Malaria - Download as PowerPoint by DA2zPL

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 Partners in Global Health Education
                                                                          Malaria
1.    How to use this
      module
2.    Learning outcomes                Welcome to the malaria
3.    Plasmodium species
4.    Malaria burden                   module!
5.    Question 1
6.    Transmission
7.    Life cycle                       Malaria is a major public health
8.    Question 2
9.    Disease severity                 problem in warm climates
10.   Question 3                       especially in developing countries.
11.   Clinical malaria
12.   Question 4
13.   Diagnosis
14.   Treatment                        It is a leading cause of disease
15.   Prevention and                   and death among children under
      control
16.   Pregnancy                        five years, pregnant women and
17.   Question 5                       non-immune
18.   Information sources
                                       travellers/immigrants.

                                                                             Children under 5 are the major at risk group in malarious
                                                                             regions. Inset: An Anopheles mosquito taking a blood meal
                                   For more information about the
                                                                             Sources:   http://www.ifnc.org/pictures.html
                                   authors and reviewers of this
         1 of 54                   module, click here                                   http://phil.cdc.gov/phil/quicksearch.asp
 Partners in Global Health Education
                                                    How to use this module
1.    How to use this
      module
2.    Learning outcomes
3.    Plasmodium species
4.    Malaria burden                   •   This self-directed learning (SDL) module has been designed for medical and
5.    Question 1                           other health care students
6.    Transmission
7.    Life cycle                       •   We suggest that start with the learning objectives and try to keep these in
8.    Question 2
9.    Disease severity                     mind as you go through the module slide by slide, in order and at your own
10.   Question 3
11.   Clinical malaria
                                           pace.
12.
13.
      Question 4
      Diagnosis
                                       •   Print-out the malaria SDL answer sheet. Write your answers to the questions
14.   Treatment                            on the mark sheet as best you can before looking at the answers.
15.   Prevention and
      control                          •   Repeat the module until you have achieved a mark of > 22/27 (>80%).
16.   Pregnancy
17.   Question 5                       •   You should research any issues that you are unsure about. Look in your
18.   Information sources
                                           textbooks, access the on-line resources indicated at the end of the module
                                           and discuss with your peers and teachers.
                                       •   Finally, enjoy your learning! We hope that this module will be enjoyable to
                                           study and complement your learning about malaria from other sources.

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                                                        Learning Outcomes
 Partners in Global Health Education


1.    How to use this
      module
                                       By the end of the module, you would be expected to be able to describe:
2.    Learning outcomes
3.    Plasmodium species
4.    Malaria burden                   • How P. falciparum malaria is a major killer of people in warm climates and that
5.    Question 1                         children <5 years, pregnant women and non-immune visitors/immigrants are at
6.    Transmission
7.    Life cycle
                                         greatest risk
8.    Question 2                       • The 4 main species of malaria, their geographical distribution and the major
9.    Disease severity                   stages of the life cycle
10.   Question 3
11.   Clinical malaria                 • How malaria is transmitted by the female anopheles mosquito and how levels of
12.
13.
      Question 4
      Diagnosis
                                         endemicity vary according to climate and mosquito ecology
14.   Treatment                        • How parasite and host factors determine disease severity
15.   Prevention and
      control                          • The clinical features of simple, uncomplicated disease and 8 important severe
16.   Pregnancy                          manifestations of malaria
17.
18.
      Question 5
      Information sources
                                       • How malaria is diagnosed by blood film examination, antigen detection and
                                         molecular methods
                                       • The role of chloroquine, quinine, artemesinin and other drugs in treatment
                                       • How malaria can be prevented by reducing man-mosquito contact,
                                         chemoprophylaxis, intermittent presumptive treatment and what approaches are
                                         being taken in vaccine development
         3 of 54
                                                         What is malaria ?
 Partners in Global Health Education


1.    How to use this
      module                           Malaria is a disease caused by single-celled protozoan parasites of the genus
2.    Learning outcomes                Plasmodium. The 4 species that commonly infect man are:
3.    Plasmodium species
4.    Malaria burden
5.    Question 1
6.
7.
      Transmission
      Life cycle
                                         Species         Major features
8.    Question 2
9.    Disease severity
10.   Question 3
                                         P. falciparum    The most important species as it is responsible for 50% of all malaria cases
11.   Clinical malaria                                   worldwide and nearly all morbidity and mortality from severe malaria
12.   Question 4                                          Found in the tropics & sub-tropics
13.   Diagnosis
14.   Treatment
                                         P. vivax         The malaria parasite with the widest geographical distribution
15.   Prevention and
      control                                             Seen in tropical and sub-tropical areas but rare in Africa
16.   Pregnancy
17.   Question 5
                                                          Estimated to cause 43% of all malaria cases in the world
18.   Information sources
                                         P. ovale         This species is relatively rarely encountered
                                                          Primarily seen in tropical Africa, especially, the west coast, but has been reported
                                                         in South America and Asia

                                         P. malariae      Responsible for only 7% of malaria cases
                                                          Occurs mainly in sub-tropical climates
         4 of 54
 Partners in Global Health Education
                                              The burden of malaria
1.    How to use this

2.
      module
      Learning outcomes
                                       This can be divided into:
3.    Plasmodium species
4.    Malaria burden
5.    Question 1
                                                                             Direct
                                       • The “direct” health burden:
6.    Transmission
7.    Life cycle
8.    Question 2                                                             burden
9.
10.
      Disease severity
      Question 3                         morbidity and mortality
11.   Clinical malaria
12.
13.
      Question 4
      Diagnosis                        • The “indirect” burden: impaired
14.   Treatment
15.   Prevention and
      control
                                         human and economic
16.
17.
      Pregnancy
      Question 5                         development                         Indirect
18.   Information sources
                                                                             burden

                                       Click on the boxes to find out more
         5 of 54
                                             Geographical Distribution of Malaria
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1.    How to use this                  Although previously
      module                           widespread, today
2.    Learning outcomes
3.    Plasmodium species               malaria is confined
4.    Malaria burden                   mainly to Africa, Asia and
5.    Question 1                       Latin America. About
6.    Transmission
                                       40% of the world’s
7.    Life cycle
8.    Question 2                       population is at risk of
9.    Disease severity                 malaria. It is endemic in
10.   Question 3                       91 countries, with small
11.   Clinical malaria
12.   Question 4
                                       pockets of transmission
13.   Diagnosis                        occurring in a further 8
14.   Treatment                        countries.
15.   Prevention and
      control
16.   Pregnancy
17.   Question 5
18.   Information sources              Malaria is transmitted by the female anopheles mosquito. Factors which affect mosquito ecology,
                                       such as temperature and humidity, are key determinants of malaria transmission. Mosquitoes breed in
                                       hot, humid areas and below altitudes of 2000 meters. Development of the malaria parasite occurs
                                       optimally between 25-30oC and stops below 16oC. Indigenous malaria has been recorded as far as
                                       64oN and 32oS.
                                       Malaria has actually increased in sub-Saharan Africa in recent years. The major factor has been the
         6 of 54                       spread of drug-resistant parasites. Other important factors include the persistence of poverty,
                                       HIV/AIDS, mosquito resistance to insecticides, weak health services, conflict and population
                                       migration.
                                               Endemicity and immunity to malaria
 Partners in Global Health Education


