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Photos taken from blood film prepared from Jimbai ak Muping’s blood sample at
admission to hospital (all trophozoite).

Photos taken from blood film prepared from Jeffrey ak Igam’s blood sample at
admission to hospital.

schizont late trophozoite early trophozoite schizont gametocyte

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Difficult term:
Intermittent - occurring at irregular interval, not continuous or steady
Rigor - a sudden feeling of cold with shivering accompanied by a rise in
temperature often with copious sweating, especially at the onset or height
of fever
Myalgia is pain in muscle or groups of muscles
Nausea stomach discomfort and the sensation of wanting of vomit
Trophozoite - is caused by the protozoan parasite Plasmodium
Schizont 1. (in certain sporozoan protozoans) a cell that divides by schizogony to form
daughter cells.
Zoonotic is caused by the protozoan parasite Plasmodium
malaria
Antimalarial a type of anti-parasitic chemical agent often naturally derives that can be
drugs used to treat or to prevent malaria, in the latter case, most often aiming at
two susceptible target group, young children and pregnant woman, to treat
the malaria
Hypnozoite a dormant form in a life cycle of a certain parasitic protozoa that belong to
stage the Sporozoa (only Plasmodium vivax and Plasmodium ovale)
Blood film A blood smear, peripheral blood smear or blood film is a thin layer of
blood smeared on a glass microscope slide and then stained in such a way
as to allow the various blood cells to be examined microscopically

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Biological
 Life cycle of parasite
 Period of incubation
 Type of Malaria
 Vectors of Malaria
 Transmission of malaria

Life cycle of parasite

1. Mosquitoes take blood meal and injects sporozoites in to human body.

2. The sporozoites invade the liver cells.by binding to the hepatocyte receptors for the serum
proteins thrombospondin and properdin and mature into schizonts which rupture to release
merozoites.

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3. For P.ovale and P.vivax form latent hypnozoites in hepatocytes, which cause relapse of
malaria weeks to months after initial infection. The infection of liver and development of
merozoites in this stage is called the exoerythrocytic stage where no symptoms present.

4. Merozoites invade rbcs.

5. The ring stage trophozoites mature into schizonts again which rupture and release
merozoites.

6. Parasites at erythrocytic stage is responsible for the clinical manifestations of disease.

7. Gametocytes (male=microgametocytes, female=macrogametocytes) which developed from

trophozoites are ingested by female Anopheles mosquitoes during blood meal.

8. While the mosquitoes’ gut, microgametocytes penetrate macrogametocytes to generate

zygote.

9. Zygotes turn into motile and elongated ookinetes which invade the midgut wall of mosquito
and develop into oocysts.

10. Oocysts grow and rupture to release sporozoites which will deposit in salivary gland.

11. Inoculation of sporozoites into a new human host perpetuates malaria life cycle.

https://www.youtube.com/watch?v=A2-XTlHBf_4

Life cycle of mosquitoes

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Period of incubation

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Incubation Period in Liver

Malaria is an acute febrile illness with an incubation period of 7 days or longer. Thus, a febrile
illness developing less than 1 week after the first possible exposure is not malaria. 12 days for
P. falciparum and P. knowlesi, 14 days for P. vivax and P. ovale and 30 days for P. malariae

P. vivax and P. ovale can remain dormant in the liver. Relapses caused by these persistent liver
forms (“hypnozoites”) may appear months, and rarely several years, after exposure. Relapses
are not prevented by current chemoprophylactic regimens, except for primaquine.

    Plasmodium species
   P. vivax P. ovale  P. malariae  P. falciparum 
 Pro-erythrocytic phase
 6-8  9  14-16  5-7
(days)
 Erythrocytic cycle
 48  50  72  48
(hours)
 12-17 or even 6-12  16-18 or
 Incubation period (days)  18-40 or more  9-14
months more
 Sporogony (days)  8-10  12-14  14-16  9-10

What is the duration of each species to stay in the liver and erythrocytes?

