MALARIA

Dr. Ruby A. Simon

Parasitology Section
DMSF
Malaria
Malaria was first documented in China in 1700
B.C.
90 countries
Most important parasitic disease affecting
man
90% in Africa
300-500 M cases/year
2.4 B at risk; 40% of world population
 Malaria
1.5-2.7 M deaths/year
1 million of these are children under 5 years old. In
endemic areas, infected children will show symptoms
between 4 to 8 months of age (fever, irritability, poor
feeding, vomiting, diarrhea and convulsions)
 Malaria
only about 20% of infected individuals in
highly endemic regions where transmission is
high show symptoms; asymptomatic
parasitemic individuals may be important
reservoirs for continued transmission.
Congenital malaria occurs in endemic areas
30% of infected pregnant woman will have the
placenta infected
If the mother is non immune, the probability is
10% that the baby will be infected
If the mother is semi immune, the probability that
the baby will be infected is less than 3%.
• Endemic areas in Western Pacific:
Cambodia, China, Lao, Malaysia,
Papua New Guinea, Philippines, Korea,
Solomon Island, Vanuatu,Vietnam
• Worsening Malaria Problem due to:
• resistance of parasites to antimalarials
• resistance of vectors to insecticides
• socioeconomic problems leading to decreased capacity
to combat the disease
• movement of non immune populations into areas
where malaria is transmitted
In the Philippines:
• 65/78 provinces endemic
• 11.3 M at risk (14% of population)
• 7/1000 incidence
• One of the ten leading morbidity
• 53% cases in Mindanao
• Peak transmission at the beginning and end of
rainy season
DOH Malaria Control Program
Cat. A: more than 1000 cases/year
: 20 provinces ( Davao Oriental, D. del
Sur, D. del Norte, Sarangani,
Agusan, Butuan, Tawi-tawi, Sulu,
Basilan, Palawan, Kalinga, Apayao,
Ifugao …)
Cat. B: 100-1000 cases/ year
: 27 provinces ( Zamboanga,
Bukidnon, S. Cotobato, Sultan
Kudarat, Lanao…)
Cat. C: less than 100 cases/ year
Cat. D: malaria-free zone
: No more indigenous cases in 3
years)
: Cebu, Bohol, Catanduanes,
Aklan, Capis, Leyte, Samar

Multi-drug resistance cases:

: Davao del Norte, Campostela Valley
Palawan with treatment failure from
32-75%.
Transmission of Malaria
Human parasites:
Plasmodium falciparum (70 % of cases)
P. vivax (30%)
P. malariae (1%)
P. ovale
vector: female Anopheles mosquito
Anopheles flavirostris
A. litoralis
A. maculatus
A. mangyanus
vertebrate host

environmental conditions:
climate; temperature; humidity, rainfall,
topography, soil, flora, fauna
Modes of Transmission:
• bite of female mosquito (dusk to dawn)
• congenital transmission
• blood transfusion; use of contaminated
needles
Life cycle
hypnozoites
Sporozoites Hepatocytes
EE schizonts
Salivary gland
EE merozoites

Oocyst Gut Wall

RBC

Trophozoites
Ookinete

Schizonts

Macrogamete
+ E Merozoites
Microgamete
macrogametocytes microgametocytes

GUT lumen

Mosquito Man
LIFE CYCLE:
• Mosquito or Invertebrate :
Definitive Host: Extrinsic Stage- 8-35 days
Microgamete
Macrogamete
Ookinete
Oocyst
Sporozoite
• Man or Vertebrate :
prepatent period 11days to 4 weeks
Intermediate Host: Intrinsic Stage
Exoerythrocytic cycle:
exoerythrocytic schizont
EEmerozoite
Erythrocytic cycle: RBC
trophozoite- early; late
erythrocytic schizont – early;late
erythrocytic merozoites
microgametocyte
macrogametocyte
In mosquito vector
 In Man
Plasmodium falciparum
 In Man
Plasmodium vivax
 In Man
Plasmodium malariae
 In Man
Plasmodium ovale
High Index of suspicion:

