MALARIA:

EPIDEMIOLOGY,
CLINICAL FEATURES,
DIAGNOSIS, AND
TREATMENT
Dr Manju Rose Sebastian
SR- ID
Govt Medical College, Kottayam
Introduction to Malaria
• Malaria is a life-threatening disease caused by
Plasmodium parasites.
• Transmitted through bites of infected Anopheles
mosquitoes.
• Endemic in tropical and subtropical regions.
Epidemiology
•In 2022, 249 million malaria cases were reported worldwide.
•608,000 deaths occurred, with the highest burden in sub-Saharan Africa.
•Children under 5 years account for ~80% of malaria deaths.

Geographic Distribution
•Endemic in 91 countries, mainly in Africa, South Asia, and South America.

•High-burden countries: Nigeria, DR Congo, Uganda, Mozambique, and India.

•Plasmodium falciparum (most severe) is dominant in Africa.

•Plasmodium vivax is more common in Asia and Latin America
Epidemiology
Transmission & Seasonality
•Peak transmission occurs in rainy seasons due to increased mosquito breeding.
•Stable transmission: Continuous year-round cases (e.g., West Africa).
•Unstable transmission: Seasonal outbreaks (e.g., parts of South Asia).

Risk Factors
•Environmental: Warm temperatures, stagnant water (breeding sites).
•Social: Poor healthcare access, poverty, lack of preventive measures.
•Biological: Lack of immunity in young children and pregnant women.
Etiology & Transmission
• Caused by Plasmodium species:
- P. falciparum (most severe)
- P. vivax
- P. ovale
- P. malariae
- P. knowlesi (zoonotic)
• Spread via mosquito bites, blood transfusion, congenital
transmission.
Life cycle
 Pathogenesis
• Red cells infected with malaria are prone to hemolysis.
• P falciparum causes more severe hemolysis as it affects red cells
of all ages especially young cells. P vivax and ovale affect
reticulocytes

• In falciparum malaria, the infected RBCs adhere to the vascular

endothelium in the postcapillary venules in brain, kidney, lungs,
liver, brain and gut by the formation of knob proteins.

• They form rosettes and rouleaux with uninfected red cells

• Vessel congestion causes organ damage.

Pathogenesis
Clinical Features
•Uncomplicated Malaria:
•Cyclical fever, chills, headache, muscle pain.

Nausea, vomiting, diarrhea.

Hepatosplenomegaly

•Severe Malaria
Cerebral malaria, jaundice, anemia
Severe malaria
Category Severe Malaria Features

Neurological Impaired consciousness, seizures, coma (cerebral malaria)

Respiratory Severe breathing difficulty, pulmonary edema (ARDS)

Cardiovascular Circulatory collapse, shock, severe hypotension

Hematological Severe anemia (Hb < 5 g/dL), DIC, abnormal bleeding

Metabolic Acidosis High lactate, deep breathing (Kussmaul respiration)

pH < 7.3, Bicarbonate < 15 mmol/L

Hypoglycemia Confusion, seizures, coma

Blood glucose < 2.2 mmol/L (40 mg/dL)
Renal Failure Acute kidney injury, dark urine (blackwater fever)
Creatinine > 3 mg/dL (265 µmol/L)

Jaundice Yellowing of skin/eyes, liver dysfunction

Bilirubin > 50 µmol/L (3 mg/dL)
Diagnosis of Malaria
• Microscopy (Gold Standard): Blood smear for parasite
detection.
• Rapid Diagnostic Tests (RDTs): Detect antigens from
Plasmodium.
• Polymerase Chain Reaction (PCR): Highly sensitive but
expensive.
• Serology: Detects past infections (not useful for active
disease).
 GIEMSA STAIN
Smears for diagnosis

THIN SMEAR THICK SMEAR

Sensitive for low level

Species identification infection
Parasite morphology Estimates the parasite
density

Advantages Limitations

 Gold standard  Skilled technicians

 All malaria species  Time consuming
 Parasite density  Special staining and
microscopy
Species differentiation
Plasmodium falciparum
Ring forms and gametocytes
seen.
Giemsa stain showing Plasmodium vivax schizont
containing 20 merozoites.
 RDT for diagnosis

- Point of care tests

- Rapid diagnosis

Types of RDTs
•HRP2-based RDTs: Detect P. falciparum antigen
(Histidine-Rich Protein 2).
•pLDH-based RDTs: Detect multiple Plasmodium
species (Parasite Lactate Dehydrogenase).
•Aldolase-based RDTs: Used for detecting non-
falciparum species.
Quina- quina (bark
of barks)

Countess of
chinchon
Treatment of Malaria
Uncomplicated Malaria:
• P. falciparum: Artemisinin-based combination therapy (ACTs).
• P. vivax, P. ovale: Chloroquine + Primaquine (to clear liver
stages).