1.    How to use this
      module                           “Endemicity” refers to the level of transmission of malaria. Malaria is endemic in an area or
2.    Learning outcomes                community when there is a constant incidence of cases over successive years. People
3.    Plasmodium species
4.    Malaria burden                   gradually develop immunity to malaria if continuously exposed. Malaria endemicity can be
5.    Question 1                       classified as:
6.    Transmission
7.    Life cycle
8.    Question 2
                                                                                                        Holoendemic or highly
9.    Disease severity                                                                                  endemic
10.   Question 3                                                                  Hyperendemic
11.   Clinical malaria                                                            Intense but           Intense transmission occurs
12.   Question 4                                              Mesoendemic                               throughout the year. Severe
13.   Diagnosis                        Hypoendemic                                seasonal
                                                              Moderate                                  malaria and deaths occur
14.   Treatment
                                       Little transmission;                       transmission;
15.   Prevention and                                          transmission;                             mainly in children under 5
      control                          malaria has little                         malaria occurs in
                                                              malaria becomes                           years. Pregnant women are
16.   Pregnancy                        effect on the                              all age groups
17.   Question 5                       population.            a more important                          also highly susceptible,
18.   Information sources                                                         and is an
                                                              disease.                                  especially in the fist
                                                                                  important cause
                                                                                  of deaths.            pregnancy, because immune
                                                                                                        defence mechanisms are
                                                                                                        impaired during pregnancy.


         7 of 54                        Malaria epidemics occur when transmission increases amongst susceptible populations.
                                           Epidemics do not occur in holoendemic areas because of the high level of immunity.
                                                End of Section 1
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1.    How to use this

                                                            Well done!
      module
2.    Learning outcomes
3.    Plasmodium species
4.    Malaria burden                         You have come to the end of the first section.
5.    Question 1
6.    Transmission
7.    Life cycle
8.    Question 2
9.    Disease severity
10.   Question 3
11.   Clinical malaria
12.   Question 4
13.   Diagnosis
14.   Treatment
15.   Prevention and
      control
16.   Pregnancy
17.   Question 5
18.   Information sources              We suggest that you answer Question 1 to assess your learning so
                                        far. Please remember to write your answers on the mark sheet
                                                    before looking at the correct answers!



         8 of 54
                                            Question 1
                                            Write “T” or “F” on the answer sheet. When you have completed all 5
 Partners in Global Health Education        questions, click on the box and mark your answers.
                                                                                                          Click for the correct answer
1.    How to use this
      module
2.
3.
      Learning outcomes
      Plasmodium species               a)   P. ovale occurs mainly in West Africa                                      a
4.    Malaria burden
5.    Question 1
6.    Transmission                     b)   P. falciparum is the most important species
7.    Life cycle
8.    Question 2
                                            of malaria                                                                 b
9.    Disease severity
10.   Question 3
11.
12.
      Clinical malaria
      Question 4                       c)   The largest burden of malaria occurs in
13.   Diagnosis
14.   Treatment                             South East Asia                                                            c
15.   Prevention and
      control
16.
17.
      Pregnancy
      Question 5
                                       d)   Malaria epidemics are likely to occur in a
18.   Information sources
                                            holoendemic area                                                           d

                                       e)   Environmental factors which affect mosquito
                                            breeding are closely related to the intensity                              e
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                                            of malaria transmission
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                                            How is malaria transmitted?
1.    How to use this             •    Malaria parasites are transmitted from one
      module
2.    Learning outcomes                person to another by the bite of a female
3.    Plasmodium species               anopheles mosquito.
4.    Malaria burden
5.    Question 1                  •    The female mosquito bites during dusk and
6.    Transmission
7.    Life cycle                       dawn and needs a blood meal to be able to
8.    Question 2
9.    Disease severity
                                       produce eggs.
10.   Question 3                  •    Male mosquitoes do not transmit malaria as
11.   Clinical malaria
12.   Question 4                       they feed on nectar and plant juices and not
13.   Diagnosis
14.   Treatment
                                       blood.
15.   Prevention and
      control
                                  •    There are about 380 species of anopheles
16.   Pregnancy                        mosquito but only about 60 are able to
17.   Question 5
18.   Information sources              transmit malaria.
                                                                                        Female Anopheles mosquito taking a blood meal
                                  •    Like all mosquitoes, anopheles breed in
                                       water - hence accumulation of water favours      Source:http://phil.cdc.gov/phil/quicksearch.asp
                                       the spread of the disease.
                                  •    The flight range of Anopheles is only about
                                       2-3 km but they may travel further if blown by
        10 of 54
                                       the wind or carried in ships or aeroplanes.
 Partners in Global Health Education          How does infection develop ?
1.    How to use this
      module                           Plasmodium infects the human and insect host alternatively and several phases
2.    Learning outcomes
3.    Plasmodium species
                                          of the parasite occur. The duration of each phase varies according to the
4.    Malaria burden                      species and is as follows for P. falciparum:
5.    Question 1
6.    Transmission
7.    Life cycle                          Mosquito phase: During feeding, the mosquito injects anticoagulant saliva
8.    Question 2                          into the blood stream. If the mosquito is infected, the saliva contains
9.    Disease severity                    primitive stages of malaria called sporozoites.
10.   Question 3
11.   Clinical malaria
12.   Question 4                                Hepatic, tissue or pre-erythrocytic phase: Sporozoites immediately
13.   Diagnosis                                 invade liver cells and begin to develop. The infected hepatocyte ruptures
14.   Treatment
15.   Prevention and
                                                to release merozoites after about 5-7 days.
      control
16.   Pregnancy                                      Erythrocytic phase: Merozoites then invade red blood cells. The red
17.   Question 5
                                                     cells lyse and this causes bouts of fever and other symptoms. This cycle
18.   Information sources          Then the          repeats about every 36 hours as merozoites invade other red cells.
                                     cycle
                                    repeats              Sexual phase: Sexual forms develop and are ingested when another
                                                         female anopheles mosquito feeds. These develop into sporozoites in the
                                                         gut of the insect host and migrate to its salivary glands.
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                                             The life cycle of the malaria parasite is shown on the next slide
                                                    The Malaria Parasite Life Cycle
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1.    How to use this                    Click on the
      module
2.    Learning outcomes                  diagram to
3.    Plasmodium species               explore different
4.    Malaria burden
5.    Question 1                       areas of the life
6.    Transmission                           cycle
7.    Life cycle
8.    Question 2
9.    Disease severity
10.   Question 3
11.   Clinical malaria
12.   Question 4
13.   Diagnosis
14.   Treatment
15.   Prevention and                      Show Me
      control
16.   Pregnancy
17.   Question 5
18.   Information sources




        12 of 54
                                                  Severity of disease and host factors
 Partners in Global Health Education


1.    How to use this
                                       In addition to parasite factors, several host factors determine the outcome of exposure to malaria:
      module
2.    Learning outcomes
3.    Plasmodium species
4.    Malaria burden
                                       •      Naturally-acquired immunity. People who are constantly exposed to malaria gradually acquire
5.    Question 1                              immunity, firstly against clinical disease and later against parasite infection. Clinical manifestations of
6.    Transmission                            malaria are most severe in the non-immune. In holoendemic areas, these are children aged <5 years
7.    Life cycle                              and pregnant women (especially primagravidae). People of any age from areas that are free from
8.    Question 2
9.    Disease severity                        malaria, or have limited malaria transmission, are at risk when they are exposed to malaria.
10.   Question 3
11.   Clinical malaria
12.   Question 4                       •      Red cell and haemoglobin variants. Well known examples of inherited factors that protect against
13.   Diagnosis                               malaria are Haemoglobin S carrier state, the thalassaemias and Glucose-6-phosphate
14.   Treatment                               dehydrogenase (G6PD) deficiency. Malaria provides the best known example whereby an
15.   Prevention and
                                              environmental factor (malaria) has selected human genes because of their survival advantage.
      control
16.   Pregnancy
17.   Question 5
18.   Information sources
                                       •      Foetal haemoglobin (HbF): High levels of HbF occur in neonates, and in some people with inherited
                                              haemoglobin variants, protect against severe forms of P. falciparum malaria.

