Malaria

Malaria

Malaria is an infectious disease caused by a parasite belonging to the Plasmodium genus. It is primarily transmitted from one person to another through female mosquitoes of the Anopheles genus. The illness presents with acute febrile symptoms, including cycles of chills, fever, pain, and sweating.

Historical records indicate that malaria has been afflicting humans since ancient times. There are four main species of malaria parasites that affect humans, namely:

1. Plasmodium falciparum
2. Plasmodium vivax
3. Plasmodium malariae
4. Plasmodium ovale
5. Plasmodium knowlesi

Among these, Plasmodium falciparum stands out as the most virulent malaria parasite worldwide and also happens to be the most prevalent one in Uganda.

Signs and Symptoms of Malaria

Malaria manifests through a variety of signs and symptoms, with fever being the most prominent and characteristic feature. The fever in malaria follows an intermittent pattern, coming and going repeatedly. A typical malaria attack can be categorized into three phases:

1. The Cold Stage: During this stage, the patient experiences a sensation of coldness and shivers.

2. The Hot Stage: In this stage, the patient feels intense heat and feverish.

3. The Sweating Stage: This stage is accompanied by profuse sweating and a sense of relief from symptoms.

Apart from fever, other common symptoms of malaria include:

• Loss of appetite
• Weakness and lethargy
• Nausea and vomiting
• Headache
• Joint and muscle pains
• Diarrhea
• Dehydration
• Enlarged spleen (spleenomegaly)

In severe and complicated cases of malaria, the following symptoms may arise:

• Changes in behavior, confusion, or drowsiness
• Altered level of consciousness or coma
• Convulsions
• Hypoglycemia (low blood sugar levels)
• Acidosis (excess acid in the body)
• Difficulty in breathing, often due to pulmonary edema or respiratory distress syndrome
• Acute renal failure
• Severe anemia
• Shock
• Presence of hemoglobin in urine (haemoglobinuria)
• Oliguria with very dark urine (similar to the color of coca-cola or coffee)
• Jaundice (yellowing of the skin and eyes)
• Bleeding tendency
• Prostration (extreme weakness)
• High levels of malaria parasites in the blood (hyperparasitaemia)
• Extremely high body temperature (hyperpyrexia)
• Severe vomiting

Transmission of Malaria

Malaria is transmitted to humans through the bite of an infected female Anopheles mosquito, which injects malaria parasites (sporozoites) into the bloodstream. The life cycle of the malaria parasite (Plasmodium) is complex and involves two hosts: humans and Anopheles mosquitoes.

Illustration of the Malaria Parasite Life Cycle:

1. Infection begins when an infected female Anopheles mosquito bites a person, introducing Plasmodium sporozoites into the bloodstream.
2. The sporozoites swiftly move into the human liver.
3. Over the next 7 to 10 days, the sporozoites multiply asexually in liver cells, causing no noticeable symptoms.
4. The parasites, now in the form of merozoites, are released from liver cells and travel through the heart to the lungs, where they settle within lung capillaries. The vesicles eventually disintegrate, releasing merozoites into the blood phase of their development.
5. In the bloodstream, the merozoites invade red blood cells (erythrocytes) and undergo further multiplication until the cells burst. They then invade more erythrocytes, repeating this cycle and causing fever each time they break free and infect new blood cells.
6. Some of the infected blood cells deviate from the asexual multiplication cycle and instead develop into sexual forms of the parasite known as gametocytes, which circulate in the bloodstream.
7. When an infected mosquito bites a human, it ingests these gametocytes, which further mature into sexually active gametes within the mosquito.
8. The fertilized female gametes transform into mobile ookinetes that penetrate the mosquito\’s midgut wall, forming oocysts on its exterior surface.
9. Inside the oocyst, numerous active sporozoites develop. Eventually, the oocyst bursts, releasing sporozoites into the mosquito\’s body cavity, which then migrate to its salivary glands.
10. The cycle of human infection begins anew when the mosquito bites another person.

Incubation Period:

The period between the mosquito bite and the onset of malarial illness typically ranges from one to three weeks (7 to 21 days). 

However, certain types of malaria, such as P. vivax and P. ovale, may take much longer, up to eight to 10 months, to cause symptoms. These parasites remain dormant (inactive or hibernating) in the liver cells during this extended period. 

Unfortunately, some dormant parasites may persist even after a patient recovers from malaria, leading to the possibility of relapsing malaria, wherein the patient may fall ill again.

Diagnosis of Malaria

Diagnosing malaria involves considering the patient\’s clinical signs and symptoms, which can be challenging due to the similarity of malaria symptoms with other diseases, including yellow fever, typhoid fever, respiratory tract infections, meningitis, otitis media, tonsillitis, skin sepsis, and measles.

