Module M-1

Overview of Malaria

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Learning Objectives

At the end of this module, participants will be able

to
• Describe the etiologic agents and modes of
transmission
• Understand and define methods of malaria diagnosis
noting where each is most effective
• Explain the National Strategic Plan for Malaria
Prevention, Control and Elimination in Ethiopia, 2014
- 2020
• List the different diagnostic methods for malaria
• Describe malaria strata in Ethiopia

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Content Outline

• Malaria etiology

• Lifecycle

• Malaria diagnostic methods

• Malaria situation in Ethiopia

• National Strategic Plan for Malaria Prevention,

Control and Elimination in Ethiopia, 2014 - 2020

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Malaria Etiology

• A serious public health problem in many parts of the world

• Caused by a very small living organism called Plasmodium,

• Transmitted by the bite of infected female anopheline

mosquito.

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life cycle and Transmission

• Two hosts
– Definitive host- Female Anopheles mosquito
– Intermediate host - Human

• Three cycles:
– Exo-erythrocytic cycle: in the liver
– Erythrocytic cycle: in the erythrocytes
– Sporogonic cycle: in the mosquito
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Lifecycle….

 During a blood meal, infected female Anopheles mosquito

inoculates sporozoites in to human blood.

 Sporozoites infect liver cells and mature into schizonts

(Exoerythrocytic shzogony) , which rupture and release merozoites .
Note: in P. vivax and P. ovale a dormant stage [hypnozoites] can
persist in the liver and cause relapses .

 The merozoits infect erythrocytes and undergo asexual

multiplication (Erythrocytic schizogony ) and mature in to schizonts,
which rupture releasing merozoites .

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Lifecycle…

Some parasites differentiate into sexual erythrocytic

stages (gametocytes)
The gametocytes are ingested by an Anopheles mosquito
during a blood meal to follow the sporogonic cycle.
While in the mosquito's stomach, the gametes fuse and
generating zygotes Ookinetes oocysts .
 The oocysts grow, rupture, and release sporozoites ,
which deposited on to mosquito's salivary glands.

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Clinical Feature

Typical Malaria attacks show sequentially over 4-6hrs

– Shaking chills (the cold stage)
– Fever (the hot stage)
– Marked diaphoresis (the sweating stage).

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Associated Symptoms

– Malaise
– Headache
– Dizziness
– Gastrointestinal symptoms
– Myalgia, arthralgia, backache, and dry cough.

 This are common in the presence of asexual forms in

the blood without any of the complications.

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Complicated malaria

• P. falciparum is the usual cause.

• The risk group for severe and complicated malaria are:
– Under five children
– Pregnant women
– People living with HIV

• A patient with clinical manifestation of sever and

complicated malaria should be referred immediately
to the nearest health facility.
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Complicated Malaria expressed by

– Altered consciousness

– Not able to drink or feed

– Frequent vomiting

– Convulsion or recent history of convulsion

– Unable to sit or stand up

– No urine output in the last 24 hours

– Difficult breathing

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Malaria Diagnostic Methods

1. Clinical Diagnosis
• The first essential steps to disease management.
• The only approach where lab support doesn’t
exist.
• Most prominent symptom is fever
• Symptoms are non-specific and overlap with
other febrile illnesses.
• Alone is unreliable, and when possible should be
confirmed by laboratory tests.
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Malaria diagnostic …

2. Laboratory Diagnosis
• Routine lab diagnostic methods
Light microscopy
• identify malaria parasites from the blood

Rapid diagnostic tests/RDTs/

• Detect antigens produced by malaria parasite in blood

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Advanced diagnostic methods

• QBC test

• Microscopy using fluorochromes,

• PCR

• Serology: Ab detection.

• Flowcytometry

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1. QBC Test

• New method for identifying malarial parasite in blood.

• Involves staining of the centrifuged and compressed

red cell layer with acridine orange and examination
under UV light source.

• Fast, easy and claimed to be more sensitive than thick

film examination.

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QBC…

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 QBC…

• Advantage
– quick
– Can accidentally detect filarial worms
– Sensitive (at least as good as thick film)
• Challenges of QBC
– May provide false positive result/Artifacts may be
reported as positive/
– Species differentiation can be difficult
– Expensive

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2. Antimalarial Antibody test

• Antibodies to the asexual blood stages

– Appear a few days after infection,
– Increase in titer over the next few weeks
– May persist for months or years.
• The usual techniques are IFA & ELISA
• IFA uses specific antigen prepared on a slide,
coated and kept at -30 oC until use, and
quantifies both IgG and IgM antibodies in patient
serum samples.