Severe Malaria:
• Intravenous Artesunate.
• Supportive care (fluids, blood transfusion, oxygen).
 Artemisinin-based
Combination Therapy (ACT)
Gold standard treatment for uncomplicated P.
falciparum malaria. Common ACTs:
- Artesunate-sulphadoxine
Combines fast-acting artemisinin derivative - Artemether-Lumefantrine
with a long-acting partner drug. (AL)
- Artesunate-Amodiaquine
(AS+AQ)
- Dihydroartemisinin-
Reduces parasite load rapidly, preventing Piperaquine (DHA-PPQ)
resistance. - Artesunate-Mefloquine
(AS+MQ)
Recommended for first-line treatment in
malaria-endemic regions.
Uncomplicated vivax
malaria
First-line Treatment
•
•Chloroquine (CQ):
25 mg/kg over 3 days (where CQ
SPECIAL resistance is not present).
CONSIDERATIONS
•G6PD Deficiency: Primaquine is contraindicated; use weekly PQ (0.75
•Artemisinin-based Combination Therapy (ACT): If CQ-resistant P. vivax is
mg/kg) for 8 weeks under medical supervision.
suspected
•Pregnant Women: Chloroquine is safe; Primaquine is avoided until
after delivery.
•Lactating Women: Primaquine can be used if the infant is G6PD-
normal and over 6 months old.
Radical Cure (Hypnozoite Clearance)
•Primaquine (PQ): 0.25–0.5 mg/kg/day for 14 days (to prevent relapse).
•Tafenoquine (alternative to PQ): Single dose (3.5 mg/kg), requires G6PD
testing before administration.
 Severe malaria
First-line Treatment
•Intravenous (IV) Artesunate (preferred option)

•Dose: 2.4 mg/kg at 0, 12, and 24 hours, then once daily until oral
therapy is tolerated.

Alternative Treatments (if IV Artesunate is unavailable)

•Intramuscular (IM) Artesunate (same dosing as IV).

•Intramuscular Artemether (3.2 mg/kg loading dose, then 1.6 mg/kg daily).

•Intravenous Quinine (if no artemisinin available; requires cardiac

monitoring).
 Severe malaria
•Blood transfusion for severe anemia.

•Anticonvulsants if seizures occur.

•Glucose monitoring (risk of hypoglycemia with quinine or artesunate).

•Fluids and electrolytes monitoring to prevent complications.

Switch to Oral Therapy

•After 24 hours of IV treatment, complete therapy with 3 days of Artemisinin-
based Combination Therapy (ACT).
Prevention & Control
• Mosquito control: Insecticide-treated nets (ITNs), indoor
spraying.
• Prophylaxis for travelers: Mefloquine, Chloroquine,
Atovaquone-proguanil, Doxycycline.
• Vaccine (RTS,S/AS01 – limited efficacy).
 RTS,S Vaccine
•The RTS,S/AS01 vaccine is the first approved malaria vaccine and was
developed by GSK.
WHO endorsed for high-risk areas.

•Targets Plasmodium falciparum.

•Contains a part of the P. falciparum circumsporozoite protein (CSP).
• Triggers an immune response to prevent liver-stage infection

• Reduces clinical malaria by 30-40% in children

• 4 dose regimen at 5,6,7 and 18 months.

• Requires booster doses to maintain immunity
Test your knowledge
Which stage of the
Plasmodium life cycle infects
human red blood cells?
a) Sporozoite
b) Merozoite
c) Gametocyte
d) Hypnozoite
Which test is considered the
“gold standard” for malaria
diagnosis?
a) Rapid Diagnostic Test (RDT)
b) PCR
c) Peripheral Blood Smear
(Microscopy)
d) Serology
Which stain is most
commonly used for
microscopic detection of
malaria parasites?
a) Gram stain
b) Ziehl-Neelsen stain
c) Giemsa stain
d) India ink
Which of the following is the first-line
treatment for P. falciparum malaria?
a) Chloroquine
b) Primaquine
c) Artemisinin-based Combination Therapy
(ACT)
d) Doxycycline
•Which of the following is NOT a
feature of severe malaria?
a) Cerebral malaria
b) Severe anemia
c) Hemoglobinuria
d) Rhinorrhea
•The RTS,S vaccine primarily
provides protection against which
malaria species?
a) Plasmodium vivax
b) Plasmodium falciparum
c) Plasmodium malariae
d) Plasmodium knowlesi
Primaquine is used to treat the
hypnozoites of which malaria
species?
a) P. falciparum
b) P. malariae
c) P. vivax
d) P. knowlesi
A 25-year-old male presents to the emergency department with a
history of fever, chills, and profuse sweating for the past 3
days. His fever pattern is irregular. He has recently returned from
Jharkhand.

On examination, he is febrile (39.5°C), tachycardic, and mildly

jaundiced. Laboratory investigations reveal:
•Hemoglobin: 7.8 g/dL
•Platelet count: 90,000/mm³
•Bilirubin: 4.2 mg/dL
•Blood smear
Based on the image and clinical findings,
which of the following is the most appropriate
next step in management?
A) Start oral chloroquine therapy
B) Admit the patient and start IV artesunate
C) Perform a blood culture for bacterial sepsis
D) Discharge with symptomatic treatment