million
people are covered by it.
However, its coverage in Figure 6: : Trends of confirmed malaria cases in Bangladesh,
high
endemic
districts 1970-2009
ranges between 40% to 63%.

Figure 7: Distribution of ACT and Number of malaria deaths in Bangladesh, 2005-2009

Figure 8: 2Cumulative availability of effective LLINs & ITNs in

Bangladesh, 2005-2009

Total financing for malaria in 2009 was approximately US$ 9.5 million, the
main sources being the Government (US$ 555 000), the Global Fund (US$
7.7 million), the World Bank (US$ 890 000) and WHO (US$ 230 000).
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Figure 9: Availability of funds by Source in Bangladesh, 2006-2009

Pogramme Goals and Targets:

To reduce malaria morbidity and mortality until the disease is no longer a
public health problem in the country.
Targets

Baseline
data in
2005

201
0

To provide early diagnosis and prompt

treatment (EDPT) with effective drugs to 80%
of malaria patients

40%

80%

To provide effective malaria prevention to

80% of population at risk

24%

80%

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To strengthen malaria epidemiological

surveillance system

60%

100
%

To establish Rapid Response Team (RRT) at

national and district levels and increase
preparedness and response capacity for
containment of outbreaks

80%

100
%

To promote community participation, and

strengthen partnership with private sector
and NGOs for malaria control

25%

80%

Control strategy:
Malaria control activities are integrated with the general health services
Active Case Detection (ACD) and Passive Case Detection (PCD) with
laboratory diagnosis Prompt treatment
Case management of severe malaria and complicated cases in hospital.
Vector control minimal, no IRS with DDT since 1993.
SEAR working group recommendation on revised control strategy has
been adopted
Due to spread of chloroquine resistance, drug regimen has been revised
and COARTEM has been introduced by programme
Strengthening programme management is of high priority
Best practices and success stories
Establishment of partnership with NGO consortium.
Promotion and use of ITNs/LLINs
Quality diagnosis using RDT and effective treatment using ACTs

Issues and Challenges:

Inadequate access to treatment and diagnostic facilities especially in
the remote areas
Inadequate programme management capacity at various level and
management of severe malaria in hospitals
Poor coverage of prevention and control methods (IRS, ITN/LLIN
coverage still low) in the community
Referral system is weak and pre-referral treatment provisions are
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limited;
Optimum treatment of cases of
severe
malaria
in
different
categories
of
hospitals
are
Cross-border
malaria
at
the
Bangladesh
India
and
BanMyanmar border

inadequate

Partners and donors

WHO
World Bank
Global fund
BRAC and 14 member NGO Consortium
4 Local NGOs in Chittagong Hill Tract (CHT)

Treatments:
Preventing malaria - four steps
There is an ABCD for prevention of malaria. This is:
Awareness of risk of malaria.
Bite prevention.
Chemoprophylaxis (taking antimalarial medication exactly as
prescribed).
Prompt Diagnosis and treatment.
Awareness of the risk of malaria:
The risk varies between countries and the type of trip. For example, backpacking or travelling to rural areas is generally more risky than staying in
urban hotels. In some countries the risk varies between seasons - malaria is
more common in the wet season. The main type of parasite, and the amount
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of resistance to medication, varies in different countries. Although risk varies,