                                       •      Duffy blood group: P. vivax requires the Duffy blood receptor to enter red blood cells. Therefore,
                                              people who do not carry the Duffy blood group are resistant to this malaria species. This explains the
                                              rarity of P. vivax in Africa, as most Africans are Duffy blood group negative.

        18 of 54
                                                 End of Section 2
 Partners in Global Health Education


1.    How to use this

                                                             Well done!
      module
2.    Learning outcomes
3.    Plasmodium species
4.    Malaria burden                              This is the end of the second section.
5.    Question 1
6.    Transmission
7.    Life cycle
8.    Question 2
9.    Disease severity
10.   Question 3
11.   Clinical malaria
12.   Question 4
13.   Diagnosis
14.   Treatment
15.   Prevention and
      control
16.   Pregnancy

                                       We suggest that you proceed to answer questions 2 and 3 to assess
17.   Question 5
18.   Information sources
                                        your learning further. Do remember to write your answers on the
                                                  mark sheet before looking at the right answer!



        19 of 54
                                        Question 2: Parasite factors and disease
                                        severity.
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                                                                                                                         Click
1.    How to use this
                                                                                                                        here for
      module                            Study the table below. Write down on your answer sheet 2                          the
2.    Learning outcomes
3.    Plasmodium species
                                        features of the biology of P. falciparum which contribute to it                 answers
4.
5.
      Malaria burden
      Question 1
                                        being responsible for nearly all severe malaria. Then click on
6.    Transmission                      the box and mark your answers.
7.    Life cycle
8.    Question 2
9.    Disease severity
10.   Question 3                                           Duration of      Incubation         Number of           Red cells
11.   Clinical malaria                                       tissue        period (days)*      merozoites /        invaded
12.   Question 4
13.   Diagnosis
                                                          phase (days)                            cell
14.   Treatment
15.   Prevention and                   P. falciparum         5.5 – 7            8 - 11            40,000        cells of all ages
      control
16.   Pregnancy
17.   Question 5                       P. vivax                6-8         10 – 17 or up to       10,000          reticulocytes
18.   Information sources                                                    12 months
                                       P. ovale                 9             10 – 17 or          15,000          reticulocytes
                                                                                longer
                                       P. malariae            14-16           18 – 40 or           2,000          mature cells
                                                                                longer
        20 of 54
                                         * Incubation period is the number of days from exposure (injection of sporozoites)
                                         to the onset of clinical symptoms.
                                            Question 3: The following people
 Partners in Global Health Education        are at risk of severe malaria:
1.    How to use this
                                            Write “T” or “F” on the answer sheet. When you have completed all 7   Click for the
                                                                                                                     correct
      module                                questions, click on the box and mark your answers.                       answer
2.    Learning outcomes
3.    Plasmodium species
4.    Malaria burden
5.    Question 1                       a)     Pregnant women                                                        a
6.    Transmission
7.    Life cycle
8.    Question 2
9.    Disease severity                 b)     Neonates                                                               b
10.   Question 3
11.   Clinical malaria
12.
13.
      Question 4
      Diagnosis
                                       c)     Immigrants from Europe                                                 c
14.   Treatment
15.   Prevention and

16.
      control
      Pregnancy
                                       d)     A 20 year old man who has lived all of his life in                     d
17.   Question 5                              Nigeria
18.   Information sources
                                       e)     A 3 year old girl resident in an area holoendemic for                  e
                                              malaria
                                       f)     A 10 year old child with sickle cell disease                           f
                                       g)     A 3 year old boy with Duffy negative blood group                      g
        21 of 54
                                           The clinical course of P. falciparum
 Partners in Global Health Education


1.    How to use this
      module
2.    Learning outcomes                Following a bite by an infected mosquito, many people do not develop
3.    Plasmodium species
4.    Malaria burden                   any signs of infection. If infection does progress, the outcome is one of
5.    Question 1
6.    Transmission                     three depending on the host and parasite factors enumerated in the
7.    Life cycle
8.    Question 2                       previous slides:
9.    Disease severity
10.   Question 3
11.   Clinical malaria
12.   Question 4                       A. Asymptomatic           B. Acute,                  C. Severe
13.
14.
      Diagnosis
      Treatment                        parasitaemia              uncomplicated              malaria
15.   Prevention and
      control
                                                                 malaria
16.   Pregnancy
17.   Question 5                       (clinical immunity)       (mild malaria)
18.   Information sources




        22 of 54
                                             A. Asymptomatic parasitaemia
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1.    How to use this
      module
2.    Learning outcomes
3.
4.
      Plasmodium species
      Malaria burden
                                       This is usually seen in older children and adults who have
5.
6.
      Question 1
      Transmission                     acquired “clinical immunity” to disease as a consequence
7.    Life cycle
8.    Question 2                       of living in areas with high malaria endemicity. There are
9.    Disease severity
10.   Question 3                       malaria parasites in the peripheral blood but no
11.   Clinical malaria
12.
13.
      Question 4
      Diagnosis
                                       symptoms. These individuals may be important reservoirs
14.
15.
      Treatment
      Prevention and
                                       for disease transmission.
      control
16.   Pregnancy
17.
18.
      Question 5
      Information sources              Some individuals may even develop “anti-parasite
                                       immunity” so that they do not develop parasitaemia
                                       following infection.

