Malaria

Surveillance Protocol
January 2017

Malaria is a parasitic infection that results from being bitten by an infected female Anopheles mosquito.
While there are approximately 430 species of Anopheles, only 30-40 transmit malaria [1]. Five species of
parasites within the genus Plasmodium are the agents for malaria. Globally, malaria is a major public
health problem in tropical regions and results in nearly one million deaths per year, primarily in Africa.
One-hundred eight countries, inhabited by approximately 3 billion people, are endemic for malaria [3].
Malaria is one of the most common causes of fever with an unknown origin among those traveling from
a malaria endemic country. In West Virginia, 1–2 travel-associated cases of malaria are reported each
year from persons who have visited malaria-endemic areas. Cases of malaria must be reported within
one week to local health department in the patient’s home county.

Provider Responsibilities
1. Report suspect or confirmed cases to your local health department within one week. Supply
requested clinical information to the local health department to assist with case ascertainment.
2. Health care providers needing assistance with diagnosis or management of suspected cases of
malaria should call the CDC Malaria Hotline: 770-488-7788 or 855-856-4713 toll-free (M-F, 9am-
5pm, eastern time).
a. Coordinate with the West Virginia Office of Laboratory Services on shipping specimens
to CDC for testing.
3. Submit any positive laboratory results pertaining to malaria to the local health department
located in the patient’s home county.

Laboratory Responsibilities
1. Perform appropriate testing for patients with suspected malaria. This involves thin or thick
peripheral blood films, a Polymerase Chain Reaction test (PCR), or a Rapid Diagnostic Test (RDT)
if a reliable microscope diagnosis is not available. PCR is most useful for confirming the species
of parasite after the diagnosis has been established by either smear microscopy or RDT [4].
2. Forward copies of any positive malaria test results to the local health department in the
patient’s home county within one week of diagnosis.

Local Health Responsibilities

1. Conduct an appropriate case investigation.
a. Contact the healthcare provider that ordered the laboratory test to obtain the clinical
information on the WVEDSS form.
b. If needed, contact the patient to obtain information regarding travel history.
c. Educate the patient and the patient’s family on mosquito bite prevention (to prevent
local transmission of disease) and other appropriate prevention messages.
d. Report all case data using WVEDSS.
2. Educate the public about malaria, especially regarding prevention measures when traveling.
3. Educate providers, laboratories, and infection control practitioners about diagnosis and
reporting of malaria.
4. If a suspect or confirmed case has no travel history to an area where malaria is endemic,
contact DIDE immediately.
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a. Conduct a home visit and perform an environmental assessment to identify potential
risk factors for exposure to mosquitoes if there is an outbreak or cluster of malaria
cases.
5. Consult with DIDE for guidance on appropriate case management and public health actions.

State Health Responsibilities

1. Review completed case reports from local health departments within one week.
2. Report all confirmed and suspected cases to CDC using West Virginia’s Electronic Disease
Surveillance System (WVEDSS).
3. Provide consultation to local health departments regarding case ascertainment.

Disease Control Objectives

1. Implement measures to prevent contact with female Anopheles mosquitoes while in a malaria-
endemic.
2. Administer early treatment of infected patients to prevent severe stage malaria.

Disease Surveillance Objectives

1. To identify and monitor the epidemiologic characteristics of imported malaria infections in West
Virginia.
2. To identify new or invasive Anopheles mosquito species not previously identified in West
Virginia that could be capable of transmitting malaria.
3. To identify and characterize instances of local transmission if they occur. This information would
direct vector surveillance (by species and geographic distribution) to evaluate their relative roles
in potential transmission within West Virginia.

Disease Prevention Objectives

1. Reduce disease risk through:
a. Public education regarding use of personal protective measures.
b. Public education regarding travel to areas where malaria is endemic
2. Educate travelers regarding the importance of reporting onset of illness after travel to endemic
countries.
3. Educate travelers to take malaria chemoprophylaxis prior to traveling to an area that is malaria-
endemic.

