What is malaria?

Malaria is an infectious disease caused by a parasite, Plasmodium, which infects red blood cells. Malaria is
characterized by cycles of chills, fever, pain and sweating. Historical records suggest malaria has infected humans
since the beginning of mankind. The name "mal 'aria" (meaning "bad air" in Italian) was first used in English in 1740
by H. Walpole when describing the disease. The term was shortened to "malaria" in the 20th century. C. Laveran in
1880 was the first to identify the parasites in human blood. In 1889, R. Ross discovered that mosquitoes transmitted
malaria. Of the four species of malaria, the most serious type is Plasmodium falciparum malaria. It can be life-
threatening. The other three species of malaria (P. vivax, P. malariae, and P. ovale) are generally less serious and
are not life-threatening.

How is malaria transmitted?

The life cycle of the parasite is complicated (for life cycle details, see
http://www.cdc.gov/malaria/biology/life_cycle.htm) and involves two hosts, humans and Anopheles mosquitoes. The
disease is transmitted to humans when an infected Anopheles mosquito bites a person and injects the malaria
parasites (sporozoites) into the blood. Sporozoites travel through the bloodstream to the liver, mature, and eventually
infect the human red blood cells. While in red blood cells, the parasites again develop until a mosquito takes a blood
meal from an infected human and ingests human red blood cells containing the parasites. Then the parasites reach
the Anopheles mosquito's stomach and eventually invade the mosquito salivary glands. When an Anopheles
mosquito bites a human, these sporozoites complete and repeat the complex Plasmodium life cycle. P. ovale and P.
vivax can further complicate the cycle by producing dormant stages (hypnozoites) that may not develop for weeks to
years.

Where is malaria a particular problem?

Malaria is a particular problem and a major one in areas of Asia, Africa, and Central and South America.
Unless precautions are taken, anyone living in or traveling to a country where malaria is present can get the
disease. Malaria occurs in about 100 countries; approximately 40% of the world population is at risk for
contracting malaria. To get information on countries that have current malaria infection problems, the CDC
(Centers for Disease Control) has a constantly updated website that lists the problem areas in detail: What
is the incubation period for malaria?

The period between the mosquito bite and the onset of the malarial illness is usually one to three weeks (seven to 21
days). This initial time period is highly variable as reports suggest that the range of incubation periods may range
from four days to one year. The usual incubation period may be increased when a person has taken an inadequate
course of malaria prevention medications. Certain types of malaria (P. vivax and P. ovale) parasites can also take
much longer, as long as eight to 10 months, to cause symptoms. These parasites remain dormant (inactive or
hibernating) in the liver cells during this time. Unfortunately, some of these dormant parasites can remain even after a
patient recovers from malaria, so the patient can get sick again. This situation is termed relapsing malaria.

How is malaria diagnosed?

Clinical symptoms listed above, when associated with travel to countries that have identified malarial risk, suggest
malaria as a diagnosis. Malaria tests are not routinely ordered by most physicians in developed countries so
recognition of travel history is essential.

The classic and most used test is the blood smear on a microscope slide that is stained (Giemsa stain) to show the
parasites inside red blood cells. Although this test is easily done, correct results are dependent on the technical skill
of the lab technician who prepares and examines the slides with a microscope. Other tests based on immunologic
principles exist, including RDT's (rapid diagnostic tests) approved for use in the U.S. in 2007 and the polymerase
chain reaction (PCR) tests. These are not yet widely available and are more expensive than the traditional Giemsa
blood smear. Some investigators suggest such immunologic based tests be confirmed with a Giemsa blood smear.

How is malaria treated?

 Three main factors determine treatments: the infecting species of Plasmodium parasite, the clinical situation of the
patient (for example, adult, child, or pregnant female with either mild or severe malaria), and the drug susceptibility of
the infecting parasites. Drug susceptibility is determined by the geographic area where the infection was acquired.
Different areas of the world have malaria types that are resistant to certain medications. The correct drugs for each
type of malaria must be prescribed by a doctor who is familiar with malaria treatment protocols. Since people infected
with P. falciparum malaria can die (often because of delayed treatment), immediate treatment for P. falciparum
malaria is necessary.

Mild malaria can be treated with oral medication; severe malaria (one or more symptoms of either impaired
consciousness/coma, severe anemia, renal failure, pulmonary edema, acute respiratory distress syndrome, shock,
disseminated intravascular coagulation, spontaneous bleeding, acidosis, hemoglobinuria [hemoglobin in the urine],
jaundice, repeated generalized convulsions, and/or parasitemia [parasites in the blood] of > 5%) requires intravenous
(IV) drug treatment and fluids.

