MALARIA

Definition : a protozoan infection of red blood cells transmitted by the bite of a blood-feeding female anopheline mosquito.

Epidemiology :
a. distribution

 Approximately 5% of the world’s population is infected, and it causes over 1 million deaths each year.
 Malaria is endemic in 109 countries and is found throughout the tropics
 It is the most important of the parasitic diseases of humans, with transmission in 107 countries containing 3 billion people
and causing 1–3 million deaths each year.
 Malaria has now been eliminated from the United States, Canada, Europe, and Russia but, despite enormous control
efforts, has resurged in many parts of the tropics.
 Occasional local transmission after importation of malaria has occurred recently in several southern and eastern areas of
the United States and in Europe, indicating the continual danger to nonmalarious countries.
 a heavy burden on tropical communities, a threat to nonendemic countries, and a danger to travelers.
 In Africa, P. falciparum predominates, as it does in Papua New Guinea and Haiti
 P. vivax is more common in Central and parts of South America, North Africa, the Middle East and the Indian subcontinent.
 The prevalence of both species is approximately equal in other parts of South America, South-east Asia and Oceania.
 P. vivax is rare in sub-Saharan Africa (except for the horn of Africa), whereas P. ovale is common only in West Africa. P.
malariae is found in most areas, but is relatively uncommon outside Africa.
 Malaria was once endemic in Europe and northern Asia, and was introduced to North America, but it has been eradicated
from these areas.
 In northern China and North Korea P. vivax strains (P. vivax hibernans) with long incuba- tion periods and long intervals (10–
12 months) between relapses may still be found.

b. mosquito vector
 Malaria is transmitted by some species of anopheline mosquitoes.
 The optimum conditions for transmission are high humidity and an ambient temperature between 20 and 30°C. Although
rainfall provides breeding sites for mosquitoes, excessive rainfall may wash away mosquito larvae and pupae.
 The most important pertain to the anopheline mosquito vector, and in particular its longevity. As sporogony (development
of the sporozoite parasites in the vector) takes over a week (depending on ambient temperatures), the mosquito must
survive for longer than this after feeding on a gametocyte-carrying human, if malaria is to be transmitted.
 malaria transmission is directly proportional to the density of the vector, the square of the number of times each day that
the mosquito bites man, and the tenth power of the probability of the mosquito survivng for 1 day.
 There is also considerable variation in the ability of anopheline mosquitoes to transmit malaria (the vectorial capacity).
There are nearly 400 species of anopheline mosquitoes and many are species complexes. Confusingly, the taxonomy
continually changes as differences within species complexes are characterized. Approximately 80 anopheline species can
transmit malaria, 66 are considered natural vectors, and about 45 are considered important vectors. Each vector has its
own behaviour patterns and even within species these can vary between geographical areas.

c. The human host

 The behaviour of man also plays an important role in the epidemiology of malaria. There must be a human reservoir of
viable gametocytes to transmit the infection.
 In areas of high transmission, infants and young children are more susceptible to malaria than the more immune older
children and adults. Parasite densities are higher and gametocytaemia is detected more frequently in children. In endemic
areas the relative contributions to overall transmission of the younger age group, who have higher parasite densities,
become ill more often, and are therefore more likely to receive drugs, versus the older asymptomatic individuals who have
more immunity, lower parasite densities, and are less likely to receive antimalarial treatment, are unclear.

d. Malaria mortality and morbidity

 e. Clinical epidemiology

Etiology

 4 species of genus Plasmodium : P. falciparum, P. vivax, P. ovale, and P. malariae

 Almost all deaths are caused by falciparum malaria
Diagnosis

 Malaria is diagnosed by microscopic examination of the blood. The diagnosis of malaria rests on the demonstration of
asexual forms of the parasite in stained peripheral-blood smears. After a negative blood smear, repeat smears should be
made if there is a high degree of suspicion. Of the Romanowsky stains, Giemsa at pH 7.2 is preferred; Wright’s, Field’s, or
Leishman’s stain can also be used. Both thin (Figs. 203-4 and 203-5) and thick (Figs. 203-6, 203-7, 203-8, and 203-9) blood
smears should be examined. The thin blood smear should be rapidly air-dried, fixed in anhydrous methanol, and stained;
the RBCs in the tail of the film should then be examined under oil immersion ( 1000 magnification).

Thin film Thick film

immersed in the red stain (Field’s B) for 6 s, then the slide is first immersed in the blue stain (Field’s A) for 5 s, then gently
gently washed off for 5 s, then immersed in the washed off (5 s) then the red stain (Field’s B) for 5 s, then gently washed off
blue stain (Field’s A) for 3–4 s and then gently (5 s). Slides should be dried in a slide rack before examining under oil
washed off (5 s) immersion at a magnification of 1000.

the tail of the film should be examined the area of optimum thickness and staining and least artefact is chosen

more accurate for parasite counting approximately 30 times more sensitive

Speciation of malaria at the trophozoite stage is gametocytes and schizonts are more likely to be seen on the thick film
easier on the thin film
FIGURE 203-4 Thin blood films of Plasmodium falciparum. A. Young trophozoites. B. Old trophozoites. C. Pigment in polymorphonuclear cells and trophozoites. D.
Mature schizonts. E. Female gametocytes. F. Male gametocytes.