Travel to and overnight stay in malarious area

Blood transfusion during the past 6 months
Intravenous drug use
Man: the VICTIM
Vulnerable groups:
• infants 6 months – 5 y/o
• malnourished
• pregnant women : 2nd-3rd trimester; first
pregnancy
• non-immune migrant : 30,000 Americans and
Europeans travellers contract every year
• anyone who travels to malarious area is at risk
regardless of measures taken to prevent
infection up to two years or longer after
leaving the area

• majority : 2 weeks after exposure

95% in 6 weeks
Clinical Manifestations:
Incubation period: 8-40 days
Malaria Paroxysm
1. Cold stage: chills; 15-60 mins.
2. Hot stage: fever; 2- 6 hours
3. Wet stage: sweating; 2-4 hours
• Malignant Tertian Malaria

• Benign Tertian Malaria

• Benign Quartan Malaria

Clinical Presentations:
• acute
• chronic
• with complications
• Hyperreactive Malarious Splenomegaly (HMS)
• Tropical Splenomegaly Syndrome (TSS)
-Young adult in malarious area
- High IgM and malaria antibodies
- Episodes of anemia, increased
susceptibility to infection
- Functional suppressor T cell
defect
- Associated with HLA DR2
Parasite P. falciparum P. vivax P. ovale P. malariae

I.P. 7-27 d 8-31 d 11-16 d 28-37 d

EE cycle 48 h 48 h 48 h 72 h

Dormant stage (-) (+) (+) (-)

Ave. parasitemia 50,000 20,000 9,000 6,000

Max. 500,000-2M 50,000 30,000 20,000
Parasitemia

Complication Severe Splenic Immune

malaria rupture complex
HMS GN
Severe Malaria:
• caused by P. falciparum, in holoendemic and
hyperendemic areas
• young children over 6 months
• mortality highest among 1- 3 y/o
Severe Malaria:

1. cerebral malaria: encephalopathy

80% of all deaths; 20 % case fatality

- increased permeability of the blood/brain

barrier
- mechanical microcirculation obstruction
- immunological vasculitis
- associated with increased level of TNF
- Nitric oxide : disrupts neuron function;
vasodilatation; release of endothelial
derived relaxing factor (EDRF)
2. severe anemia:
hct <20; hgb < 7 gms/l
 RBC rupture;
 TNF-alpha suppression of
hematopoetin)
3. renal failure: creatinine > 265mmol/l
4. pulmonary edema: ARDS
5. hypoglycemia:
 patients receiving quinine
 pregnant patients
 severe infection
- increased glucose consumption
- glycogen depletion
- impaired gluconeogenesis
6. circulatory collapse

7.spontaneous bleeding: DIC

8. acidemia/acidosis

9. Hemoglobinuria

10. hyperparasitemia : > 5%

11. Jaundice with bilirubin > 50mmol/l

12. hyperpyrexia
 Pathogenesis:

Rupture of schizont Anemia

GP1
Knobs Cytoadherence
Loss of RBC deformability

Microvascular obstruction
TNF
Glucose consumption
Hypoglycemia
Lactic acidosis fever/ hypoglycemia

Tissue hypoxia & hypoglycemia

cerebral, renal, pulmonary other complications

 Ligands and receptors
Life cycle event Parasite ligand Host receptor

Hepatocyte entry by Circumsporozoite Heparan sulfate; low

sporozoite protein (CSP) density lipoprotein
receptor; related
protein

RBC entry by merozoite

P. vivax Pv 135 Duffy factor
P. falciparum Erythrocyte-binding glycophorin
protein(EBA175)

Rosetting of P. P. falciparum infected Complement

falciparum parasitized erythrocyte membrane Receptor 1
RBC protein (pfEMP)

Cytoadhernce of PfEMP; HRP Thrombospondin;