        23 of 54
                                           B. Simple, uncomplicated malaria
 Partners in Global Health Education


1.    How to use this
                                       This can occur at any age but
2.
      module
      Learning outcomes
                                       it is more likely to be seen in
3.
4.
      Plasmodium species
      Malaria burden                   individuals with some degree
5.    Question 1
6.    Transmission                     of immunity to malaria. The
7.    Life cycle
8.    Question 2                       affected person, though ill,
9.    Disease severity
10.
11.
      Question 3
      Clinical malaria
                                       does not manifest life-
12.
13.
      Question 4
      Diagnosis
                                       threatening disease.
14.   Treatment
15.   Prevention and
      control
16.   Pregnancy                        Fever is the most constant
17.   Question 5
18.   Information sources              symptom of malaria. It may
                                       occur in paroxysms when lysis     Children with malaria waiting to be seen at a
                                       of red cells releases             malaria clinic in the south western part of
                                                                         Nigeria. Identifying children with severe malaria,
                                       merozoites resulting in fever,    and giving them prompt treatment, is a major
                                                                         challenge when large numbers attend clinics.
        24 of 54                       chills and rigors
                                       (uncontrollable shivering).
                                                 The periodicity of malaria fever
 Partners in Global Health Education


1.    How to use this
      module                           Erythrocytic schizogony is the time
2.    Learning outcomes
3.    Plasmodium species
                                        taken for trophozoites to mature into
4.    Malaria burden                    merozoites before release when the
5.    Question 1
6.    Transmission                      cell ruptures.
7.    Life cycle
8.    Question 2
                                       It is shortest in P. falciparum (36
9.    Disease severity                  hours), intermediate in P. vivax and
10.   Question 3
11.   Clinical malaria                  P. ovale (48 hours) and longest in P.
12.   Question 4                        malariae (76 hours).
13.   Diagnosis
14.   Treatment                        Typical paroxysms thus occur every
15.   Prevention and
      control                          • 2nd day or more frequently in P.
16.   Pregnancy
17.   Question 5                        falciparum (“sub-tertian” malaria)      Note how the frequency of spikes of fever
18.   Information sources
                                       •   3rd  day in P. vivax and P. ovale    differ according to the Plasmodium species.
                                           (“tertian” malaria)                  In practice, spikes of fever in P. falciparum,
                                       • 4th day in P. malariae infections,     occur irregularly - probably because of the
                                                                                presence of parasites at various stages of
                                        (“quartan” malaria)
                                                                                development.

        25 of 54
                                                   Other features of simple,
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                                                uncomplicated malaria include:
1.    How to use this                  o   Vomiting
      module
2.    Learning outcomes                o   Diarrhoea – more commonly seen in young children and, when vomiting also occurs, may be
3.    Plasmodium species                   misdiagnosed as viral gastroenteritis
4.    Malaria burden
5.    Question 1                       o   Convulsions – commonly seen in young children. Malaria is the leading cause of convulsions with
6.    Transmission                         fever in African children.
7.    Life cycle
                                       o   Pallor – resulting mainly from the lysis of red blood cells. Malaria also reduces the synthesis of red
8.    Question 2
9.    Disease severity                     blood cells in the bone marrow.
10.   Question 3                       o   Jaundice – mainly due to haemolysis.
11.   Clinical malaria
12.   Question 4
13.   Diagnosis                        Malaria is a multisystem disease. Other common clinical features are:
14.   Treatment
15.   Prevention and                   o     Anorexia
      control                          o     Cough
16.   Pregnancy
17.   Question 5                       o     Headache
18.   Information sources              o     Malaise
                                       o     Muscle aches
                                       o     Splenomegaly
                                       o     Tender hepatomegaly


        26 of 54                       These clinical features occur in “mild” malaria. However, the infection requires urgent
                                          diagnosis and management to prevent progression to severe disease.
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                                            C. Severe and complicated malaria
1.    How to use this
      module
2.    Learning outcomes
3.    Plasmodium species
                                       Nearly all severe disease and the estimated >1 million deaths from
4.    Malaria burden                   malaria are due to P. falciparum. Although severe malaria is both
5.    Question 1
6.    Transmission                     preventable and treatable, it is frequently a fatal disease.
7.    Life cycle
8.    Question 2
9.    Disease severity                 The following are 8 important severe manifestations of malaria:
10.   Question 3                       Click on each severe manifestation for details
11.   Clinical malaria
12.   Question 4
13.   Diagnosis
14.   Treatment
                                       1.    Cerebral malaria                           5. Acute renal failure
15.   Prevention and
      control
                                       2.    Severe malaria anaemia                     6. Pulmonary oedema
16.   Pregnancy
17.   Question 5                                                                        7. Circulatory collapse, shock or
                                       3.    Hypoglycaemia
18.   Information sources
                                                                                           “algid malaria”
                                       4.    Metabolic acidosis                         8. Blackwater fever

                                         Note: It is common for an individual patient to have more than
                                         one severe manifestation of malaria!
        27 of 54
                                               Summary of differences in the clinical features
                                                 of severe malaria in adults and children
 Partners in Global Health Education

                                                                              Frequency of occurrence
1.    How to use this
      module
2.    Learning outcomes                  Clinical Manifestation              Children         Adults
3.    Plasmodium species
4.    Malaria burden                   Similar in adults and children
5.    Question 1
6.    Transmission                     • Prostration                           +++             +++
7.    Life cycle
8.    Question 2                       • Circulatory collapse                   +               +
9.    Disease severity
10.   Question 3                       More common in children
11.   Clinical malaria                 • Cerebral malaria                      +++             ++
12.   Question 4
13.   Diagnosis                        • Severe anaemia                        +++              +
14.   Treatment
15.   Prevention and                   • Multiple convulsions                  +++              +
      control
16.   Pregnancy                        • Metabolic acidosis                    +++              +
17.   Question 5                       • Hypoglycaemia                         ++              +/-
18.   Information sources
                                       More common in adults
                                       • Jaundice                               +              +++
                                       • Pulmonary oedema                      +/-             ++
                                       • Haemoglobinuria                       +/-              +
                                       • Abnormal bleeding                     +/-              +
        28 of 54
                                       • Renal failure                         +/-              +
                                                End of Section 3
 Partners in Global Health Education


1.    How to use this

                                            You have made tremendous progress!
      module
2.    Learning outcomes
3.    Plasmodium species
4.    Malaria burden                               This is the end of the third section.
5.    Question 1
6.    Transmission
7.    Life cycle
8.    Question 2
9.    Disease severity
10.   Question 3
11.   Clinical malaria
12.   Question 4
13.   Diagnosis
14.   Treatment
15.   Prevention and
      control
16.   Pregnancy
17.   Question 5
18.   Information sources              You should now be able to answer Question 4 to assess what you have
                                         learnt. You are to remember to write your answers on the mark
                                                    sheet before looking at the right answer!



        29 of 54
                                            Question 4: Clinical malaria
                                            Write “T” or “F” on the answer sheet. When you have completed all 7
 Partners in Global Health Education        questions, click on the box and mark your answers.
1.    How to use this
      module                                                                                                      Click for the correct
2.    Learning outcomes                                                                                                  answer
3.    Plasmodium species
4.
5.
      Malaria burden
      Question 1
                                       a)   Asymptomatic parasitaemia signifies acquired immunity                           a
6.    Transmission                          to malaria
7.    Life cycle
8.    Question 2                       b)   Symptoms typically occur during the hepatic phase of
9.    Disease severity
                                            infection
                                                                                                                             b
10.   Question 3
11.   Clinical malaria
12.   Question 4                       c)   Young children with mild malaria require urgent
13.   Diagnosis                             assessment and treatment                                                         c
14.   Treatment
15.   Prevention and                   d)   A single convulsion signifies severe disease
      control                                                                                                                d
16.
17.
      Pregnancy
      Question 5
                                       e)   The clinical signs of acidosis are rapid respirations with
18.   Information sources                   deep breathing
                                                                                                                             e
                                       f)   Acute renal failure occurs in older children and adults
                                       g)   A patient with malaria and dark urine is unlikely to be                          f
                                            anaemic
                                                                                                                             g
        30 of 54
                                                                   Diagnosis
 Partners in Global Health Education