Public Health Significance

When European explorers and colonists arrived in the Americas they brought P. malariae and P. vivax
with them; P. falciparum was imported to the Western Hemisphere by Africans during slavery. The
combination of a vulnerable population and an environment that facilitated the breeding of Anopheles
mosquitoes allowed the disease to flourish. Malaria plagued the United States until the early 20th
century. The modernization of the rural South and hydroelectric power in the 1930s resulted in a
decrease of malaria cases. Malaria was practically eradicated in the United States until World War II
when it reemerged with vigor due to soldiers returning home from the Pacific campaign. More soldiers
died from malaria then from battle 8].
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Malaria is infamous for its morbidity and mortality that it has caused and continues to cause around the
globe, particularly in Africa, but the disease is also responsible for the creation of the Centers for Disease
Control and Prevention [8].

Image accessed at: http://gamapserver.who.int/mapLibrary/Files/Maps/Global_Malaria_ITHRiskMap.JPG?ua=1

Clinical Description
Malaria can be divided into two categories, uncomplicated and severe. Most commonly a person
experiencing uncomplicated malaria will present with flu like symptoms: fever, chills, sweats,
headaches, nausea and vomiting, and body aches. In rare cases, uncomplicated malaria is accompanied
with attacks that last 6-10 hours and occur every other day. These attacks consist of a cold stage
(sensation of cold, shivering) followed by a hot stage (fever, headaches, vomiting; seizures in young
children), and finally a sweating stage (sweats, return to normal temperature, tiredness) [5].
Severe malaria occurs when infections are complicated by organ failures or abnormalities in patient’s
blood or metabolism. The major complications of severe malaria include cerebral malaria, pulmonary
edema, acute renal failure, severe anemia, and/or bleeding. Acidosis and hypoglycemia are the most
common metabolic complications. Any of these complications can develop rapidly and progress to death
within hours or days [6].

Etiologic Agent
Malaria is caused by protozoan parasites in the Plasmodium genus. Five species
of Plasmodium can infect humans: P. vivax, P. ovale, P. malariae, P. falciparum, and P.
knowlesi [2]. The most common species that cause illness in humans are P. vivax or P.
falciparum. P. falciparum causes the most severe form of malaria. In areas of Africa and Plasmodium spp.
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January 2017
Asia with hyperendemic infection, reinfection in people with partial immunity results in a high prevalence
of asymptomatic parasitemia [10].

Reservoir
Humans are the only important reservoir species [6].

Mode of Transmission
Malaria is transmitted by the bite of an infected female Anopheles mosquito.
Malaria can also be transmitted from person to person through the use of an
infected needle, receiving blood or tissue contaminated blood during a transfusion,
and from mother to child (congenital) [7].
Female Anopheles mosquito
Incubation Period
The incubation period varies based on the species of parasite [7]:
 9-14 days for P. falciparum
 12-18 days for P. vivax and P. ovale
 18-40 days for P. malariae
 10-12 days for P. knowlesi

The use of prophylactic medication may prolong the incubation period or mask symptoms.

Period of Communicability
Humans can spread malaria as long as infectious gametocytes remain in the blood. Gametocytes usually
appear within three days of parasitaemia with P. vivax and P. ovale, and after 10-14 days with P.
falciparum [7]. Untreated or inadequately treated patients may be a source of infection for several years
with P. malariae, up to 5 years with P. vivax and generally not more than 1 year with P. falciparum [7].
Transmission by transfusion (or needle stick injuries) may occur as long as asexual forms remain in the
circulating blood. With P. malariae, this can continue for over 40 years. Stored blood can remain
infectious for at least a month.

Case Definition
The 2014 case definition is the most current (CSTE Position Statement Number 13-ID-08)

Background
Malaria is a mosquito-borne disease caused by a parasite; intraerythrocytic protozoa of the genus
Plasmodium (e.g., P. falciparum, P. vivax, P. ovale, and P. malariae among other species). The first two
species cause the most infections worldwide. P. falciparum is the agent that most commonly causes
severe and potentially fatal malaria. P. vivax and P. ovale may have dormant liver stage parasites, which
can reactivate and cause malaria several months or years after the infecting mosquito bite. P. malariae
can result in long-lasting infections and if untreated can persist asymptomatically in the human host for
years, even a lifetime. About 1,600 cases of malaria are reported each year in the United States, most of
which are imported, i.e., acquired in malaria-endemic countries.

