What is malaria?

Malaria is an infectious disease caused by a parasite, Plasmodium, which infects red blood cells.
Malaria is characterized by cycles of chills, fever, pain, and sweating. Historical records suggest
malaria has infected humans since the beginning of mankind. The name "mal aria" (meaning
"bad air" in Italian) was first used in English in 1740 by H. Walpole when describing the disease.
The term was shortened to "malaria" in the 20th century. C. Laveran in 1880 was the first to
identify the parasites in human blood. In 1889, R. Ross discovered that mosquitoes transmitted
malaria. Of the four common species that cause malaria, the most serious type is Plasmodium
falciparum malaria. It can be life-threatening. However, another relatively new species,
Plasmodium knowlesi, is also a dangerous species that is typically found only in long-tailed and
pigtail macaque monkeys. Like P. falciparum, P. knowlesi may be deadly to anyone infected.
The other three common species of malaria (P. vivax, P. malariae, and P. ovale) are generally
less serious and are usually not life-threatening. It is possible to be infected with more than one
species of Plasmodium at the same time.

What are malaria symptoms and signs?

The symptoms characteristic of malaria include flulike illness with fever, chills, muscle aches,
and headache. Some patients develop nausea, vomiting, cough, and diarrhea. Cycles of chills,
fever, and sweating that repeat every one, two, or three days are typical. There can sometimes be
vomiting, diarrhea, coughing, and yellowing (jaundice) of the skin and whites of the eyes due to
destruction of red blood cells and liver cells.

People with severe P. falciparum malaria can develop bleeding problems, shock, liver or kidney
failure, central nervous system problems, coma, and can die from the infection or its
complications. Cerebral malaria (coma, or altered mental status or seizures) can occur with
severe P. falciparum infection. It is lethal if not treated quickly; even with treatment, about 15%-
20% die.

Etiologic Agent:

Protozoa of genus plasmodia

1. The disease is caused by four species of protozoa:

a. Plasmodium falciparum (malignant tertian)

· This is considered as the most serious malarial infection because of the

development of high parasitic densities in blood (RBC) with
tendency to agglutinate and form into microemboli.

· This is most common in the Philippines.

 b. Plasmodium vivax (Benign tertian)

· This is nonlife threatening except for the very young and the old.

· It is manifested by chills every 48 hours on the 3rd day onward

especially if untreated.

c. Plasmodium malariae (Quartan)

· It is less frequently seen.

· This specie is nonlife threatening.

· Fever and chills usually occur every 72 hours usually on the 4th day
after onset.

d. Plasmodium ovale is the rare type of protozoan species.

· This is rarely seen in the Philippines.

2. The primary vector of malaria is the female Anopheles mosquito which has the
following characteristics:

a. It breeds in clear, flowing, and shaded streams usually in the mountains.

b. It is bigger in size than the ordinary mosquito.

c. It is brown in color.

d. It is a night-biting mosquito.

e. It usually does not bite a person in motion.

f. It assumes a 36º position when it alights on walls, trees, curtains, and the like.

Incubation period:

1. 12 days for P. Falciparum

2. 14 days for P. vivax and ovale
3. 30 days for P. malariae
 Risk Factors of Malaria

Malaria comes from being bitten by a mosquito carrying the malaria

organism. Risk factors include traveling in areas in which such mosquitoes
are found or, rarely, being bitten by a mosquito that has previously fed on
an "imported" case of malaria (such that the case can occur in an area of the
world where malaria is not endemic).

Period of Communicability:

Untreated or insufficiently treated patient may be the source of mosquito infection for more than
three years in P. malariae, one to two years in P. vivax, and not more than one year on P.
falciparum.

Mode of Transmission:

1. The disease is transmitted

mechanically through the
bite of an infected female
anopheles mosquito
2. It can be transmitted
parenterally through blood
transfusion.
3. On rare occasions, it is
transmitted from shared
contaminated needles.
4. However, transplacental
transmission of congenital
malaria is a rare case.