1.    How to use this              Malaria is a multisystem disease. It presents with a wide variety of non-specific clinical features:
      module
2.    Learning outcomes
                                      there are no pathognomonic symptoms or signs. Many patients have fever, general aches
3.    Plasmodium species              and pains and malaise and are initially misdiagnosed as having “flu”.
4.    Malaria burden
5.    Question 1
6.    Transmission                 P. falciparum malaria can be rapidly progressive and fatal. Prompt diagnosis saves lives and
7.    Life cycle                       relies on astute clinical assessment:
8.    Question 2
9.    Disease severity
10.   Question 3
11.   Clinical malaria
                                   •   A good history
12.   Question 4                        – Residence or a recent visit (in the preceding 3 months) to a malaria endemic area
13.   Diagnosis
14.   Treatment                         – History of fever (may be paroxysmal in nature)
15.   Prevention and                    – Recognise significance of non-specific clinical features such as vomiting, diarrhoea,
      control
16.   Pregnancy                            headache, malaise
17.   Question 5                   •   Physical examination
18.   Information sources
                                        – Identify signs consistent with malaria: fever, pallor, jaundice, splenomegaly
                                        – Exclude other possible causes of fever (e.g. signs of viral and bacterial infections)


                                   The diagnosis of malaria should be considered in any
        31 of 54
                                     unwell person who has been in a malarious area recently
                                                          Investigations
 Partners in Global Health Education


1.    How to use this               Blood Film Examination
      module
2.    Learning outcomes            Thick and thin blood films (or “smears”) have
3.    Plasmodium species
4.    Malaria burden                  remained the gold standard for the
5.
6.
      Question 1
      Transmission
                                      diagnosis of malaria. The films are stained
7.
8.
      Life cycle
      Question 2
                                      and examined by microscopy.
9.    Disease severity
10.   Question 3                   Thick blood film - Used for detecting
11.   Clinical malaria
12.   Question 4                     malaria: a larger volume of blood is
13.   Diagnosis
14.   Treatment                      examined allowing detection of even low
15.   Prevention and
      control
                                     levels of parasitaemia. Also used for
16.
17.
      Pregnancy
      Question 5
                                     determining parasite density and monitoring
18.   Information sources            the response to treatment.         Show Me      Source- SOM 208 Microbiology Syllabus

                                   Thin blood film – Gives more information
                                     about the parasite morphology and,
                                     therefore, is used to identify the particular
                                     infecting species of Plasmodium. Show Me
        32 of 54
                                                  Appearance of P. falciparum in thin
 Partners in Global Health Education
                                                            blood films
1.    How to use this
      module                                                                                        Ring forms or trophozoites;
2.
3.
      Learning outcomes
      Plasmodium species
                                                                                                    many red cells infected – some
4.    Malaria burden                                                                                with more than one parasite
5.    Question 1
6.    Transmission
7.    Life cycle
8.    Question 2
9.    Disease severity
10.   Question 3
11.   Clinical malaria
12.   Question 4
13.   Diagnosis
14.   Treatment
15.   Prevention and
      control
16.   Pregnancy
17.   Question 5
18.   Information sources



                                       Gametocytes (sexual stages); After a
                                       blood meal, these forms will develop in
                                       the mosquito gut

        35 of 54
                                                                http://phil.cdc.gov/phil/quicksearch.asp
                                                Other methods of diagnosis of malaria
 Partners in Global Health Education


1.    How to use this

2.
      module
      Learning outcomes
                                       These are not routinely used in clinical practice. They include :
3.    Plasmodium species
4.    Malaria burden
5.
6.
      Question 1
      Transmission
                                       a)   Antigen capture kits. Uses a dipstick and a finger prick blood
7.    Life cycle                            sample. Rapid test - results are available in 10-15 minutes.
8.    Question 2
9.    Disease severity                      Expensive and sensitivity drops with decreasing parasitaemia.
10.   Question 3
11.   Clinical malaria                 b)   PCR based techniques. Detects DNA or mRNA sequences
12.
13.
      Question 4
      Diagnosis
                                            specific to Plasmodium. Sensitivity and specificity high but test is
14.   Treatment                             expensive, takes several hours and requires technical expertise.
15.   Prevention and
      control                          c)   Fluorescent techniques. Relatively low specificity and sensitivity.
16.   Pregnancy
17.   Question 5                            Cannot identify the parasite species. Expensive and requires
18.   Information sources                   skilled personnel.
                                       d)   Serologic tests. Based on immunofluorescence detection of
                                            antibodies against Plasmodium species. Useful for epidemiologic
                                            and not diagnostic purposes.

        36 of 54
                                                                     Treatment
 Partners in Global Health Education


1.    How to use this
                                        The treatment of malaria depends on a number of factors which include :
      module
2.    Learning outcomes
3.    Plasmodium species
4.    Malaria burden
5.    Question 1                                                     patient factors
6.    Transmission
7.
8.
      Life cycle
      Question 2
                                                                  age, pregnancy, prior
9.    Disease severity                                                 treatment or
10.   Question 3
11.   Clinical malaria                                             chemoprophylaxis,             severity of the
12.   Question 4
                                          parasite factors          likelihood of drug             infection
13.   Diagnosis
14.   Treatment                                                         compliance
15.   Prevention and                       species, drug                                     simple, uncomplicated
      control
16.   Pregnancy                              sensitivity                                     or severe, complicated
17.   Question 5
18.   Information sources                                                                            malaria



                                       In the absence of reliable diagnosis, clinical assessment alone can not
                                       differentiate malaria from other common febrile illnesses. In this situation, anti-
        37 of 54
                                       malarial treatment should be given routinely for people with fever.
                                                       Treatment of uncomplicated malaria
 Partners in Global Health Education                            – single agents
1.    How to use this
      module                       National treatment guidelines for first-line treatment are available in
2.    Learning outcomes               most malarious countries. Commonly used drugs include:
3.    Plasmodium species
4.    Malaria burden               •   4-aminoquinolines - chloroquine
5.    Question 1
                                         – cheap and widely available and previously the most widely used
6.    Transmission                         antimalarial drug. Use is now severely limited because of widespread
7.    Life cycle                           resistance of P. falciparum in South East Asia, East and West Africa.
8.    Question 2                         – blood schizonticide - kills the erythrocyte stages but has no effect on the
9.    Disease severity                     exo-erythrocytic (liver) stages or gametocytes.
10.   Question 3                         – P. vivax is usually sensitive to chloroquine, although resistance is
11.   Clinical malaria                     emerging.
12.   Question 4                         – Amodiaquine is an alternative for chloroquine-resistant falciparum
13.   Diagnosis                            malaria.
14.   Treatment
15.   Prevention and
                                   •   Sulphadoxine-pyrimethamine – “Fansidar”; first line treatment for P.
      control
                                       falciparum malaria in many countries, although resistance to this
16.   Pregnancy
                                       drug has also developed rapidly.
17.   Question 5
18.   Information sources
                                   •   8- aminoquinolines: Primaquine is active against the exo-
                                       erythrocytic forms of P. vivax and P. ovale and is added to
                                       treatment to prevent relapses.