P. falci parasitized RBC CD36; ICAM1;
VCAM1;ELAM1
Pathology:
- Altered red cell surface membranes
- Host’s immunologic response
 obstruction in regional blood flow and
vascular endothelium
 biochemical changes
 anemia
 tissue hypoxia
 increased capillary permeability
The PfEMP1 molecules mediate adhesion of the
parasitised RBCs to host tissues (and therefore
sequestration in some tissues), thus allowing them to
avoid destruction during the otherwise inevitable
passage through the spleen.
PfEMP1 variants exist that have specificity for many
different host ligands, including variants that are
specific for adhesion to chondroitin sulphate A
(CSA). CSA is a host-derived molecule, prevalent in
the syncytiotrophoblast of (the placenta of) pregnant
women.
Laboratory Diagnosis:
Traditional
Alternative
Traditional Method:
• Microscopy: blood smear using Giemsa staining still
as gold standard
• Taken any time, usually every 6-8 hrs.
• routine: 2-3% stain for 30 mins- 1 hour
• rapid- 10-15% stain for 10 mins.
Peripheral Blood Smear
– thin smear for morphologic/species identification
– thick smear to determine level of parasitemia
(parasite counting) - asexual/sexual per ul of
blood
– negative only if 200 fields are examined
– if negative, repeat every 12 hours for 36-48 hours
– needs at least 16-36 parasites/ul blood to be
positive
Peripheral Blood Smear

Advantages:
• low direct cost
• sensitive
• species differentiation
• parasite density determination
• can also diagnose other conditions
Peripheral Blood Smear

Disadvantages:
• dependence on the availability of trained
microscopist
• time taken to screen slide properly
• inability to batch process blood films
examination
• difficulty detecting low levels of parasitemea
Alternative methods
1.Fluorescent Microscopy: to detect antigen
a. QBC ( Quantitative Buffy Coat)
Principle: capillary tube coated with
acridine orange dye
: Centrifuged
: Parasites take-up stain
and appear as bright
green and yellow in
fluorescent microscope
Fluorescent Microscopy:
Advantages:
• rapid, easy to perform and read
• no need for technical expertise
Fluorescent Microscopy:
Disadvantages:
• expensive, needs fluorescent microscope
• inadequate quantification of parasitemia
• poor discrimination of species
• difficulty of storage of QBC for checking
b. BCP (BenzothioCarboxyPurine) Stain
- uses dried smear
- smears cannot be kept for > 48 hours
- special light source (halogen lamp)

c. Kawamoto Acridine Orange method

New methods
a. detect nucleic acid sequence
i. DNA probes/hybridization
ii. PCR: Polymerase Chain Reaction
Detection of DNA
Advantage:
• extremely sensitive and specific which can
detect very low level of parasitemia
Detection of DNA:
Disadvantages:
• cannot detect viable parasites
• false negatives and false positives
• needs technical skills/expertise
• high cost of reagents and equipments
b. detect antigens, enzymes by
immunochromatography
(Rapid Diagnostic Tests- RDTs)
i. to detect Pf HRP II
(histidine-rich protein)
ex. Parasight F; ICT; Paracheck;
Parahit

ii. to detect pLDH

ex. Diamed Optimal; Orchid
Optimal; Flow
Mode of action of common malaria RDT format
• Dye-labeled antibody, specific for target antigen,
is present on the lower end of nitrocellulose
strip or in a plastic well provided with the strip.
Antibody, also specific for the target antigen, is
bound to the strip in a thin (test) line, and either
antibody specific for the labeled antibody, or
antigen, is bound at the control line.
• Blood and buffer, which have been placed on
strip or in the well, are mixed with labeled
antibody and are drawn up strip across the lines
of bound antibody.

• If antigen is present, some labeled antibody will

be trapped on the test line. Excess-labeled
antibody is trapped on the control line.
Factors affecting infection:
o habits
• natural: genetic or innate traits
independent of previous infection
– Duffy factor: necessary for invasion of P. vivax
– Sickle cell trait HbaS: protective against severe
malaria
– G6PD deficiency: protective (?)
– Thalassemia ( fetal Hgb): protective

