malaria treatment updates and guidelines-final-1

8/12/2019 Malaria Treatment Updates and Guidelines-final-1

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Malaria Treatment Updates and Guidelines

Module 1

Learning Objectives

To orient practitioners to the background of malaria including historical aspects of thedisease, epidemiology, current scenario, etiopathogenesis of malaria and latest

treatment guidelines

To review the pathophysiology of malaria with special emphasis on the malaria lifecycle with regard to the immune system

To revise essential clinical features and management goals of malaria in the light ofthe latest recommendations of WHO and the National Vector Borne Disease Control

Programme, Government of India

To serve as a refresher for practitioners in relation to current guidelines for diagnosisof different types of malaria

To acquaint professionals with the challenges of drug resistant malaria which arefrequently seen in clinical practice


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Contents:

1. IntroductionCause of Malaria

Epidemiological Terms

History

Current Situation

Treatment Objectives

2. PathophysiologyLife cycle of malaria parasite

Immune Response

3. Clinical PresentationDifference between adult and paediatric malaria

Difference between P. Vivax and P.Falciparum malaria

Important Points for Complications of P. Falciparum

4. DiagnosisParasitological diagnosis

5. Antimalarial treatment policyResistance to antimalarial medicines

Global impact of drug resistance

Criteria for antimalarial treatment policy change

Therapeutic efficacy threshold for changing treatment policy


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1) IntroductionMalaria is a parasitic disease caused by different species ofplasmodiumwhich spends part of

its life in mosquitoes and part of it in humans (1). It can manifest as a serious clinical

condition and remains one of the major public health problems in India (2). The cause,history, current situation and treatment objectives are described ahead.

1.1Cause of MalariaThe causative organism for malaria is a single-celled parasite belonging to the genus

Plasmodium. Several different types of Plasmodiumoccur in nature. They result in malaria

not only in humans but also in animals and birds. Humans can be infected commonly by four

species of Plasmodium. Each of these has distinctive microscopic features and is

characterized by somewhat distinct pattern of symptoms. A single individual can be infected

by more than one species co-existing in the same area. Out of the various types of species,

Plasmodium falciparumis the most lethal and is responsible for a majority of deaths due to

malaria. The infection can develop suddenly resulting in many life-threatening complications.

However it is mostly curable with immediate and effective treatment. Plasmodium vivax isthe most widespread species geographically and produces symptoms which are less severe.

Relapses, however, can take place for up to 3 years, and chronic disease has lasting adverse

effects. Plasmodium malariaeinfections produce typical malaria symptoms and can persist

for very long periods in the blood, sometimes for decades, without ever producing symptoms.

A person with asymptomaticPlasmodium malariae, can however infect others, either through

mosquito bites or blood donation.Plasmodium ovaleis uncommon with the potential to cause

relapses (3).

In India, malaria epidemiology is complex as a result of diversity and distribution of nine

different anopheline vectors which transmit three Plasmodial species:P. vivax,P. Falciparum

and P. malariae. Anopheles culicifacies is found widely and is the main vector of rural

malaria andAn. stephensiis the main urban vector (2).

1.2Epidemiological TermsThere are several measures related to malaria. However the most commonly used terms

which one should be familiar with are the following.

ABER or Annual Blood Examination Rate. calculated as (number of slidesexamined/population) x 100. WHO recommendation for malarious areas is that the

number of slides examined per month should equal at least 1% of the population (4).

API or Annual Parasite Index calculated as (confirmed cases during 1year/population under surveillance) x 1000 (4).

SPR or Slide Positivity Rate calculated as (No. of blood smears found positive formalaria parasite/No. of blood smears examined) X 100 (5).

Sporozoiteis the infective stage of the malaria parasite that is passed to the humanhost from the salivary glands of the mosquito. Sporozoites infect liver cells,

disappearing from bloodstream within 30 minutes (4).

Sporozoite rate is the percentage of female anopheline mosquitoes of a particularspecies that bear sporozoites in their salivary glands. Expressed as a percentage (4).


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Table 1: Geographical areas classified by intensity of transmission (based upon percent of

children, age 29, with enlarged spleens and malaria parasitemia)

Sl.

No.

Category Transmission Immunity Epidemic

potential

Spleen and

parasite rates

1) Holoendemic Intense High No Over 75%

2) Hyperendemic Regular, oftenseasonal

Varied No 50-75%

3) Mesoendemic Regular at

lower level

Varied Yes, in those with

little immunity

10-50%

4) Hypoendemic Limited Little or

nil

Yes, involving all

age groups


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India

In 1947, when India became independent, there were approximately 75 million malaria cases

in a population of 330 million. During the eradication era in the late 1950s and early 1960s, a

spectacular achievement was witnessed on the malaria eradication front because malariacases significantly declined to just 100,000 in 1964. However, reversal was experienced, and

malaria staged a comeback. By 1976, malaria cases had touched the 6.4 million mark. A

continued rise in P. falciparum was witnessed, and its proportion has gradually risen to nearly

50% in the recent past (see figure 1 below) (2).

