KURSUS PENYELIAAN TEKNIK SEMBURAN

PENGENALAN PENYAKIT MALARIA, CARA JANGKITAN DAN RAWATAN

MALARIA
Italian, mala=bad, aria= air A mosquito-borne infectious disease Protozoan parasites of the genus Plasmodium Transmitted only by Anopheles Mosquitoes Disease can be: Acute Chronic Four species: P falciparum P vivax P ovale P malariae Occasionally P. knowlesi

Transmission
Man is the only important reservoir Vector is female Anopheles mosquito
Temperature: below 86 F, above 68 F

Rainfall:
Altitude: Terrain:

thrive in tropical areas

rarely exist above 2000 meters coastal areas and lowlands with lots of freshwater breeding sites

Transmission
Mosquito vector: ANOPHELES

Transmission also possible through:

1. Blood transfusion

2. Contaminated needle
3. Organ transplant 4. Congenital

Susceptibility
Universal susceptibility No absolute immunity
Partial immunity in areas of high endemicity

Plasmodium Species
P. falciparum
Most severe and prevalent 40-60% of cases Widespread CHLOROQUINE resistance Infects RBCs of all agesHeavy parasitemia

Plasmodium Species
P. vivax
30-40% of cases Liver phase INFECTS YOUNG RBCs: LESS SEVERE THAN FALCIPARUM

P. ovale
Liver phase INFECTS YOUNG RBCs

P. malariae
Can persist SUBCLINICALLY for extended periods of time INFECTS OLD RBCs

Incubation Period
P. Falciparum P. Vivax P. Ovale P. Malariae 12 days 14 days* 14 days* 30 days

* May be 8 - 10 months or longer for some strains

Acute Symptoms
Classical cyclic paroxysm:
Cold stage: chills and shaking Hot stage: warm, headache, vomiting

Sweating stage: weakness

Feel well for period of time, then cycle repeats itself

Presentation
Fever Chills Headache Muscle Pain Palpable liver Palpable Spleen Nausea or vomiting Abdominal pain/diarrhea 96% 96% 79% 60% 33% 28% 23% 6%

Complicated Malaria
Hyperparisitemia: (>3%) Hypoglycemia: (<60 mg/dl) Severe anemia (hct < 21% or rapidly falling hct) Renal failure Hyponatremia Cerebral malaria Prolonged hypothermia High output vomiting or diarrhea

Pregnancy

DIAGNOSIS

Gold standard: thick and thin smears

Malaria drugs
Chloroquine
Chloroquine is a 4-aminoquinoline that has been used extensively for the treatment and prevention of malaria. Widespread resistance has now rendered it virtually useless against P. falciparum infections in most parts of the world, although it still maintains considerable efficacy for the treatment of P. vivax, P. ovale and P. malariae infections. As with other 4-aminoquinolines, it does not produce radical cure. Chloroquine interferes with parasite haem detoxification (1, 2). Resistance is related to genetic changes in transporters (PfCRT, PfMDR), which reduce the concentrations of chloroquine at its site of action, the parasite food vacuole.
Formulations Tablets containing 100 mg or 150 mg of chloroquine base as hydrochloride, phosphate or sulfate.

Malaria drugs
Mefloquine Mefloquine is a 4-methanolquinoline and is related to quinine. The drug is effective against all forms of malaria. Formulations Tablets containing either 250 mg salt (United States of America) or 250 mg base (elsewhere).

Malaria drugs
Artemisinin
Artemisinin, also known as qinghaosu, is a sesquiterpene lactone extracted from the leaves of Artemisia annua (sweet wormwood). It has been used in China for the treatment of fever for over a thousand years. It is a potent and rapidly acting blood schizontocide and is active against all Plasmodium species. It has an unusually broad activity against asexual parasites, killing all stages from young rings to schizonts. In P. falciparum malaria, artemisinin also kills the gametocytes including the stage 4 gametocytes, which are otherwise sensitive only to primaquine. These drugs should be given as combination therapy to protect them from resistance.

Formulations Tablets and capsules containing 250 mg of artemisinin. Suppositories containing 100 mg, 200 mg, 300 mg, 400 mg or 500 mg of artemisinin.

Treatment
Radical treatment for Falciparum and Malariae Malaria
Chloroquine Primaquine Fansidar Quinine Single dose- >= 1 yr ( Fansidar + Primaquine) ; < 1 yr (Chloroquine + Primaquine)

Treatment
Radical treatment of Vivax Malaria
Chloroquine 3 days Primaquine 14 days

CDC now recommends: PRIMAQUINE 30mg PO QD x 14 days

Treatment
Chemoprophylaxis
Fansidar 1 tab Chloroquine 2 tab Once/week, one week before4 weeks after visit to an malaria endemic area Doxycycline 100mg once/day

Attack The Parasite In The Human Host

Chemoprophylaxis is based on current drug resistance patterns MEFLOQUINE first line prophylaxis

Mefloquine 250 mg po q week, 1-2 wks prior to 4 wks after

Doxy 100 mg po qd, 2 days prior to 4 wks after

DOXYCYCLINE as second line drug

PRIMAQUINE
30 mg* po qd x 14 days terminal prophylaxis
*15 mg per FDA and drug product information insert

New Antimalarial for Prophylaxis: Atovaquone/Proguanil (Malarone)

Licensed July 2000 in USA for treatment and prophylaxis of P. falciparum
Atovaquone is a blood schizonticide Proguanil is metabolized to cycloguanil, a tissue schizonticide

Combination very effective for treatment of multi-drug resistant P. falciparum

Generally well tolerated with >95% efficacy vs. placebo

Dosage of Malarone
Prophylaxis dose: one tablet per day Start 1-2 days prior to entering endemic area Continue for one week after leaving
(causal prophylaxis, kills parasites in liver)

Adult formulation:
250 / 100 mg atovaquone / proguanil in single combination tablet

Pediatric formulation:
62.5 / 25 mg single tablet

Who Should Use for Prophylaxis?

Malarone

Persons on short trips who wish to avoid a long course of medication after return Persons concerned about drug side effects Persons traveling to areas where resistance to other drugs may occur Persons who prefer a daily regimen

Summary
Mosquito-borne infectious disease Tropics, subtropics P. falciparum, vivax, ovale, malariae

Incubation period nearly two weeks

Fever

Thick and think blood smears for diagnosis

Summary
Drug resistance is increasing Chemoprophylaxis can prevent infection

Questions?