• acquired: passive
active
Man: the DONOR
• MAN: THE DONOR
 only source of infecting vector
 can also transmit thru blood
transfusion; congenital
(erythrocytic stages)
 must be accessible to vector
must have gametocyte in the blood
efficient number :
P.f 1:200 leukocytes
P.v 1: 1000
P.m. 1: 330
- if macro greater than micro, fewer
mosquitoes infected
- gametocyte pool: asymptomatic
children with splenomegaly
Treatment
Optimal Treatment Requires:
• rapid parasitological and clinical classification
of patients
• rapid diagnosis/identification
• initiation of therapy to rapidly reduce and then
eliminate parasitemia
• initiation of supportive and ancillary therapy
• recognition of inadequate response to therapy
and development of complications
• recognition and treatment of recrudescence
and relapse
Treatment, ideally
1. destroy promptly all asexual,
erythrocytic forms
– acute attack
2. destroy sporozoites and EE forms
– relapses
3. suppressive therapy
– clinical signs and symptoms
4. destroy gametocyte stages
5. prevent transmission
Clinical Classification of patients:
1.Uncomplicated Malaria
- febrile condition with malarial parasite in peripheral
blood smear, absence of severe disease and signs of
chloroquine resistant P. falciparum
- may be accompanied by severe headache, chills and
diaphoresis
2. Drug-resistant P. falciparum
- if there is recrudescence of asexual
parasitemia from the 48th hour
thereafter treatment
- if there is no parasite or reduction
- monitoring blood films is done from
Day 0- Day 28
- chloroquine resistance is prevalent but
low grade and does not preclude its use
as first line drug in most malarious
areas
3. Severe Malaria
Drug vs. EE phase E asexual E sexual Vector

quinine - + - -

quinacrine - + - -

chloroquine - + - +

amodiaquine - + - -

primaquine + - + -

pyremethamine - + - +

Tetracycline/ - + - -
doxycycline

mefloquine - + - -

halofantrine - + - -

artemisine - + - -

chloroguanide - + - +
Mechanism of Action of Drugs:
* Aminoquinolones: inhibits proteolysis of hemoglobin
in food vacuoles
(chloroquine; quinine; amodiaquine; mefloquine;
halofantrine)

*chloroquine: alkalinize plasmodium

food vacuoles

*artemisinin: binds to the iron in

malarial pigment to yield
free radicals
Indications for admission:
1. Pregnancy
2. Children < 5 years old
3. Individuals with asexual P. falciparum
parasitemia
4. Individuals with persistent symptoms
despite taking antimalarials
5. Manifestations of severe malaria
 Poor prognostic signs:
1. Age less than 3 years old
2. Seizures within 3 hours of admssion
accompanied by decerebrate posturing and
absent corneal reflex
3. Hyperparasitemia (> 5%)
4. Schizonts in blood smear
5. Leukocytosis of > 12,000
6. Severe anemia <7 gms/dl
7. Low CSF sugar
8. Serum creatinine of >265umol/l
9. Hypoglycemia despite glucose infusion
10.Liver function tests >3X normal level
11. Metabolic acidosis in children
Specific treatment:
Uncomplicated Malaria
1. chloroquine: all types of malaria except in P. falciparum
®
adult: 1 gm initially
500 mg 6 hours after
500 mg OD for 2 days
parenteral: 250 mg at 125 mg IM at
each buttock q 8 hours for
total of 1000 mg
AD: 250 mg tablet; 50 mg/ml injection

2. Sulfadoxine 500mg/ 25 pyremethamine (fansidar):

P. falci ® : 2-3 tablets single dose
• Drug Resistance Patterns:
- based on chloroquine standard
treatment
- asexual stages cleared after 3
days after initiation of treatment
and definitely in 6-7days
Recrudescence: increase in surviving population of E
plasmodia

Recurrence: True Relapse: reappearance of signs and

symptoms after a significant period
during which the parasite have been
absent in PBS

Relapse: hypnozoites in EE

* mechanism: chloroquine efflux mechanism

Level of Asexual Alternative
response parasitemia Drug

Sensitive (S) Clearance within 48 hrs of

treatment, no recrudescence
Resistant
R1 Clearance by 48th hr; Pyremeth/Sulfa
recrudescence within 14 days after
start of Rx

R1 late Chloroquine repeat

Clearance by 48th
hr; course
recrudescence between 14-28 days

Pyremeth/sulfa
Reduction of parasitemia by 75%
RII within 48 hrs but no clearance by
the 7th day of Rx