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2. Antimalarial…

• Provide retrospective confirmation of malaria infection or a

history of infection,
• Useful in epidemiology surveys and the screening of blood
collected for blood banks.
• The utility of serological methods for the diagnosis of acute
malaria infection is LIMITED owing to
 The delay in antibodies development
 Lack of species confirmation
 Need fluorescence (UV) microscope.

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2. Antimalarial …

• Advantage

– Used to screen blood donors

– To test efficacy of vaccines

• Challenges

– not detect acute infection

– Expensive
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3. PCR

• Detect parasite nucleic acids.

• Highly specific and sensitive
– Sensitivity
• 1.35 to 0.38 parasites/µL for P. falciparum
• 0.12 parasites/µL for P. vivax.
• Effective in cases of low parasitemia and mixed
infections.
• Expensive, and requires a specialized laboratory.

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4. Microscopy using flurochrome

• Employs fluorescence microscopy combined with

fluorochrome staining with acridine orange (AO).
• More sensitive than Giemsa staining thick film.

• AO staining permits differential coloration of green

(nuclei) and red (cytoplasm) in stained parasites.

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5. Flowcytometry

• Useful in diagnosis of malaria during routine blood counts.

• Abnormal cell clusters and small particles with DNA fluorescence,

probably free malarial parasites, have been seen on automated
hematology analyzers.
• Malaria can be suspected based on the scatter plots produced on the
analyzer.
• Detection of malaria pigment in white blood cells can also be performed.

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Challenges of advanced malaria diagnostic methods
for field application

Technically demanding

 Unsuitable for use in routine disease

management.
Highly expensive

 Often used for research purposes.

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 Malaria-Global burden

• One of the most severe public health problems worldwide.

• 3.2 billion people are at risk and 1.2 billion are at high risk (>1
in 1000 chance of getting malaria in a year) - WHO – World
malaria report - 2014
• It is estimated that the number of cases of malaria rose from
233 million in 2000 to 244 million in 2005 but decreased to
225 million in 2009 and to 198 million in 2013

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 Malaria-Global burden

• In sub-Saharan Africa, average infection prevalence in children aged 2–10 years

fell from 26% in 2000 to 14% in 2013
– a relative decline of 48%.

• The number of infections at any one time across Africa fell from 173 million in
2000 to 128 million in 2013 – a reduction of 26% in the number of people
infected.
• The number of deaths due to malaria is estimated to have decreased from
985 000 in 2000 to 781 000 in 2009 and to 584 000 in 2013 , more than 90
% of them in Africa of which 78% in under five children (WHO Report,
2014).

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 Malaria-Global burden

• Between 2000 and 2013, estimated malaria mortality rates

decreased by 47% worldwide and by 54% in the African Region.
– They are estimated to have decreased by 53% in children aged under 5
years globally, and by 58% in the African Region.

• By 2015 malaria mortality rates are projected to decrease by

55% globally, and by 62% in the African Region.
• In children aged under 5 years, by 2015 they are projected to
decrease by 61% globally and by 67% in the African Region.

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 Malaria Situation in Ethiopia
• In Ethiopia, malaria has been the major cause of morbidity and mortality

• ~ 75% of the country is malarious .

• 60% of the total population is at risk.

• Between 2001-2005 annually:

• 9.5 million clinical cases of malaria were reported
• 488,000 confirmed cases.

• The annual average number of malaria cases in the last four years - 4.1
million (NSP - 2014)

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 Malaria Situation in Ethiopia…

• Prevalence of malaria parasitemia is 1.3% according to the

Malaria indicator survey, 2011
• According to Health and Health Related Indicators (2005 EC)
– 3,862,735 confirmed and clinical cases reported, of
these 2.85 million were confirmed (73.8%)
– P. vivax were 1.05 million and P. falciparum were 1.8
million (63%)
– Out patient morbidity
• 2nd P. falciparum (7.4%)
• 6th non P. falciparum (4.3%)

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Malaria situation…

• Malaria is endemic in Ethiopia with differing intensity of

transmission, except in the central highlands which are
malaria-free.
• The most recent epidemic occurred in 2003–2004.