Clinical Description
The first symptoms of malaria (most often fever, chills, sweats, headaches, muscle pains, nausea and
vomiting) are often not specific and are also found in other diseases (such as influenza and other
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common viral infections). Likewise, the physical findings are often not specific (elevated temperature,
perspiration, tiredness). In severe malaria (caused by P. falciparum), clinical findings (confusion, coma,
neurologic focal signs, severe anemia, respiratory difficulties) are more striking and may increase the
suspicion index for malaria.

Laboratory Criteria for Diagnosis

 Detection of circulating malaria-specific antigens using rapid diagnostic test (RDT), OR
 Detection of species specific parasite DNA in a sample of peripheral blood using a Polymerase
Chain Reaction (PCR) test. (Note: Laboratory-developed malaria PCR tests must fulfill Clinical
Laboratory Improvement Amendments [CLIA] requirements, including validation studies), OR
 Detection of malaria parasites in thick or thin peripheral blood films, determining the species by
morphologic criteria, and calculating the percentage of red blood cells infected by asexual
malaria parasites (parasitemia).

Criteria to Distinguish a New Case from an Existing Case

A subsequent attack experienced by the same person but caused by a different Plasmodium species is
counted as an additional case.

A subsequent attack experienced by the same person and caused by the same species in the United
States may indicate a relapsing infection or treatment failure caused by drug resistance or a separate
attack.

Case Classification

Suspected
Detection of Plasmodium species by rapid diagnostic antigen testing without confirmation by
microscopy or nucleic acid testing in any person (symptomatic or asymptomatic) diagnosed in the
United States, regardless of whether the person experienced previous episodes of malaria while outside
the country.

Confirmed
 Detection and specific identification of malaria parasite species by microscopy on blood films in
a laboratory with appropriate expertise in any person (symptomatic or asymptomatic)
diagnosed in the United States, regardless of whether the person experienced previous episodes
of malaria while outside the country, OR
 Detection of Plasmodium species by nucleic acid test* in any person (symptomatic or
asymptomatic) diagnosed in the United States, regardless of whether the person experienced
previous episodes of malaria while outside the country, OR
 Detection of unspeciated malaria parasite by microscopy on blood films in a laboratory with
appropriate expertise in any person (symptomatic or asymptomatic) diagnosed in the United
States, regardless of whether the person experienced previous episodes of malaria while
outside the country.

* Laboratory-developed malaria PCR tests must fulfill CLIA requirements, including validation studies.
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Surveillance Protocol
January 2017

Case Classification Comments

Clinical samples including Blood smears or EDTA whole blood from all cases can be referred to the CDC
Division of Parasitic Diseases and Malaria Diagnostic Laboratory for confirmation of the diagnosis and
antimalarial drug resistance testing. Any questionable cases should be referred to the CDC Division of
Parasitic Diseases and Malaria Diagnostic Laboratory for confirmation of the diagnosis.

Preventive Interventions
Currently there is no commercially available malaria vaccine. Travelers can protect themselves from
malaria by taking chemoprophylaxis before, during, and after their trip and by preventing mosquito
bites. The type of chemoprophylaxis administered varies based on destination and by the risk of
exposure [10]. There are three available in the United States for prevention of chloroquine-resistant
malaria.

Table 1. Malaria Chemoprophylaxis Dosages and Schedules [10]

Drug Name Dosage Dosage for Children Dosage for Duration of Treatment
for Adults Pregnant Women
Atovaquone- Daily A formula is available Should not be Start the 1-2 days before
proguanil but not approved for prescribed exposure and continue
children <11kg until one week after
(24lbs)1 leaving the malaria
endemic area
Doxycycline Daily Should not be Should not be Start 1-2 days before
prescribed to children prescribed; also exposure and continue
<8 years of age not for women of until 4 weeks after leaving
childbearing age the malaria endemic area
Mefloquine Once Not approved for Recommended Start 2 weeks prior to
weekly children <5 kg (11lbs) during the 2nd exposure and continue
or <6 months of age2 and 3rd trimester until 4 weeks after leaving
the malaria endemic area
Primaquine3 Daily Calculated based on Should not be Start 1-2 days before
weight prescribed exposure and continue
until 7 days after leaving
the malaria endemic area
1
Can be used in children less than 5kg (11lbs) when exposure to chloroquine-resistant P. falciparum cannot be avoided
2
CDC recommends that mefloquine be considered when exposure to chloroquine-resistant P. falciparum cannot be avoided
3 Travelers must be tested for glucose-6-phosphate dehydrogenase (G6PD) deficiency and have a documented G6PD in the