                                   •   Less commonly used drugs for first-line treatment are quinine,
                                       mefloquine (schizonticide; neuropsychiatric adverse effects),
                                       halofantrine (schizonticide; may cause cardiac arrhythmias and
        38 of 54                       sudden death) and atovaquone-proguanil.
                                                  Treatment of uncomplicated malaria
 Partners in Global Health Education
                                                         – drug combinations
1.    How to use this
      module                           • The rapid emergence of resistance to drugs when used as single agents
2.    Learning outcomes                  has led to the development of drug combinations for first-line treatment.
3.    Plasmodium species
4.    Malaria burden                   • Combinations combine two or more schizonticidal drugs which act
5.
6.
      Question 1
      Transmission
                                         independantly of each other. This reduces the development of parasite
7.    Life cycle                         resistance to the drugs used in the combination.
8.
9.
      Question 2
      Disease severity                 • Artemisinin and its derivatives (artemether, artesunate, artheether;
10.   Question 3                         based on the Chinese herb quinhaosu) are rapidly active against
11.   Clinical malaria
12.   Question 4
                                         erythrocytic stages and also gametocytes (therefore, may reduce
13.   Diagnosis                          transmission). Current levels of resistance are low.
14.   Treatment
15.   Prevention and                   • Several combinations include an artemisinin derivative; e.g.
16.
      control
      Pregnancy
                                         dihydroartemisinin + piperaquine; artesunate + chlorproguanil/dapsone
17.   Question 5                       • Examples of other drug combinations are chlorproguanil + dapsone
18.   Information sources
                                         (Lapdap), atovaquone + proguanil (Malarone).
                                       • The choice of which combination to use depends on many factors,
                                         including the existing pattern of resistance and cost.
                                       • As well as drug treatment, supportive treatment for associated problems
                                         such as high fever, dehydration and anaemia are important!
        39 of 54
 Partners in Global Health Education      Treatment of severe, complicated malaria
1.    How to use this
      module                           Drugs                                  Supportive therapy
2.    Learning outcomes
3.    Plasmodium species
4.    Malaria burden
5.    Question 1
                                       Quinine is the most widely used        A vital adjunct to clinical
6.    Transmission                       drug. It is administered by rate-       management. It includes the
7.    Life cycle                         controlled intravenous infusion.        general care of the unconscious
8.    Question 2
9.    Disease severity
                                         Where this is not possible, it can      patient, careful fluid balance,
10.   Question 3                         be administered by deep                 control of seizures, nasogastric
11.   Clinical malaria                   intramuscular injection. This is        tube feeding, correction of
12.   Question 4                         less desirable because of slow          metabolic derrangements (e.g.
13.   Diagnosis
14.   Treatment                          and uncertain absorption and risks      hypoglycaemia, metabolic
15.   Prevention and                     such as injection abscess and           acidosis) and blood transfusion for
16.
      control
      Pregnancy
                                         muscle necrosis.                        severe anaemia.
17.   Question 5
18.   Information sources
                                       Artemisinin derivatives are also       Bacterial infection can also co-exist
                                          used to treat severe malaria. At       with severe malaria and require
                                          rural clinics where it is not          antibiotic treatment.
                                          possible to give injections,
                                          artemesinin suppositories can be
                                          used whilst the patient is being
        40 of 54
                                          transferred.
                                         Malaria prevention and control

 Partners in Global Health Education
                                         Reducing man-mosquito contact
1.    How to use this
      module
2.    Learning outcomes                Insecticide-treated nets (ITNs) are relatively
3.    Plasmodium species                   cheap and, if used correctly, an effective
4.    Malaria burden
5.    Question 1                           means of preventing malaria. The
6.    Transmission                         development of longlasting nets may
7.    Life cycle
8.    Question 2                           help to overcome the requirement to re-
9.    Disease severity                     treat nets with insecticide regularly. The
10.   Question 3
11.   Clinical malaria
                                           major difficulty remains achieving high
12.   Question 4                           coverage rates of ITNs in the most at-
13.   Diagnosis                            risk populations.
14.   Treatment
15.   Prevention and                   Historically, indoor house-spraying with
      control
16.   Pregnancy                            residual insecticides (e.g. DDT)
17.   Question 5                           achieved many successes but was not
18.   Information sources
                                           sustainable. However, some countries
                                           still use this approach as part of their
                                           public health measures against malaria.
                                       Other means to reduce contact for                Families are advised to prioritise the use of bed
                                           individuals are wearing of protective        nets for children under 5 years and pregnant
                                           clothing and insect repellents at dawn       women – the family members at most risk of
        41 of 54                                                                        developing severe malaria.
                                           and dusk.
                                           Malaria prevention and control
 Partners in Global Health Education
                                           Chemoprophylaxis
1.    How to use this
      module
2.    Learning outcomes
3.    Plasmodium species
4.    Malaria burden                   Chemoprophylaxis is the administration of drugs to individuals likely to be
5.    Question 1
6.    Transmission                       exposed to malaria.
7.    Life cycle
8.    Question 2                       • Indicated in travellers and also pregnant women and people with sickle
9.    Disease severity
10.   Question 3                         cell disease living in malaria endemic areas
11.   Clinical malaria
12.   Question 4                       • Effective malaria prophylaxis is challenging because of cost, drug
13.   Diagnosis
14.   Treatment                          resistance and adverse effects.
15.   Prevention and
      control                          • The recommendations vary according to likely parasite resistance and
16.   Pregnancy
17.   Question 5                         patient characteristics (e.g. age, breastfeeding, pregnancy).
18.   Information sources
                                       • Commonly-used drugs include chloroquine and proguanil, mefloquine
                                         and malarone.



        42 of 54
                                            Malaria prevention and control

 Partners in Global Health Education
                                            Vaccines against P. falciparum -1
1.    How to use this
      module                           Why is a malaria vaccine needed?
2.    Learning outcomes
3.    Plasmodium species
4.    Malaria burden
5.    Question 1                       Despite well-tested and proven public health interventions to prevent malaria, the
6.    Transmission                       disease burden due to malaria has increased in recent years. This has
7.    Life cycle
8.    Question 2                         occurred for several reasons:
9.    Disease severity
10.   Question 3                       • Population growth
11.   Clinical malaria
12.   Question 4                       • The parasite constantly develops resistance to the commonly-used and
13.   Diagnosis
14.   Treatment
                                         affordable drugs
15.   Prevention and
      control
                                       • Anopheles mosquitoes develop resistance to insecticide
16.
17.
      Pregnancy
      Question 5
                                       • Malaria control programmes are often not well implemented or are interrupted
18.   Information sources                by conflict
                                       • Increased tourism and migration of non-immune people into malarious areas

