Malaria- الملاريا

BY: Sara basim

About Disease ..

Infection with malaria parasites may result in a wide variety of symptoms, ranging from absent or very mild symptoms to severe disease and even death. Malaria disease can be categorized as uncomplicated or severe (complicated). In general, malaria is a curable disease if diagnosed and treated promptly and correctly.

All the clinical symptoms associated with malaria are caused by the asexual erythrocytic or blood stage parasites. When the parasite develops in the erythrocyte, numerous known and unknown waste substances such as hemozoin pigment and other toxic factors accumulate in the infected red blood cell. These are dumped into the bloodstream when the infected cells lyse and release invasive merozoites. The hemozoin and other toxic factors such as glucose phosphate isomerase (GPI) stimulate macrophages and other cells to produce cytokines and other soluble factors which act to produce fever and rigors and probably influence other severe pathophysiology associated with malaria.

Plasmodium falciparum-infected erythrocytes, particularly those with mature trophozoites, adhere to the vascular endothelium of venular blood vessel walls and do not freely circulate in the blood. When this sequestration of infected erythrocytes occurs in the vessels of the brain it is believed to be a factor in causing the severe disease syndrome known as cerebral malaria, which is associated with high mortality.

Incubation Period

Following the infective bite by the Anophelesmosquito, a period of time (the “incubation period”) goes by before the first symptoms appear. The incubation period in most cases varies from 7 to 30 days. The shorter periods are observed most frequently with P. falciparum and the longer ones with P. malariae.

Antimalarial drugs taken for prophylaxis by travelers can delay the appearance of malaria symptoms by weeks or months, long after the traveler has left the malaria-endemic area. (This can happen particularly with P. vivax and P. ovale, both of which can produce dormant liver stage parasites; the liver stages may reactivate and cause disease months after the infective mosquito bite.)

Such long delays between exposure and development of symptoms can result in misdiagnosis or delayed diagnosis because of reduced clinical suspicion by the health-care provider. Returned travelers should always remind their health-care providers of any travel in areas where malaria occurs during the past 12 months.

 

Uncomplicated Malaria

The classical (but rarely observed) malaria attack lasts 6–10 hours. It consists of

• A cold stage (sensation of cold, shivering)
• A hot stage (fever, headaches, vomiting; seizures in young children); and
• Finally a sweating stage (sweats, return to normal temperature, tiredness).

Classically (but infrequently observed) the attacks occur every second day with the “tertian” parasites (P. falciparum, P. vivax, and P. ovale) and every third day with the “quartan” parasite (P. malariae).

More commonly, the patient presents with a combination of the following symptoms:

• Fever
• Chills
• Sweats
• Headaches
• Nausea and vomiting
• Body aches
• General malaise

In countries where cases of malaria are infrequent, these symptoms may be attributed to influenza, a cold, or other common infections, especially if malaria is not suspected. Conversely, in countries where malaria is frequent, residents often recognize the symptoms as malaria and treat themselves without seeking diagnostic confirmation (“presumptive treatment”).
Physical findings may include the following:

• Elevated temperatures
• Perspiration
• Weakness
• Enlarged spleen
• Mild jaundice
• Enlargement of the liver
• Increased respiratory rate

Diagnosis of malaria depends on the demonstration of parasites in the blood, usually by microscopy. Additional laboratory findings may include mild anemia, mild decrease in blood platelets (thrombocytopenia), elevation of bilirubin, and elevation of aminotransferases.

Severe Malaria

Severe malaria occurs when infections are complicated by serious organ failures or abnormalities in the patient’s blood or metabolism. The manifestations of severe malaria include the following:

• Cerebral malaria, with abnormal behavior, impairment of consciousness, seizures, coma, or other neurologic abnormalities
• Severe anemia due to hemolysis (destruction of the red blood cells)
• Hemoglobinuria (hemoglobin in the urine) due to hemolysis
• Acute respiratory distress syndrome (ARDS), an inflammatory reaction in the lungs that inhibits oxygen exchange, which may occur even after the parasite counts have decreased in response to treatment
• Abnormalities in blood coagulation
• Low blood pressure caused by cardiovascular collapse
• Acute kidney injury
• Hyperparasitemia, where more than 5% of the red blood cells are infected by malaria parasites
• Metabolic acidosis (excessive acidity in the blood and tissue fluids), often in association with hypoglycemia

Severe malaria is a medical emergency and should be treated urgently and aggressively.

Malaria Relapses

In P. vivax and P. ovale infections, patients having recovered from the first episode of illness may suffer several additional attacks (“relapses”) after months or even years without symptoms. Relapses occur because P. vivax and P. ovale have dormant liver stage parasites (“hypnozoites”) that may reactivate. Treatment to reduce the chance of such relapses is available and should follow treatment of the first attack.

 

Control programs

 

In Ghana ..

National Malaria Control Programme

Attempts to control malaria in Ghana began in the 1950s. Eradication methods then included massive drain construction, chloroquine impregnated salts, aerial spraying and weekly swallowing of daraprim called “Sunday Sunday” medicine as preventive care. Despite government efforts between 1960 and 2000, malaria continued to be one of the leading causes of premature death in the country.