RIII Quinine tablet

No reduction or rise after start of
Rx
Severe Malaria
1. Quinine HCl (0.25 gm/amp)
- 8 ampules in 500 cc D5W to run at 125 cc in 2
hours then q 6 hrs IV
2. Quinine SO4
- 1 gm to 500 cc D5W to run 150 cc q 8hrs for 3
doses
3. Quinine biS04 (325 mg tablet)
- 2 tablets q 8 hrs. for 7 days
4. Quinine diHCl: 500 mg/ml ampule
- IV infusion in 4 hours
- loading dose: 20 mg/kg
10 mg/kg q 8-12 hrs.
Alternative Treatment for P. falci ®
1. Mefloquine (Lariam: 250 mg tablet)
40-60 kgs: 3 tabs initially then 2
tabs after 6 hrs
60 kg >: 3 tabs initially then 2
tabs 6 hrs after, then 1 tab 6 hrs after
2. Halofantrine (Halfan: 250 mg tabs;
100 mg/5 ml susp)
> 37 kgs: 6 tablets in 2 div. doses given 6
hourly
3. Mefloquine/Sulfadoxine (Fansimef)
60 kgs: 2 tabs single dose
60 kgs >: 3 tabs single dose
4. Tetracycline: 250 mg QID for 7 days
Doxycycline: 100 mg BID for 7-10 days

Tissue Stages:
Primaquine: 25 mg base OD for 14 days
 chemoprophylaxis

Drug ® in area Prophylactic alternative

drug

none chloroquine Pyremeth/sulfa

chloroquine doxycycline Pyremeth/sulfa

Chloroquine & Doxycycline or Quinine sulfate

pyremeth/sulfa mefloquine tablet +
tetracycline
(erythromycin for <
7 y/o
Chemoprophylaxis

1.chloroquine: start 1-2 weeks prior to travel up to

4 weeks upon leaving the area
adult dose: 300 mg base weekly
pedia: 5 mg/kg base max. 300 mg

2. doxycycline: 2-3 days prior to travel up to 4

weeks upon leaving the area
adult: 100 mg OD
pedia: 2 mg/kg up to 100mg OD for >7y/o
3. mefloquine: start 1 week prior
to travel up to 4 weeks upon
leaving the area
> 45 kg= 250 mg weekly
< 45 kg= 5 mg/kg to max. 250
mg weekly
Mosquito: THE VECTOR
Mosquito: THE VECTOR
Anopheles flavirostris :
primary vector in the Phils.

A. litoralis:
secondary vector
- breeds in slow-flowing , clear , partially
shaded streams with vegetations; foothills
and also in wells

• endophagic, endophilic, anthrophilic

 not transovarial
 infective for as long as 90 days
 may hibernate
• Vectorial Capacity:
– susceptible to infection
– present in effective numbers near human
habitation
– repeatedly takes human blood rather than
animal blood
– lives long enough for gametocytes to develop
into sporozoites
Control measures:
1.Prevention of human-vector contact
 Chemically treated bednets
 Repellants; spraying living places
 DEET, topical application as repellants
 Soap with DEET and permethrin
 Screen, protective clothings
 Zooprophylaxis
2. Destruction of adult vector
Biologic control, predators
Chemical control: residual spraying
malathion, DDT
3. destruction of larvae
Biologic control: predators
Chemical control: petrolatum oil,
temephos
4. reduction of breeding sites
Environmental modification
Water management

5. destruction of parasites
Chemotherapy/chemoprophylaxis
vaccine
New concepts:

 Malaria immunity is specific for homologous

strains of parasites but ineffective against
heterologous strains and species
 Major protective mechanism of the parasite:
antigenic variation
Natural Resistance: humoral
1. Species specificity
2. Stage specificity:
vaccination vs. blood stages has NO
effect on initial sporozoite induced
infection
- vs. sporozoite
- vs. merozoite
- vs. schizont
3. Antigenic variation demonstrated by:
a. reaction to monoclonal antibodies
b. identification of surface antigen
types
c. reaction with immune sera
d. molecular characterization

4. Immune suppression