all travellers to malaria-risk countries should take precautions to prevent
malaria.
The mosquitoes which transmit malaria commonly fly from dusk to dawn and
therefore evenings and nights are the most dangerous time for transmission.
Bite prevention:
We can an effective insect repellent to clothing and any exposed skin.
Diethyltoluamide (DEET) is safe and the most effective insect repellent and
can be sprayed on to clothes. It lasts up to three hours for 20%, up to six
hours for 30% and up to 12 hours for 50% DEET. There is no further increase
in duration of protection beyond a concentration of 50%. When both
sunscreen and DEET are required, DEET should be applied after the
sunscreen has been applied. DEET can be used on babies and children over
two months of age. In addition, DEET can be used, in a concentration of up to
50%, if anyone is pregnant. It is also safe to use if you are breast-feeding.
If we sleep outdoors or in an unscreened room, we should use mosquito nets
impregnated with an insecticide (such as pyrethroid). The net should be long
enough to fall to the floor all round your bed and be tucked under the
mattress. We should check the net regularly for holes. Nets need to be reimpregnated with insecticide every six to twelve months (depending on how
frequently the net is washed) to remain effective. Long-lasting nets, in which
the pyrethroid is incorporated into the material of the net itself, are now
available and can last up to five years.
If practical, we should try to cover up bare areas with long-sleeved, loosefitting clothing, long trousers and socks - if we are outside after sunset - to
reduce the risk of mosquitoes biting. Clothing may be sprayed or
impregnated with permethrin, which reduces the risk of being bitten through
our clothes.
Sleeping in an air-conditioned room reduces the likelihood of mosquito bites,
due to the room temperature being lowered. Doors, windows and other
possible mosquito entry routes to sleeping accommodation should be
screened with fine mesh netting. we should spray the room before dusk with
an insecticide (usually a pyrethroid) to kill any mosquitoes that may have
come into the room during the day. If electricity is available, we should use
an electrically heated device to vaporize a tablet containing a synthetic
pyrethroid in the room during the night. The burning of a mosquito coil is not
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as effective.
Herbal remedies have not been tested for their ability to prevent or treat
malaria and are therefore not recommended. Likewise, there is no scientific
proof that homoeopathic remedies are effective in either preventing or
treating malaria, and they are also not recommended.
Antimalarial medication (chemoprophylaxis):
Antimalarial medication helps to prevent malaria. The best medication to
take depends on the country you visit. This is because the type of parasite
varies between different parts of the world. Also, in some areas the parasite
has become resistant to certain medicines.
There is a possibility of antimalarials that we may buy in the tropics or over
the Internet, being fake. It is therefore recommended that we obtain our
antimalarial treatment from our doctor's surgery, a pharmacist or a travel
clinic. Medications to protect against malaria are not funded by the NHS. We
will need to buy them, regardless of where we obtain them.
The type of medication advised will depend upon the area you are travelling
to. It will also depend on any health problems we have, any medication you
are currently taking, the length of our stay, and also any problems we may
have had with antimalarial medication in the past.
We should seek advice for each new trip abroad. Do not assume that the
medication that we took for your last trip will be advised for your next trip,
even to the same country. There is a changing pattern of resistance to some
medicines by the parasites. Doctors, nurses, pharmacists and travel clinics
are updated regularly on the best medication to take for each country.
We must take the medication exactly as advised. This usually involves
starting the medication up to a week or more before you go on your trip. This
allows the level of medicine in our body to become effective. It also gives
time to check for any side-effects before travelling. It is also essential that
we continue taking the medication for the correct time advised after
returning to our home (often for four weeks). The most common reason for
malaria to develop in travellers is because the antimalarial medication is not
taken correctly. For example, some doses may be missed or forgotten, or the
tablets may be stopped too soon after returning from the journey.
Symptoms of malaria (to help with prompt diagnosis):
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Symptoms are similar to flu. They include fever, shivers, sweating, backache,
joint pains, headache, vomiting, diarrhoea and sometimes delirium. These
symptoms may take a week or more to develop after you have been bitten
by a mosquito. Occasionally, it takes a year for symptoms to develop.
This means that we should suspect malaria in anyone with a feverish illness
who has travelled to a malaria-risk area within the past year, especially in
the previous three months.
Special situations:

Pregnant women are at particular risk of severe malaria and should,

ideally, not go to malaria-risk areas. Full discussion with a doctor is
advisable if you are pregnant and intend to travel. Most antimalarial
medications are thought to be safe to the unborn child. Some, such as
mefloquine, should be avoided in the first twelve weeks of pregnancy.
Non-pregnant women taking mefloquine should avoid becoming
pregnant. You should continue with contraception for three months
after the last dose.
If you are given doxycycline and are also taking the combined oral
contraceptive pill (COCP) or using the patch, then you should use
alternative contraception for the first three weeks of taking the
doxycycline. This is because doxycycline may interfere with the
effectiveness of the COCP (or patch). After three weeks you will not
need to use any additional contraception.
If you have epilepsy, kidney failure, some forms of mental illness, and
some other uncommon illnesses, you may have a restricted choice of
antimalarial medication. This may be due to your condition, or to
possible interactions with other medication that we may be taking.
If we do not have a spleen (if you have had it removed) or our spleen
does not work well, then we have a particularly high risk of developing
severe malaria. Ideally, we should not travel to a malaria-risk country.
However, if travel is essential, every effort should be made to avoid
infection and we should be very strict about taking our antimalarial
medication.
Travellers going to remote places far from medical facilities sometimes
take emergency medication with them. This can be used to treat
suspected malaria until proper medical care is available.

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References:

http://www.mayoclinic.com/health/malaria/DS00475/DSECTION=compli
cations
http://malaria.emedtv.com/malaria/malaria-diagnosis-p2.html
http://www.malariasite.com/malaria/Complications2.htm
http://en.wikipedia.org/wiki/Malaria
http://www.patient.co.uk/health/Malaria-Prevention.htm
http://www.google.com/imghp?hl=en&tab=wi

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