The following investigations are crucial in accurately confirming a malaria diagnosis:

1. Blood Smear Examination (Malaria Parasite Smear – MPS): The classic and widely used diagnostic test for malaria involves examining a blood smear under a microscope. A small amount of the patient\’s blood is placed on a microscope slide, stained, and then observed for the presence of malaria parasites inside red blood cells. This test helps identify the Plasmodium species.

2. Rapid Diagnostic Tests (RDTs): Rapid diagnostic tests detect specific malaria antigens or proteins in the patient\’s blood. RDTs are especially useful in areas with limited access to microscopy facilities and can provide rapid results for immediate management.

3. Complete Blood Count (CBC): A CBC is essential for evaluating the overall health of the patient and can reveal valuable information about the levels of different blood components, including red blood cells and white blood cells. In malaria, a decrease in red blood cells (anemia) is often observed.

4. Hemoglobin Estimation: Hemoglobin estimation provides information about the patient\’s hemoglobin levels, which can be significantly affected in malaria due to the destruction of red blood cells.

5. Liver Function Tests (LFTs): In certain cases, liver function tests may be conducted to assess liver health, as the malaria parasites initially multiply in the liver.

6. Blood Chemistry Panel: A blood chemistry panel may be performed to evaluate various parameters, including electrolyte levels, kidney function, and liver enzymes, providing a comprehensive picture of the patient\’s overall health status.

7. Polymerase Chain Reaction (PCR): PCR is a highly sensitive molecular technique that can detect the genetic material of malaria parasites in the blood. It is particularly useful for detecting low levels of parasites and differentiating between various Plasmodium species.

8. Serological Tests: Serological tests detect specific antibodies produced by the body in response to malaria infection. These tests may not be suitable for early diagnosis but can be valuable for determining past exposure to malaria.

Treatment of Malaria

1. Treatment of Uncomplicated Malaria:

• The recommended first-line medication for uncomplicated malaria is Artemether/Lumefantrine (Coartem).
• In case Artemether/Lumefantrine is unavailable, the first-line alternative treatment is Atesunate + Amodiaquine.
• The recommended second-line medication is Dihydroartemisinin + Piperaquine (Duocotecxin).

1. Treatment of Severe and Complicated Malaria:

• Parenteral Artesunate is the recommended treatment for managing severe malaria in all patients.
• In the absence of Artesunate, Parenteral Quinine or Artemether can be used as alternatives.

1. Treatment of Malaria in Pregnancy:

• Uncomplicated malaria:
  • First trimester: Quinine tablets.
  • Second and third trimesters: Artemether/Lumefantrine or Quinine tablets.
• Severe malaria in pregnancy should be treated with intravenous Artesunate.

Additional Treatment Measures:

1. Antipyretic to Reduce Body Temperature:

• Paracetamol: 10mg/kg body weight every six hours in children, 1g 6-8 hourly in adults.
• Tepid sponging or fanning can also be used to reduce fever.

1. Anticonvulsants:

• Diazepam: 0.2mg/kg body weight intravenously or intramuscularly in adults.

1. Treat Detectable Causes of Convulsions:

• For example, hypoglycemia can be managed with Dextrose administration.

1. Nursing Care:

• Provide supportive care and symptomatic treatment, such as tepid sponging for fever.
• Regularly observe temperature, pulse, respiration rate, and blood pressure. Record all observations.
• Educate patients on personal protection, malaria prevention, and the importance of adhering to treatment.
• Administer antiemetic medicine 30 minutes to 1 hour before antimalarial drugs if vomiting occurs.
• Advise patients to rest for 1-2 hours after taking the medicine to avoid dizziness, vomiting, and hypotension.
• Offer psychological support and comfort to patients.
• Encourage a nourishing diet with plenty of oral fluids. In cases of difficulty in eating or drinking, consider passing a naso-gastric tube.
• Monitor fluid intake and output and maintain a fluid balance chart.
• Ensure proper patient and environmental hygiene.

Complications of Malaria:

• Impaired consciousness/coma
• Severe anemia
• Renal failure
• Pulmonary edema
• Acute respiratory distress syndrome
• Shock
• Spontaneous bleeding
• Acidosis
• Hemoglobinuria (hemoglobin in urine)
• Jaundice
• Repeated generalized convulsions.

Prevention and Control of Malaria

1. Implement Effective Treatment and Prophylaxis:

• Early diagnosis and prompt treatment are essential to eliminate parasites from the human population. Timely treatment helps prevent the spread of malaria.
• Vulnerable groups, such as pregnant women, should receive chemoprophylaxis (preventive medication). The following drugs are used for this purpose: Chloroquine, Doxycycline, Mefloquine, and Primaquine.
• All pregnant women should be provided with Intermittent Preventive Treatment (IPT) to protect both the mother and the unborn child from malaria.

