Malaria New(2)

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INTRODUCTIONINTRODUCTION Malaria is one of the most common infectiousMalaria is one of the most common infectious

diseases and an enormous public healthdiseases and an enormous public health

problem.problem. The disease has been recognized forThe disease has been recognized for

thousands of years and it is widespread inthousands of years and it is widespread intropical and subtropical regions, includingtropical and subtropical regions, including

parts of the Americas, Asia, and Africa.parts of the Americas, Asia, and Africa.

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Currently, malaria occurs in 100 countries andterritories inhabited by a total of 2.4 billion

people.

The World Health Organization estimates thatthere are 300 million to 500 million clinical

cases annually, resulting in approximately 1.5

million to 3 million deaths. The human

suffering and economic costs are enormous.

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90% of the deaths are in children under fiveyears of age. Other risk groups include

pregnant women, internally displaced

persons and refugees, and international

travelers.

Malaria is still the main cause of morbidityMalaria is still the main cause of morbidity

and mortality among children in Cambodia.and mortality among children in Cambodia.

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A delay of treatment and/or inappropriatetreatment are responsible of the high rate of

lethality.

Malaria is complex but it is a curable and

preventable diseases. Lives can be saved if

the disease is detected early and

adequately treated.

Mass education and appropriate

organization of health facilities with well

trained staffs can reduce the mortality.5


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How People Get Malaria ?

Malaria is caused by a parasite called Plasmodium, which istransmitted via the bites of infected mosquitoes. In the human

body, the parasites multiply in the liver, and then infect red bloodcells. Usually, people get malaria by being bitten by an infectivefemale Anopheles mosquito. When a mosquito bites an infected

person, a small amount of blood is taken in which containsmicroscopic malaria parasites. About 1 week later, when themosquito takes its next blood meal, these parasites mix with themosquito's saliva and are injected into the person being bitten.

Because the malaria parasite is found in red blood cells of an

infected person, malaria can also be transmitted through bloodtransfusion, organ transplant, or the shared use of needles orsyringes contaminated with blood. Malaria may also be transmittedfrom a mother to her unborn infant before or during delivery("congenital" malaria).

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Malaria Symptoms

Symptoms of malaria include fever and shaking chills,

headache, muscle aches, tiredness and nausea, vomiting,and diarrhea may also occur.

Malaria cause anemia and jaundice because of thedestruction of red blood cells. Symptoms usually appear

between 10 and 15 days after the mosquito bite. If not treated, malaria can quickly become life-threatening

by disrupting the blood supply to vital organs.

Infection with one type of malaria, Plasmodium

falciparum, if not promptly treated, may cause kidneyfailure, seizures, mental confusion, coma, and death. Inmany parts of the world, the parasites have developedresistance to a number of malaria medicines.

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How soon will a person feel sick after being bitten by aninfected mosquito?

For most people, symptoms begin 10 days to 4 weeks afterinfection, although a person may feel ill as early as 7 days oras late as 1 year later. Two kinds of malaria, P. vivax and P.ovale, can occur again. In P. vivax and P. ovale infections,some parasites can remain dormant in the liver for several

months up to about 4 years after a person is bitten by aninfected mosquito. When these parasites come out ofhibernation and begin invading red blood cells ("relapse"), the

person will become sick.

Infection with malaria parasites may result in a wide variety of

symptoms, ranging from absent or very mild symptoms tosevere disease and even death. Malaria disease can becategorized as uncomplicated orsevere complicated .

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Malaria Incubation Period

The incubation period in most cases varies from 7 to

30 days. The shorter periods are observed mostfrequently with P. falciparum and the longer oneswith P. malariae.

Antimalarial drugs taken for prophylaxis can delaythe appearance of malaria symptoms by weeks ormonths. (This can happen particularly with P. vivaxand P. ovale, both of which can produce dormantliver stage parasites; the liver stages may reactivateand cause disease months after the infective mosquito

bite.) Such long delays between exposure and developmentof symptoms can result in misdiagnosis or delayeddiagnosis because of reduced clinical suspicion by thehealth-care provider.

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Uncomplicated Malaria

The classical malaria attack lasts 6-10 hours. It consists of:

Cold stage (sensation of cold, shivering) Hot stage (fever, headaches, vomiting; seizures in young children)

Sweating stage (sweats, return to normal temperature, tiredness)

More commonly, the patient presents with a combination of the following symptoms:

Fever

Chills

Sweats Headaches

Nausea and vomiting

Body aches

General malaise.

Enlarged spleen.

Enlargement of the liver Mild jaundice

Diagnosis of malaria depends on the demonstration of parasites on a blood smearexamined under a microscope. In P. falciparum malaria, additional laboratoryfindings may include mild anemia, mild decrease platelets, elevation of bilirubin,and hemoglobinuria.

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Complicated malaria

Severe malaria occurs when P. falciparum infections are complicated by seriousorgan failures or abnormalities in the patient's blood or metabolism. The

manifestations of severe malaria include:

Cerebral malaria, with abnormal behavior, impairment of consciousness,seizures, coma, or other neurologic abnormalities

Severe anemia

Hemoglobinuria

Pulmonary edema or acute respiratory distress syndrome

Cardiovascular collapse and shock

Acute kidney failure

Metabolic acidosis

Hypoglycemia .