1.4 Current Situation (2)

Fig 1: Malaria incidence trends in India from 1960 to 2005.

Note Eradication was nearly achieved in 1960s (< 100,000 cases). Resurgence was seen in

the mid-1970s (6.4 million cases) stabilizing to 2 million cases by the 1990s. P.

falciparumproportion has gradually risen to 50% in recent past. The rest is accounted byP.

vivaxand a small proportion byP. malariae.

SPR:slide positivity rate; ABER: annual blood examination rate.

Source: Kumar A, Valecha N, Jain T et. al. (2007)

Please seek permission for reproduction

Malara incidence varies across India. The distribution of malaria in different states is as

follows. API in most of the country is < 2, 25 API can be seen in scattered regions, and

places with > 5 API were found in the states of Gujarat, Rajasthan, Karnataka, Goa, Southern

Madhya Pradesh, Jharkhand, Chhattisgarh and Orissa as well as in northeastern states (Figure2) (2).


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Fig. 2. Distribution of malaria incidence in India according to annual parasite incidence in2004.

Note: Majority of India had < 2 cases per 1,000 population, 25 cases in some scattered

regions, and > 5 cases per 1,000 population where ethnic tribes live and stable malaria

conditions prevail.

Source: Kumar A, Valecha N, Jain T et. al. (2007)

Please seek permission for reproduction

Amongst the states of India, malaria contribution by Orissa is by far the most. Although the

population was around 4% of India, the number of cases was 25% of the 1.52 million annual

malaria cases, approximately 40% ofP. falciparummalaria, along with 30% of deaths due to

malaria in India. Similarly, in other states characterized by ethnic tribes residing in forestareas, meso to hyperendemic exist with 90% or more of the cases being P. falciparum. The

proportion ofP. vivax andP. falciparumis different in different parts of India. Mostly Indo-

Gangetic plains, northwestern India , northern hilly states, and southern Tamil Nadu have 95%, assessed in clinical trials.


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modelling to support malaria control and elimination. Progress and Impact Series.

November 5 2010.

2. Kumar A, Valecha N, Jain T, Dash AP. Burden of Malaria in India: Retrospective andProspective View. Am J Trop Med Hyg. 2007;77(6 Suppl):69-78.

3. Understanding Malaria - Fighting an Ancient Scourge. U.S. Department of Healthand Human Services. National Institutes of Health. National Institute of Allergy and

Infectious Diseases. NIH Publication No. 07-7139. February 2007.

www.niaid.nih.gov

4. http://www.malaria.org/malariaglossary.html5. nvbdcp.gov.in/Doc/MalariaSurveillance.doc6. Marrow R. Open Course Ware, Johns Hopkins University. Epidemiology and Control

of Malaria

7. Tren R.Malaria Control and Climate Change in India. A Liberty Institute/AfricaFighting Malaria/ESEF Working Paper.Julian Simon Centre for Policy Research.

October 2002.

8. Guidelines for the treatment of malaria. 2ndedition. World Health Organization, 2010.9. Sadanand S. Malaria: An Evaluation of the Current State of Research on Pathogenesis

and Antimalarial Drugs. Yale Journal of Biology and Medicine 83 (2010), pp.185-

191.

10.Supplemental materials to the lectures given by Dr. Wiser in Malaria (TRMD 782)can be found at: http://www.tulane.edu/~wiser/malaria/.

11.Guidelines for Diagnosis and Treatment of Malaria in India 2009.National Institute ofMalaria Research.

12.Lalloo DG, Shingadia D, Pasvol G, Chiodini PL, Whitty CJ, Beeching NJ, Hill DR,Warrell DA, Bannister BA; HPA Advisory Committee on Malaria Prevention in UK

Travellers. UK Malaria Treatment Guidelines. J Infect. 2007;54(2):111-21.

13.Galloway, R, 2003. Anemia prevention and control What works? USAID, WorldBank, PAHO/WHO, Micronutrient Initiative, FAO, and UNICEF.

14.Lin E, Kiniboro B, Gray L, Dobbie S, Robinson L, Laumaea A et al. Differentialpatterns of infection and disease with P. falciparum and P. vivax in young Papua New

Guinean children. PLoS One. 2010;5(2):e9047.

15.MackintoshCL,BeesonJG,MarshK.ClinicalFeaturesandPathogenesisofSevereMalaria.TrendsParasitol.2004;20(12):597603.

16.Sullivan D. Open Course Ware, Johns Hopkins University, Diagnosis and ClinicalComplications of Malaria.

17.www.cdc.gov/malaria/glossary.html18.Dash AP, Valecha N, Anvikar AR, Kumar A. Malaria in India: challenges and

opportunities. J Biosci. 2008;33(4):583-92.

19.Global report on antimalarial drug efficacy and drug resistance: 2000-2010. WorldHealth Organization, 2010

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