1. Reduce Human-Mosquito Contact:

• Encourage the use of insecticide-treated nets (ITNs) while sleeping to create a physical barrier between individuals and malaria-carrying mosquitoes.
• Implement indoor residual spraying of dwellings with insecticides or use knockdown sprays to control adult mosquitoes within households.
• Advise individuals to wear clothing that covers the arms and legs, and to use mosquito repellent coils and creams when sitting outdoors at night to prevent mosquito bites.

1. Control Breeding Sites:

• Eliminate stagnant water collection sites where mosquitoes breed, such as empty cans/containers, potholes, old car tires, and plastic bags. This can be achieved through proper disposal, draining, or covering with soil.
• Use insecticides to treat stagnant water bodies to destroy mosquito larvae, or employ biological methods such as introducing larvae-eating fish to these water sources.

1. Provide Public Health Education:

• Conduct public health education campaigns to raise awareness about malaria prevention measures, including the use of mosquito nets, personal protection measures, and the importance of seeking early diagnosis and treatment.
• Educate communities about the significance of eliminating breeding sites and promoting good environmental hygiene to reduce mosquito populations.

Test Questions.

What is the primary mode of transmission of malaria to humans?
a) Contaminated food and water
b) Contact with infected animals
c) Bites from female Anopheles mosquitoes
d) Airborne droplets from infected individuals
Answer: c) Bites from female Anopheles mosquitoes
Explanation: Female Anopheles mosquitoes transmit malaria by injecting malaria parasites (sporozoites) into the bloodstream during their bite.
Which diagnostic test is considered the gold standard for confirming malaria infection?

a) Rapid Diagnostic Test (RDT)
b) Polymerase Chain Reaction (PCR)
c) Complete Blood Count (CBC)
d) Blood smear examination
Answer: d) Blood smear examination

Explanation: The blood smear examination under a microscope is the classic and most widely used diagnostic test for malaria. It allows visualization of malaria parasites inside red blood cells, helping to identify the Plasmodium species and guide appropriate treatment.

What is the recommended first-line treatment for uncomplicated malaria?
a) Artemether/Lumefantrine (Coartem)
b) Dihydroartemisinin + Piperaquine (Duocotecxin)
c) Quinine tablets
d) Doxycycline
Answer: a) Artemether/Lumefantrine (Coartem)

Explanation: Artemether/Lumefantrine is the recommended first-line medicine for treating uncomplicated malaria cases.

Which antimalarial drug is used as chemoprophylaxis to protect vulnerable groups from malaria?
a) Paracetamol
b) Chloroquine
c) Artemether
d) Diazepam
Answer: b) Chloroquine

Explanation: Chloroquine is one of the drugs used for chemoprophylaxis to protect vulnerable groups, such as pregnant women, from contracting malaria.

What intervention can help reduce human-mosquito contact and prevent malaria transmission?
a) Wearing clothes that cover the arms and legs
b) Spraying dwellings with insecticides
c) Drinking boiled water
d) Applying sunscreen
Answer: a) Wearing clothes that cover the arms and legs

Explanation: Wearing clothes that cover the arms and legs can help reduce mosquito bites and lower the risk of malaria transmission.

In severe malaria cases, what is the recommended first-line treatment for all patients?
a) Parenteral Quinine
b) Parenteral Artesunate
c) Intramuscular Artemether
d) Parenteral Mefloquine
Answer: b) Parenteral Artesunate

Explanation: Parenteral Artesunate is the recommended first-line treatment for severe malaria in all patients.

How long is the incubation period for malaria?
a) 1-3 days
b) 1-3 weeks
c) 1-3 months
d) 1-3 years
Answer: b) 1-3 weeks

Explanation: The incubation period for malaria is usually 1-3 weeks (7 to 21 days) after the mosquito bite.

Which complication of malaria is characterized by the presence of hemoglobin in urine?
a) Severe anemia
b) Jaundice
c) Acidosis
d) Hemoglobinuria
Answer: d) Hemoglobinuria

Explanation: Hemoglobinuria is the presence of hemoglobin in urine, which can occur as a complication of malaria.

What method is used to control mosquito breeding sites and prevent malaria transmission?
a) Introducing larvae-eating fish
b) Using insect repellent coils
c) Administering antimalarial drugs
d) Fumigating dwellings with pesticides
Answer: a) Introducing larvae-eating fish

Explanation: Introducing larvae-eating fish to stagnant water bodies is a biological method used to control mosquito larvae and prevent malaria transmission.

How can midwifery students contribute to malaria prevention in pregnant women?
a) Administering chemoprophylaxis during pregnancy
b) Providing insecticide-treated nets to pregnant women
c) Educating pregnant women about personal protection measures
d) All of the above
Answer: d) All of the above

Explanation: Midwifery students can play a vital role in malaria prevention for pregnant women by administering chemoprophylaxis, distributing insecticide-treated nets, and educating them about personal protection measures against malaria.