                                       A malaria vaccine offers the prospect of an affordable intervention that could be
                                          administered as part of existing immunisation programmes.
        43 of 54
                                       Malaria prevention and control
 Partners in Global Health Education
                                       Progress towards a vaccine
1.    How to use this
      module                           Is a malaria vaccine possible?         So why is developing a vaccine
2.    Learning outcomes
3.    Plasmodium species
                                                                                 difficult?
4.    Malaria burden
5.    Question 1
                                       There are several factors which
6.    Transmission                        suggest that immunisation against   There are several obstacles:
7.    Life cycle                          malaria is possible:                • P. falciparum is a highly complex
8.    Question 2
9.    Disease severity                 • Natural immunity against malaria        parasite with different antigens at
10.   Question 3                          develops after repeated exposure       different stages of the life cycle
11.   Clinical malaria
12.   Question 4                       • Passive immunity occurs in young     • Many of these antigens show
13.   Diagnosis                           infants (probably as a result of       marked polymorphism
14.
15.
      Treatment
      Prevention and
                                          maternal antibody) and also in      • Single parasite clones show
      control                             individuals who were given             antigenic variability; the parasite
16.   Pregnancy                           purified immunoglobulins from          constantly changes its antigens
17.   Question 5                          people with natural immunity        • The basis of naturally-acquired
18.   Information sources
                                       • Administration of UV attenuated         immunity is not well understood
                                          sporozoites confers protection      • There is no animal model to help
                                       • Experimental malaria vaccines           with the development and testing
                                          have shown some modest efficacy        of vaccine candidates
                                          in clinical trials
        44 of 54
                                        Malaria prevention and control
                                        What vaccines are under development?
 Partners in Global Health Education


1.    How to use this                   There are around 75 candidate vaccines under
      module                            development. Vaccines can be grouped according
2.    Learning outcomes                 to the stage of the parasite life cycle:
3.    Plasmodium species                                                                     Pre-erythrocytic: aim to
4.    Malaria burden
5.    Question 1
                                                                                            prevent clinical disease by
6.    Transmission                                                                       targetting sporozoites and intra-
7.    Life cycle                                                                                hepatocytes stages
8.    Question 2
9.    Disease severity
10.   Question 3
11.   Clinical malaria                 Transmission-blocking:
12.   Question 4                       aim to prevent human-to-
13.   Diagnosis                        human transmission by
14.   Treatment                        targeting the sexual
15.   Prevention and                   stages in the mosquito                                         Erythrocytic or blood
      control
16.   Pregnancy
                                                                                                       stage: aim to reduce
17.   Question 5                                                                                        disease severity by
18.   Information sources                                                                              preventing invasion or
                                                                                                     increasing the clearance
                                                                                                            of red cells.



        45 of 54
                                       Malaria prevention and control

 Partners in Global Health Education
                                       What are the leading vaccine candidates?
1.    How to use this

2.
      module
      Learning outcomes
                                       There are hundreds of parasite proteins which could form targets for
3.    Plasmodium species                 vaccines. Various strategies of stimulating the host’s immune
4.
5.
      Malaria burden
      Question 1
                                         response are being evaluated including prime-boost, virosomes
6.    Transmission                       and synthetic parasite peptides. Most of the vaccines currently
7.    Life cycle                         under development are targeted against:
8.    Question 2
9.    Disease severity                        • the circumsporozoite protein (CSP)
10.   Question 3
11.   Clinical malaria                        • the merozoite surface protein (MSP)
12.
13.
      Question 4
      Diagnosis                               • the apical membrane antigen (AMA-1)
14.   Treatment
15.   Prevention and

16.
      control
      Pregnancy
                                       The most advanced vaccine to date, RTS,S/AS02A, has been
17.   Question 5                         developed jointly by GlaxoSmithKline and the Malaria Vaccine
18.   Information sources                Initiative. It is a pre-erythrocytic, sub-unit vaccine which combines
                                         CSP with the hepatitis-B surface antigen. Clinical trials have
                                         shown that this vaccine reduced malaria episodes by 30% and
                                         severe malaria by 58% in children in Mozambique.

        46 of 54
                                                                 Malaria in pregnancy
 Partners in Global Health Education


1.    How to use this
      module                           More than 45 million women (30 million in Africa) become
2.    Learning outcomes                   pregnant in malaria endemic areas each year. The
3.    Plasmodium species
4.    Malaria burden                      adverse effects of malaria affect primigravidae more
5.    Question 1                          than multigravidae and HIV infection increases malaria
6.    Transmission                        in pregnancy. The following adverse events are well-
7.    Life cycle
8.    Question 2                          recognised:
9.    Disease severity                 Mother:
10.   Question 3
11.   Clinical malaria                       –   Anaemia
12.   Question 4                             –   Cerebral malaria
13.   Diagnosis
14.   Treatment                              –   Hypoglycaemia
15.   Prevention and                         –   Puerperal sepsis
      control
                                             –   Pulmonary oedema and heamorrhage
16.   Pregnancy
17.   Question 5                       Fetus:
18.   Information sources
                                             –   Abortion and stillbirth
                                             –   Preterm delivery
                                             –   Intra-uterine growth retardation (IUGR) and anaemia
                                       Infant:
                                             –   Low birth weight (<2500 gms; both prematurity and IUGR
                                                 may contribute)
        47 of 54                             –   Reduced levels of maternal antibody (e.g. against
                                                 tetanus)
                                               Malaria in pregnancy
 Partners in Global Health Education           Prevention and control
1.    How to use this
      module
2.    Learning outcomes                As usual, this requires using more than one approach that
3.    Plasmodium species                   are appropriate to the local situation. The following are
4.    Malaria burden
5.    Question 1                           key components of malaria control programmes for
6.    Transmission                         pregnant women recommended by WHO:
7.    Life cycle
8.    Question 2                       • Prompt and effective case management according to
9.    Disease severity                     national treatment guidelines. Commonly used drugs
10.   Question 3
11.   Clinical malaria
                                           include chloroquine, sulfadoxine-pyrimethamine and
12.   Question 4                           quinine.
13.   Diagnosis
14.   Treatment
                                       • Insecticide-treated mosquito nets (ITNs)
15.   Prevention and                   • Intermittent preventive treatment (IPT): the
      control
16.   Pregnancy
                                           administration of an anti-malarial drug (e.g.
17.   Question 5                           sulphadoxine-pyrimethamine) in areas of stable
18.   Information sources                  malaria transmission whether or not women show
                                           symptoms or have parasites in the blood. 3 full doses
                                           are given at least 1 month apart during the second and
                                           third trimesters. IPT has now replaced
                                           chemoprophylaxis (e.g. with chloroquine) in many            Source:
                                           countries.                                                  http://phil.cdc.gov/phil/quicksearch.asp
        48 of 54
                                                             International initiatives
 Partners in Global Health Education


1.    How to use this
      module                           Many international organisations are involved in the fight against
2.    Learning outcomes                malaria.
3.    Plasmodium species
4.    Malaria burden                   The WHO in partnership with UNICEF, UNDP and the World Bank
5.    Question 1                       initiated Roll Back Malaria (RBM) in 1998 to promote an effective
6.    Transmission
7.    Life cycle                       control strategy to combat the disease. The goal of RBM is to
8.    Question 2                       halve the world’s burden of malaria by 2010. RBM was later joined
9.    Disease severity                 by a broader group of partners including governments of countries
10.   Question 3                       affected by the disease, multi and bilateral agencies, NGOs,
11.   Clinical malaria
12.   Question 4                       international private sector representative and research groups.
13.   Diagnosis
14.   Treatment                        RBM focuses on –
15.   Prevention and
      control
                                        Rapid clinical case detection and provision of prompt access to
16.   Pregnancy                        effective malaria treatment, especially in the home.
17.   Question 5
18.   Information sources               Preventing and controlling malaria during pregnancy.
                                        Promoting the use of insecticide treated bed nets (ITN) as a
                                       means of prevention, especially in young children and pregnant
                                       women.
                                        Dealing effectively with malaria in emergency and epidemic
                                       situations.                                                          Prompt effective malaria treatment
                                                                                                            saves lives
        49 of 54
                                                End of Section 4
 Partners in Global Health Education


1.    How to use this

                                                   You have come a long way!
      module
2.    Learning outcomes
3.    Plasmodium species
4.    Malaria burden                                  This is the last of the sections.
5.    Question 1
6.    Transmission
7.    Life cycle
8.    Question 2
9.    Disease severity
10.   Question 3
11.   Clinical malaria
12.   Question 4
13.   Diagnosis
14.   Treatment
15.   Prevention and
      control
16.   Pregnancy
17.   Question 5

                                       For the section just ended, you should be able to answer Question 5
18.   Information sources

                                       to assess what you have learnt. It is still required that you put down
                                        your answers on the mark sheet before looking at the right answer!