normal range before use

It is important to note that women who are pregnant or likely to become pregnant should avoid
traveling to malaria endemic areas because chemoprophylaxis is not completely effective. Chloroquine
or hydroxychloroquine are considered safe to use in all trimesters of pregnancy and is the drug of choice
in chloroquine-sensitive areas [11]. Mefloquine is the agent of choice for chloroquine-resistant areas,
and evidence suggests it is not associated with an increased risk to the fetus [11].
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Surveillance Protocol
January 2017
There are many ways to prevent mosquito bites during travel [10]:
 Repellants with DEET (30-35%), oil of lemon eucalyptus, IR3535, and picaridin ( ≥20%).
 Cover exposed skin by wearing long-sleeved shirts, long pants, and hats.
 Wear clothing that has been treated with permethrin (or another pyrethroid).
 Use a bed net when you are not sleeping in a sealed air-conditioned room.

Treatment
Malaria can be severe and is potentially fatal therefore, treatment should be initiated as soon as
possible. The choice of the appropriate treatment depends on: the species of infecting parasite, possible
drug resistance, and the severity of disease. Patients with severe malaria require intensive care and
parenteral treatment until the parasite density decreases to less than 1% and they can tolerate oral
therapy. If parasitemia exceeds 10% or if there is evidence of complications exchange transfusion may
be necessary.

Surveillance Indicators
1. Proportion of cases with complete clinical, laboratory, and epidemiologic information including
clinical symptoms, testing, and risk factor information (e.g. travel history, outdoor activities).
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Surveillance Protocol
January 2017
References
1. CDC (2015) “Anopheles Mosquitoes” https://www.cdc.gov/malaria/about/biology/mosquitoes/
2. CDC (2016) “Malaria Parasites” https://www.cdc.gov/malaria/about/biology/parasites.html
3. White, N., Pukrittayakamee, S., Hein, T., Faiz, M. A., A Mokuolu, O., & Dandorp, A. (2013, August 15).
Malaria. Lancet, 383, 723-735.
4. CDC (2015). “Malaria Diagnosis (United States).”
https://www.cdc.gov/malaria/diagnosis_treatment/diagnosis.html
5. CDC (2015) “Disease” https://www.cdc.gov/malaria/about/disease.html
6. Trampuz A, Jereb M, Muzlovic I, Prahbu RM. Clinical review: severe malaria. Crit Care. 2003;7:315.
doi: 10.1186/cc2183.
7. Queensland Health (2016) “Malaria-Queensland Health Guidelines for Public Health Units.”
https://www.health.qld.gov.au/cdcg/index/malaria#pc
8. Institute of Medicine (US) Committee on the Economics of Antimalarial Drugs; Arrow KJ, Panosian C,
Gelband H, editors. Saving Lives, Buying Time: Economics of Malaria Drugs in an Age of Resistance.
Washington (DC): National Academies Press (US); 2004. 5, A Brief History of Malaria. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK215638/
9. CDC (2014). “Malaria (Plasmodium spp.) 2014 Case Definition.”
https://wwwn.cdc.gov/nndss/conditions/malaria/case-definition/2014/
10. Pickering, L. K. (2009). Red book: 2009 report of the Committee on Infectious Diseases. Elk Grove
Village, IL: American Academy of Pediatrics.
11. Irvine M-H, Einarson A, Bozzo P. Prophylactic use of antimalarials during pregnancy. Canadian Family
Physician. 2011;57(11):1279-1281.
12. CDC (2015) “Treatment of Malaria: Guidelines For Clinicians (United States)”
https://www.cdc.gov/malaria/diagnosis_treatment/clinicians2.html