Clinical Manifestations:

1. Paroxysms with shaking

chills
2. Rapidly rising fever with severe headache
3. Profuse sweating
4. Myalgia, with feeling of well-being in between
5. Splenomegally, hepatomegally
 6. Orthostatic hypotension
7. Paroxysms may last for 12 hours, then, maybe repeated daily or after a day or two.
8. In children:
a. Fever maybe continuous
b. Convulsions and gastrointestinal symptoms are prominent
c. Splenomegally
9. In cerebral malaria
a. Changes in sensorium, severe headache, and vomiting
b. Jacksonian or grand mal seizure may occur

Diagnostic Procedure:

1. Malarial smear – In this procedure, a film of blood is placed on a slide, stained, and
examined microscopically.
2. Rapid diagnostic test (RDT) – This is a blood test for malaria that can be conducted
outside the laboratory and in the field. It gives a result within 10 to 15 minutes. This is
done to detect malarial parasite antigen in the blood.

Pathogenesis:

1. The parasite enters the mosquito’s stomach through the infected human blood obtained
by biting or during blood meal.
2. The parasite undergoes sexual conjugation.
3. After 10 to 14 days, a number of young parasites are released which work their way into
the salivary gland of the mosquito.
4. The organisms are carried in the saliva into the victim when the mosquito bites again.
5. The female alone plays the role of a vector and definitive host in conveying the disease
from man to man (sexual propagation).
6. In humans, the organisms invade the RBC where they grow and undergo sexual
schizogony.
7. Erythrocytic merozoites are produced leading to the rupture of RBC upon the release of
the tiny organisms.
8. Young merozoites invade a new batch of RBC, to start another schizonic cycle.

Nursing Management:

1. The patient must be closely monitored.

a. Intake and output should be closely monitored to prevent pulmonary edema.

b. Daily monitoring of patient’s serum bilirubin, BUN creatinine, and parasitic count
 2. If the patient exhibits respiratory and renal symptoms, determine the arterial blood gas and
plasma electrolyte

3. During the febrile stage, tepid sponges, alcohol rubs, and ice cap on the head will help
bring the temperature down.

4. Application of external heat and offering hot drinks during chilling stage is helpful.

5. Provide comfort and psychological support.

6. Encourage the patient to take plenty of fluids.

7. As the temperature falls and sweating begins, warm sponge bath maybe given.

8. The bed and clothing should be kept dry.

9. Watch for neurologic toxicity (from quinine infusion) like muscular twitching, delirium,
confusion, convulsion, and coma.

10. Evaluate the degree of anemia.

11. Watch for any signs especially abnormal bleeding.

12. Consider severe malaria as medical emergency that requires close monitoring of vital
signs.

Treatment and Medications:

Anti-Malarial Drugs

 Artemether-lumefantrine (Therapy only, commercial names Coartem and Riamet)

 Artesunate-amodiaquine (Therapy only)
 Artesunate-mefloquine (Therapy only)
 Artesunate-Sulfadoxine/pyrimethamine (Therapy only)
 Atovaquone-proguanil, trade name Malarone (Therapy and prophylaxis)
 Quinine (Therapy only)
 Chloroquine (Therapy and prophylaxis; usefulness now reduced due to resistance)
 Cotrifazid (Therapy and prophylaxis)
 Doxycycline (Therapy and prophylaxis)
 Mefloquine, trade name Lariam (Therapy and prophylaxis)
 Primaquine (Therapy in P. vivax and P. ovale only; not for prophylaxis)
 Proguanil (Prophylaxis only)
 Sulfadoxine-pyrimethamine (Therapy; prophylaxis for semi-immune pregnant women in
endemic countries as “Intermittent Preventive Treatment” – IPT)
 Hydroxychloroquine, trade name Plaquenil (Therapy and prophylaxis)
Prevention and Control:

1. Malaria cases should be reported.

2. A thorough screening of all infected persons from mosquitoes is important.
3. Mosquito breeding places must be destroyed.
4. Homes should be sprayed with effective insecticides which have residual actions on the
walls.
5. Mosquito nets should be used especially when in infected areas.
6. Insect repellents must be applied to the exposed portion of the body.
7. People living in malaria-infested areas should not donate blood for at least three years.
8. Blood donors should be properly screened.