        50 of 54
                                       Question 5: Malaria diagnosis,
7.Partners1 Global Health Education
   Quiz in
                                       prevention and treatment
1.    How to use this                  Write “T” or “F” on the answer sheet. When you have completed all 6
      module                           questions, click on the box and mark your answers.                     Click for the
2.    Learning outcomes                                                                                      correct answer
3.    Plasmodium species
4.    Malaria burden
5.    Question 1                  a)     A well-prepared and stained thick blood film is usually the
6.    Transmission
                                         most practical way to diagnose malaria                                 a
7.    Life cycle
8.    Question 2
9.    Disease severity            b)     Chloroquine prophylaxis is recommended during
10.   Question 3                                                                                                b
11.   Clinical malaria                   pregnancy in East Africa
12.   Question 4
13.   Diagnosis                   c)     More than one anti-malarial drug should be used for first-             c
14.   Treatment
15.   Prevention and                     line treatment
      control
16.   Pregnancy                   d)     Quinine is the drug of choice for severe malaria
17.   Question 5                                                                                                d
18.   Information sources

                                  e)     Poor compliance with antimalarial therapy favours the                  e
                                         development of resistance
                                  f)     Insecticide-impregnated bednets are used to prevent
                                         malaria mainly in travellers                                            f
         51 of 54
 Partners in Global Health Education
                                                   Sources of information
1.    How to use this
      module
2.
3.
      Learning outcomes
      Plasmodium species
                                       •   Malaria. Greenwood BM, Bojang K, Whitty CJ, Targett GA. Review; Lancet 2005;
4.    Malaria burden                       365:1487-98.
5.    Question 1                       •   http://mosquito.who.int/cmc_upload/0/000/015/372/RBMInfosheet_1.htm
6.    Transmission
7.    Life cycle
                                           These WHO fact sheets developed by the Roll Back Malaria Partnership cover many
8.    Question 2                           different aspects of malaria – including prevention with insecticide-treated bed nets
9.    Disease severity                     and treatment with atemesinin-based combination therapies
10.   Question 3                       •   http://www.cdc.gov/malaria/
11.   Clinical malaria
12.   Question 4                           The US Centre for Disease Control and Prevention site for malaria
13.   Diagnosis                        •   http://www.malaria.org/
14.   Treatment
15.   Prevention and                       Follow the “Learn about malaria” link on the Malaria Foundation’s website. This
      control                              contains numerous useful and accessible resources.
16.   Pregnancy                        •   http://www.rph.wa.gov.au/labs/haem/malaria/
17.   Question 5
18.   Information sources                  An interactive resource from the Royal Perth Hospital, Western Australia. Contains
                                           useful self-assessment exercises in malaria diagnosis by microscopy that are set in
                                           the context of clinical cases.
                                       •   Towards an effective malaria vaccine. Aide P, Bassat Q, Alonso P. Arch Dis Child
                                           2007;92:476-9.
                                       •   Malaria. A handbook for Health Professionals. Malaria Consortium. Macmillan
                                           Publishers Limited; 2007.
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                                                     End of Module
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                                                           Well done!
1.    How to use this
      module
2.    Learning outcomes

                                       Now that you have completed the malaria module and
3.    Plasmodium species
4.    Malaria burden
5.
6.
      Question 1
      Transmission
                                       attempted sectional questions, you may wish to take
7.    Life cycle                       on the full quiz to assess your learning for the whole
8.
9.
      Question 2
      Disease severity                        module. Please print out the questions
10.   Question 3
11.   Clinical malaria
12.
13.
      Question 4
      Diagnosis                        The questions may differ slightly from those you have
14.   Treatment                          come across in the sectional assessment but are
                                           based on the material covered in this module.
15.   Prevention and
      control
16.   Pregnancy
17.   Question 5
18.   Information sources
                                                      END OF MODULE QUIZ

                                        You will also find a link to the answers at the end of
                                               the quiz to measure your performance
        53 of 54                          Please attempt this as many times as you wish.
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                                                The “direct” burden
1.    How to use this

2.
      module
      Learning outcomes
                                       • Every year, there are about 500 million clinical attacks of malaria.
3.    Plasmodium species                 Of these, 2-3 million are severe and about 1 million people die
4.
5.
      Malaria burden
      Question 1
                                         (about 3000 deaths every day).
6.    Transmission
7.    Life cycle
8.    Question 2                       • Malaria in pregnancy accounts for about 25% of cases of severe
9.
10.
      Disease severity
      Question 3
                                         maternal anaemia and 10-20% of low birthweight. Low birthweight
11.   Clinical malaria                   due to malaria accounts for about 5-10% of neonatal and infants
12.
13.
      Question 4
      Diagnosis
                                         deaths.
14.   Treatment
15.   Prevention and
      control                          • 80% of all malaria cases occur in tropical Africa where the disease
16.
17.
      Pregnancy
      Question 5                           accounts for 10-30% of all hospital admissions
18.   Information sources
                                           is responsible for 15-25% of deaths in children aged <5 years -
                                            about 800,000 child deaths every year.
                                           kills an African child every 30 seconds


        90 of 54

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                                           The “indirect” burden of
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                                                   malaria
1.    How to use this

2.
      module
      Learning outcomes                • Human development: Impaired intellectual
3.
4.
      Plasmodium species
      Malaria burden
                                         development, developmental abnormalities (especially
5.
6.
      Question 1
      Transmission
                                         following cerebral malaria), lost school attendance and
7.    Life cycle                         productivity at work
8.    Question 2
9.
10.
      Disease severity
      Question 3
                                       • Economics: Malaria retards economic development in
11.
12.
      Clinical malaria
      Question 4
                                         the developing world. The cost of a single bout of
13.
14.
      Diagnosis
      Treatment
                                         malaria is equivalent to over 10 working days in Africa.
15.   Prevention and
      control
                                         The cost of treatment is between $US0.08 and $US5.30,
16.
17.
      Pregnancy
      Question 5
                                         depending on the type of drugs prescribed as required
18.   Information sources                by the local pattern of drug resistance.
                                       • Total cost of malaria in Africa in terms of healthcare,
                                         treatment and lost productivity, is currently estimated to
                                         be >$US12 billion every year.
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