The establishment of the Malaria Control Programme has changed the scene. Known at first as the Malaria Control Unit, it was under the Public Health Department of the Ministry of Health. It is now located under the Disease Control Unit.

The government launched an aggressive Roll Back Malaria (RBM) initiative in 1999 that emphasized the strengthening of health services through multi and inter-sectoral partnerships and making treatment and prevention strategies more widely available. In the year 2000, the first National Malaria Strategic Plan (2000-2010) was developed with the goal to reduce malaria specific morbidity and mortality by 50% by the year 2010 thereby involving a broader group of stakeholders.

Since that time, new and effective interventions such as treatment of uncomplicated malaria using artemisinin-based combination therapy (ACT), malaria prevention in pregnancy through use of sulfadoxine-pyrimethamine (SP), and indoor residual spraying (IRS) emerged.

The Abuja declaration of May 2006 aimed at achieving and sustaining universal access to appropriate interventions for all populations at risk of malaria. A second strategic plan (2008-2015) was developed to take care of these new developments as well as the Millennium Development Goals (MDGs). The National Malaria Control Strategic Plan for 2014-2020 states the overall goal of the National Malaria Control Program in Ghana as  “to reduce the malaria morbidity and mortality burden by 75% (baseline 2012) by the year 2020”.

 

Symptoms

After being bitten by an infected mosquito, Plasmodium parasites enter the person’s liver, where they begin to multiply. After a number of days (depending on the type of Plasmodium), the parasites re-enter the bloodstream, invade red blood cells and repromalaria duce (WEHI 2023).

The initial flu-like symptoms are likely to include:

• Feeling hot and shivery
• Fever, which may be constant or come and go
• Headache
• Nausea and vomiting
• Muscle and joint pains.

(NSW Health 2022; SA Health 2022)

1. malariae may persist for several years and has been associated with nephrotic syndrome in children (Langford et al. 2015).

Severe malaria may cause symptoms such as:

• Impaired consciousness or coma
• Prostration (inability to sit up without assistance)
• Convulsions
• Pulmonary oedema
• Shock
• Acidosis
• Hypoglycaemia
• Severe anaemia
• Renal impairment
• Jaundice
• Recurrent or prolonged bleeding (e.g. from nose or gums)
• Hyperparasitaemia.

 

Treating & preventing

Malaria is treated with antimalarial medicines to kill the Plasmodium parasites. The exact medicine will depend on factors such as the species of Plasmodium involved, the severity of symptoms, the age of the patient and pregnancy (Mayo Clinic 2023).

Note that there is increasing resistance to antimalarials, so it’s recommended that treatment is overseen by an infectious disease specialist or other expert (SA Health 2022).

Cases of severe malaria require intravaneous administration of antimalarials. If the attack is not classified as severe, oral medications may be used (Buck & Finnigan 2023).

1. vivax and P. ovale may have dormant stages (hypnozoites) that persist in the liver and are not killed by the medication used for the acute attack. The patient may need to take primaquine to eradicate these dormant parasites (Buck & Finnigan 2023).

Anyone travelling to a malarious region should take precautions. This includes consulting a physician to prescribe preventative antimalarial drugs (NSW Health 2022).

No antimalarial drug is 100% effective, so taking precautions to avoid mosquito bites is also crucial. These include:

• Being vigilant if spending time outdoors around dawn and dusk and into the evening
• Wearing loose, light-coloured, long-sleeved shirts and long pants when outdoors
• Wearing socks and covered shoes when outdoors
• Applying mosquito repellent to exposed skin and on clothing
• Avoiding perfumes, colognes or aftershaves, which may attract mosquitoe
• Sleeping in screened or air-conditioned rooms if possible, and using a mosquito net if not
• Using ‘knockdown’ sprays, mosquito coils and plug-in vaporising devices.

(NSW Health 2022; Better Health Channel 2015)

 

Malaria geography

In 2020, an estimated 627,000 people died of malaria—most were young children in sub-Saharan Africa. Within the last decade, increasing numbers of partners and resources have rapidly increased malaria control efforts. This scale-up of interventions has saved millions of lives globally and cut malaria mortality by 36% from 2010 to 2020, leading to hopes and plans for elimination and ultimately eradication. CDC brings its technical expertise to support these efforts with its collaborative work in many malaria-endemic countries and regions.

Malaria’s impact

Malaria occurs mostly in poor tropical and subtropical areas of the world. In many of the countries affected by malaria, it is a leading cause of illness and death. In areas with high transmission, the most vulnerable groups are young children, who have not developed immunity to malaria yet, and pregnant women, whose immunity has been decreased by pregnancy. The costs of malaria – to individuals, families, communities, nations – are enormous.

Malaria occurs mostly in poor, tropical and subtropical areas of the world. Africa is the most affected due to a combination of factors:

• A very efficient mosquito (Anopheles gambiae  complex) is responsible for high transmission.
• The predominant parasite species is Plasmodium falciparum , which is the species that is most likely to cause severe malaria and death.
• Local weather conditions often allow transmission to occur year round.
• Scarce resources and socio-economic instability have hindered efficient malaria control activities.
• In other areas of the world, malaria is a less prominent cause of deaths, but can cause substantial disease and incapacitation, especially in some countries in South America and South Asia.