• Approximately 77% of cases are caused by P. falciparum.

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Malaria situation…

• Malaria admissions decreased from an average of 44 000 in

2001 - 2005 to 30 102 in 2009 (33% decline).
• Inpatient malaria deaths fell by 43% in all age groups and by
60% in children <5 years.

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Malaria situation…
• Transmission is seasonal and unstable .
• Major epidemics occur every 5‐8 years
• Two transmission seasons
 Main : September to December
 Minor: April to and May.
• Transmission seasons often coincides with peak
periods of agricultural activity which result a
negative impact on the nation’s economy.

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Malaria Situation…

• P. falciparum and P. vivax are the most dominant

species
– P. falciparum accounts 77 % of malaria cases
and less than 1% P. ovale & P. malariae
• The main malaria vectors are
– Anopheles arabiensis (Major Vector)
– Anopheles pharoensis
– Anopheles funestus
– Anopheles nili
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 Malaria strata of Ethiopia
• Based on Annual Parasite Incidence (API per
1000 population) and altitude, four broad
strata are identified. These strata are:
malaria free – areas above 2000m altitude, API=0
Low – areas below 2000m altitude , API >0 and < 5
Moderate- areas below 2000m altitude, API ≥ 5
and < 100
High transmission – areas below 2000m altitude,
API ≥ 100
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New Malaria strata Map, 2014

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 National Malaria Strategic Plan,
2014 – 2020
Goal
•By 2020, to achieve near zero malaria deaths
(no more than 1 confirmed malaria death per
100,000 population at risk) in Ethiopia.
•By 2020, to reduce malaria cases by 75% from
baseline of 2013.
•By 2020, to eliminate malaria in selected low
transmission areas.

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 National Malaria Strategic Plan, 2014-2020……

• Objective 1:
– By 2020, all households living in malaria endemic areas will
have the knowledge, attitudes and practice towards
malaria prevention and control.
• Strategy 1: Community Empowerment and Mobilization
• Objective 2:
– By 2017 and beyond, 100% of suspected malaria cases are
diagnosed using RDTs or microscopy within 24 hours of
fever onset.
• Strategy 1: Sensitize and Mobilize Communities for Early Diagnosis

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 National Malaria Strategic Plan, 2014-2020……

Strategy 2: Diagnose all Suspected Cases

Targets
–100% of health facilities in malaria risk areas will provide RDTs and/or
microscopy diagnostic service to sustain universal coverage of diagnosis.
– 100% of laboratory professionals at health facilities will receive training
on malaria laboratory diagnosis.
–100% of HEWs will be trained on malaria diagnosis and treatment as
part of iCCM.
–100% of health centers and hospitals shall be equipped with
microscopes and other malaria laboratory commodities.
–Two university instructors of laboratory professionals will be trained
from each university on malaria laboratory diagnosis to improve pre-
service training.

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 National Malaria Strategic Plan, 2014-2020……

• Objective 3.
– By 2015 and beyond, 100% of confirmed malaria cases are
treated according to the national guidelines.
• Strategy 1: Improve Treatment Seeking behaviour
• Strategy 2: Manage Confirmed Malaria Cases
Targets
– 100% health facilities in malarious areas will be provided with ACTs
and other anti-malarial medicines to sustain universal coverage of
treatment.
– 100% health professionals in malarious areas will receive training on
malaria diagnosis and case management.
– 100% of HEWs will receive training on malaria diagnosis and
treatment as part of iCCM.

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National Malaria Strategic Plan, 2014-2020……

– Objective 4.
• By 2015 and beyond, ensure and maintain universal
access of the population at risk to at least one type of
globally recommended anti-vector intervention.
– Strategy 1: Community Mobilization
– Strategy 2: Prevention/Vector Control

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 National Malaria Strategic Plan, 2014-2020……

• Objective 5.
– By 2020, achieve and sustain zero indigenous transmission
of malaria in 50 selected districts.
• Strategy 1: Advocacy, Communication and Social Mobilization
• Strategy 2: Elimination of Falciparum Malaria
• Objective 6.
– By 2020, 100% complete data and evidence will be
generated at all levels within designated time periods to
facilitate appropriate decision making.
• Strategy 1: Surveillance and Response
• Strategy 2: Monitoring and Evaluation

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Thank you

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