FIGURE 203-5 Thin blood films of Plasmodium vivax. A. Young trophozoites. B. Old trophozoites. C. Mature schizonts. D. Female gametocytes. E. Male gametocytes.

FIGURE 203-6 Thick blood films of Plasmodium falciparum. A. Trophozoites. B. Gametocytes.

FIGURE 203-7 Thick blood films of Plasmodium vivax. A. Trophozoites. B. Schizonts. C. Gametocytes.
FIGURE 203-8 Thick blood films of Plasmodium ovale. A. Trophozoites. B. Schizonts. C. Gametocytes.

FIGURE 203-9 Thick blood films of Plasmodium malariae. A. Trophozoites. B. Schizonts. C. Ga- metocytes.

 Intradermal smears
Chinese researchers have shown that smears from intradermal blood may contain more mature forms of P. falciparum than
the peripheral blood. This is considered to allow a more complete assessment of severe malaria. The intradermal smears
may also be positive or may show pigment containing leukocytes after the blood smear is negative. In terms of diagnostic
sensitivity the intradermal smear is similar to the bone marrow (i.e. slightly more sensitive than peripheral blood)

 Rapid diagnostic tests

PfHRP2 PfLDH

Most available, least expensive, simplest to perform and the most PfLDH is cleared rapidly from blood, and so the
robust under tropical conditions. test becomes negative within days of
treatment

PfHRP2 is present in parasitized erythrocytes but it is also secreted into

plasma, and plasma concentrations (which can be assessed semi-
quantitatively from the intensity of the colour reaction) are a guide to
the parasite biomass and thus severity

detect only falciparum malaria

remain positive for up to 1 month after the acute infection, particularly

if the parasitaemia was high because PfHRP2 is cleared very slowly from
the blood (This is a disadvantage in areas where transmission is high,
and infections frequent, but is very useful in the diagnosis of severely ill
patients who have received previous antimalarial treatment. Their
parasitaemia may have cleared but the PfHRP2 test will remain strongly
positive)

The introduction of simple, rapid, sensitive, highly specific, and increasingly affordable dipstick or card tests for the
diagnosis of malaria has been a major advance in recent years. These are based on antibody detection of malaria specific
antigens in blood samples; currently histidine rich protein 2 (PfHRP2), parasite lactate dehydrogenase (which is antigenically
distinct from the host enzyme), and aldolase. Current PfHRP2 and PfLDH tests, based on colour reactions, provide a
diagnostic sensitivity for P. falciparum similar to trained microscopists. recently, specific tests for P. vivax have been
developed. Many tests also include ‘pan-malaria’ antibody which detects all malaria species. The cards or sticks then carry
two band colour reactions plus a control (which should be positive). Thus a positive test with these two bands, with a
 negative in the Plasmodium falciparum test, signifies one of the other malaria species is causing the infection (and
therefore, chloroquine rather than another antimalarial drug is required). This part of the test usually is less sensitive than
good microscopy.
 Other techniques

Unlike mature red cells, malaria parasites contain DNA and RNA. This can be stained with fluorescent dyes and visualized
TM
under ultraviolet light microscopy, or, with appropriate filters, seen under ordinary light. In the QBC technique blood
samples are taken into a specialized capillary tube containing acridine orange stain and a float. Under high centrifugal
forces (14000g) the infected erythrocytes, which have a higher buoyant density than uninfected cells, become concentrated
TM
around the float. Using a modified lens adaptor (Paralens ) with its own light source, the acridine orange fluorescence
from malaria parasites can be visual- ized through an ordinary microscope. In some series this system has proved more
sensitive than conventional light microscopy, although it does not give parasite counts or speciation with accuracy, and it is
relatively expensive. It is useful for screening large numbers of blood samples rapidly. DNA probes have also been
developed for malaria diagnosis, but their utility outside epidemiological surveys is uncertain. Detection of malaria antibody
can be useful in some circumstances, such as confirmation of earlier infection, but has no place in acute diagnosis.

 Postmortem diagnosis
The diagnosis of cerebral malaria postmortem can be confirmed from a brain smear. A needle aspirate or biopsy is obtained
through the superior orbital foramen or the foramen magnum. A smear of grey matter is examined after staining the slide
in the same way as for a thin blood film.Capillaries and venules are identified microscopically under low power, and
examined under high power. If the patient died in the acute stage of cerebral malaria, the vessels are packed with
erythrocytes containing mature parasites and a large amount of pigment.

 Laboratory findings
o Normochromic, normocytic anemia is usual.
o The leukocyte count is generally normal, although it may be raised in very severe infections.
o slight monocytosis, lymphopenia, and eosinopenia, with reactive lymphocytosis and eosinophilia
in the weeks after the acute infection.
o The erythrocyte sedimentation rate, plasma viscosity, and levels of C-reactive protein and other
acute-phase proteins are high
o The platelet count is usually reduced to ~105/L.
o Severe infections may be accompanied by prolonged prothrombin and partial thromboplastin
times and by more severe thrombocytopenia.
o Levels of antithrombin III are reduced even in mild infection.
o Findings in severe malaria may include metabolic acidosis, with low plasma concentrations of
glucose, sodium, bicarbonate, calcium, phosphate, and albumin together with elevations in
lactate, BUN, creatinine, urate, muscle and liver enzymes, and conjugated and unconjugated
bilirubin.