Severe malaria occurs most often in persons who have no immunity to malaria orwhose immunity has decreased. These include all residents of areas with lowor no malaria transmission, young children and pregnant women in areas withhigh transmission.

In all areas, severe malaria is a medical emergency and should be treatedurgently and aggressively.

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MATERIALS AND METHODSMATERIALS AND METHODS

Study design:

- Epidemiologic study

- Critical signs and symptoms

- Clinical features- Treatment

- Underlining TB primary infection

Study period:

-1st January 2008 to 31st December 2009

Patient criteria:

-All patients hospitalized with positive blood smear

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Data collections

-Age distribution

-Sex distribution

-Geographical distribution-Seasonal distribution

Outcome

Conclusion

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Number of confirmed cases compared with all

hospitalized patient during two year period

1364 confirmed cases out of73667 hospitalized patient represent 1.85%over two-year period from 2008 to2009.

73667

1364

Patient Hospitalized

Malaria

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Number of not confirmed cases

compared with all hospitalized patient

4140 suspected cases (smear negative) representsuspected cases (smear negative) represent 5.61% overover73667

cases of the year 2008cases of the year 2008 --2009.2009.

73667

4140

All Patients

Suspected Case

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Age distribution

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36 cases : 3%

639 cases : 47%689 cases : 50%

< 1year

1 - 5year

> 5 - 15year


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Sex distribution

Male :729 ( 53% )

Female : 635 ( 47% )

729635Male

Female

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18

0

100

200

300

400

500

600

700

800

780 = 57%

144132 125

70 5629 25 2 1

Siem Reap

Kampong Thom

Udor Meanchey

Preahvihea

Battambang

Banteay Meanchey

Pailin

Kampong Cham

Pursat

Kampong Speu

Geographical distribution


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Seasonal distribution

0

20

40

60

80

100

120

140

160

180

142

83

64

50

7079

111

150142

154 153

166 January

F ruary

March

April

May

Jun

July

August

S pt m r

Octo r

Nov m r

D c m r 19


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Critical signs and symptoms

Severe anemia (HB< 7g/l) : 586 (43%)

Hypoglycemia : 390 ( 28.59% )

Acute renal failure : 345 ( 25.85% )

Metabolic acidosis : 339 ( 24.85% )

Hemoglobinuria : 124 ( 9% )

Respiratory distress : 254 ( 18.62% )

Lung Edema : 7 ( 0.51% )

Shock : 6 ( 0.43% )

Digestive Hemorrhage with shock : 2 ( 0.14% )

Conscious disturbance:

- Lethargy : 481 (35.26%)

- Convulsion : 156 (11.43%)

- Delirium : 118 (8.65%)

- Coma : 36 (2.63%) 20


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Clinical featuresClinical features

Severe Malaria

(falciparum): 1064(78%)

Cerebral Malaria(falciparum)

: 309(22.65%)

Vivax Malaria : 302(22%)

Mixed Malaria (falciparum +vivax)

: 55(4%)

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Parasite distribution Plasmodium falciparum : 1062 (75%)

Plasmodium vivax : 302 (21%)

P falciparum+ vivax : 55 (4%)

1062

302 Plasmodium falciparum

Plasmodium vivax

P falciparum+ vivax

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Imaging

Lungs CT scan: In 1023 (75%) over 1364 cases,calcifications were detected.

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TreatmentTreatment

Anti-malaria drugs:

- Artesunate for falciparum malaria:

. D1: First dose 4mg/kg IV and12hr later second dose 2mg/kg IV

. D2-D5: 2mg/kg/d IV

- Quinine for Vivax malaria:. Dose 30mg/kg/d IVP for7days

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Symptomatic treatment

Severe anemia:- Hb< 7g/l or Ht< 20%

Transfusion: 10-20ml/kg of RCC or WB

Hypoglycemia:

- D50% 1-2ml/kg 1 part + sterile water 4 part orD10%: 5ml/kg

Convulsion:

- Valium: 0.5mg/kg IR or 0.2-0.5mg/kg IVP

- Phenobarbital: 10-20mg/kg IV AR :

- Furosemide: 0.5-2mg/kg/dose (maximum6mg/kg/dose)

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Treatment of TB primary infection

Rifater(Isoniazid 80mg+rifampicin120mg+ pyrazinamide 250mg):1 tablet/ 10kg for6 months.

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Outcome

Deaths : 03 (0.2%)

1361 cases : good outcome without

sequelae.

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Conclusion

Severe malaria cases are presented with one ormore of the ten main clinical manifestations:

1-severe anemia,2-hypoglycemia,3- acute renalfailure,4-metabolic acidosis,5-cerebral malaria,6-hemoglobinuria,7-respiratory distress,8-lung

edema,9-shock, and 10- digestive hemorrhage. Severe anemia is the predominant clinical symptom

of severe malaria (43%)

=>blood transfusion necessary.

Children in the age range from 1 to 5 arepredominantly affected.

75% of the present cases have underlining TBprimary infection.

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Malaria New(2)