Drug treatment of malaria is not always easy. Chloroquine phosphate is the drug of choice for all malarial parasites
except for chloroquine-resistant Plasmodium strains. Although almost all strains of P. malariae are susceptible to
chloroquine, P. falciparum, P. vivax and even some P. ovale strains have been reported as resistant to chloroquine.
Unfortunately, resistance is usually noted by drug-treatment failure in the individual patient. There are, however,
multiple drug-treatment protocols for treatment of drug resistant Plasmodium strains (for example, quinine sulfate plus
doxycycline [Vibramycin, Oracea, Adoxa, Atridox] or tetracycline [Achromycin], or clindamycin [Cleocin], or
atovaquone-proguanil [Malarone]). There are specialized labs that can test the patient's parasites for resistance, but
this is not done frequently. Consequently, treatment is usually based on the majority of Plasmodium species
diagnosed and its general drug-resistance pattern for the country or world region where the patient became infested.
For example, P. falciparum acquired in the Middle East countries is usually susceptible to chloroquine, but if acquired
in sub-Sahara African countries, is usually resistant to chloroquine.

http://www.cdc.gov/malaria/travel/index.htm#riskareas.

What are the signs and symptoms of malaria?

The symptoms characteristic of malaria include flu-like illness with fever, chills, muscle aches, and headache. Some
patients develop nausea, vomiting, cough, and diarrhea. Cycles of chills, fever, and sweating that repeat every one,
two, or three days are typical. There can sometimes be vomiting, diarrhea, coughing, and yellowing (jaundice) of the
skin and whites of the eyes due to destruction of red blood cells and liver cells.

People with severe P. falciparum malaria can develop bleeding problems, shock, liver or kidney failure,
central nervous system problems, coma, and can die from the infection or its complications. Cerebral
malaria (coma, or altered mental status or seizures) can occur with severe P. falciparum infection. It is lethal
if not treated quickly; even How do I keep from getting malaria?

If you are traveling to an area known to have malaria, find out which medications you need to take, and take them as
prescribed. Current CDC recommendations suggest individuals begin taking antimalarial drugs about one to two
weeks before traveling to a malaria infested area and for four weeks after leaving the area. Your doctor, travel clinic,
or the health department can advise you as to what medicines to take to keep from getting malaria. Currently, there is
no vaccine available for malaria, but researchers are trying to develop one.

wHow do I keep from getting malaria?

If you are traveling to an area known to have malaria, find out which medications you need to take, and take them as
prescribed. Current CDC recommendations suggest individuals begin taking antimalarial drugs about one to two
weeks before traveling to a malaria infested area and for four weeks after leaving the area. Your doctor, travel clinic,
or the health department can advise you as to what medicines to take to keep from getting malaria. Currently, there is
no vaccine available for malaria, but researchers are trying to develop one.

ith treatment, about 15%-20% die. What other precautions should I take to avoid malaria?
 If possible, avoid travel to or through countries where malaria occurs. If you must go to areas where malaria occurs,
take the prescribed preventive medicine. In addition, the 2008 CDC international travel recommendations suggest the
following precautions be taken in malaria infested areas:

 Avoid exposure to mosquitoes during the early morning and early evening hours between the hours of dusk
and dawn (the hours of greatest mosquito activity).

 Wear appropriate clothing (long-sleeved shirts and long pants, for examples) especially when you are
outdoors.

 Apply insect repellent to the exposed skin. The CDC recommended insect repellent should contains up to
50% DEET (N,N-diethyl-m-toluamide), which is the most effective mosquito repellent for adults and children
over 2 months of age.

 Spray mosquito repellents on clothing to prevent mosquitoes from biting through thin clothing.

 Use a permethrin-coated (or similar repellant) mosquito net over your all beds.

 Have screens over cover windows and doors.

 Spray permethrin or a similar insecticide in the bedroom before going to bed.

What other precautions should I take to avoid malaria?

If possible, avoid travel to or through countries where malaria occurs. If you must go to areas where malaria occurs,
take the prescribed preventive medicine. In addition, the 2008 CDC international travel recommendations suggest the
following precautions be taken in malaria infested areas:

 Avoid exposure to mosquitoes during the early morning and early evening hours between the hours of dusk
and dawn (the hours of greatest mosquito activity).

 Wear appropriate clothing (long-sleeved shirts and long pants, for examples) especially when you are
outdoors.

 Apply insect repellent to the exposed skin. The CDC recommended insect repellent should contains up to
50% DEET (N,N-diethyl-m-toluamide), which is the most effective mosquito repellent for adults and children
over 2 months of age.
 Spray mosquito repellents on clothing to prevent mosquitoes from biting through thin clothing.

 Use a permethrin-coated (or similar repellant) mosquito net over your all beds.

 Have screens over cover windows and doors.

 Spray permethrin or a similar insecticide in the bedroom before going to bed.