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 P. vivax will stay in erythrocytes for 72 hours in each cycle.
 Plasmodium falciparum cycle in the erythrocytes is irregular.
 The total length of the intra-erythrocytic development is roughly 72 hours for P. malariae.
 The developmental cycle of P. ovale in the blood lasts approximately 49 hours.

Type of Malaria
Type of plasmodium causing malaria

P. falciparum (most common), which is found worldwide in tropical and subtropical areas,
and especially in Africa where this species predominates. P. falciparum can cause severe
malaria because it multiples rapidly in the blood, and can thus cause severe blood loss (anemia).
In addition, the infected parasites can clog small blood vessels. When this occurs in the brain,
cerebral malaria results, a complication that can be fatal.

P. vivax, which is found mostly in Asia, Latin America, and in some parts of Africa. Because of
the population densities especially in Asia it is probably the most prevalent human malaria
parasite. P. vivax has dormant liver stages (“hypnozoites”) that can activate and invade the
blood (“relapse”) several months or years after the infecting mosquito bite.

P. ovale is found mostly in Africa (especially West Africa) and the islands of the western
Pacific. It is biologically and morphologically very similar to P. vivax. However, differently
from P. vivax, it can infect individuals who are negative for the Duffy blood group, which is the
case for many residents of sub-Saharan Africa. This explains the greater prevalence of P. ovale
(rather than P. vivax ) in most of Africa. P. ovale has dormant liver stages (“hypnozoites”) that
can activate and invade the blood (“relapse”) several months or years after the infecting
mosquito
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bite.

P. malariae, found worldwide, is the only human malaria parasite species that has a quartan
cycle (three-day cycle).If untreated, P. malariae causes a long-lasting, chronic infection that in
some cases can last a lifetime. In some chronically infected patients P. malariae can cause
serious complications such as the nephrotic syndrome.

P. knowlesi (no mosquito vector)no human malaria(others 4 plasmodium is transmitted by

human). Plasmodium knowlesi is the only zoonotic malaria (transmitted by infected monkey)

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• Parasitised blood cells are not enlarged.

• Rings appear fine and delicate and there may be several in one cell.
• Presence of marginal or applique forms.
• Gametocytes have a characteristic crescent shape/banana shape appearance. However,
they do not usually appear in the blood for the first four weeks of infection.
• Maurer’s dots may be present.
• Cytoadherence of red blood cells (RBCs) invade by Plasmodium falciparum parasites is
an important contributor to the sequestration of RBCs causing reduced microcirculatory
flow associated with fatal malaria syndromes.

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• Parasitised red blood cells are enlarged.

• Schuffner’s dots are frequently present in the red cells as shown above.
• The mature ring forms tend to be large and coarse.
• Trophozoites are amoeboid in shape.

• Ring forms may have a squarish appearance.

• Band forms are a characteristic of this species.
• Mature schizonts may have a typical daisy head appearance with up to ten merozoites.
• Parasitised red blood cells are not enlarged.
• Chromatin dot may be on the inner surface of the ring.

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• Only found in Africa.

• Parasitised red blood cells enlarged.
• Rings large and coarse.
• Schuffner’s dots, when present, may be prominent.
• Mature schizonts similar to those of P. malariae but larger and more coarse

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• The morphology of P. knowlesi parasites in human infections closely resembled those of P.

falciparum in the early trophozoite stage and P. malariae in the later stages.
• It would be difficult to identify knowlesi malaria based on morphology alone.
• However, in the absence of PCR facilities, severe symptoms, a parasitemia >5,000/μl blood,
with P. malariae parasite morphology and a recent history of time spent in the forest fringe
areas ofSoutheast Asia should be enough to make a diagnosis of knowlesi malaria.
• Parasitised red blood cells are not enlarged.

Vectors of Malaria

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Reservoir host for malaria parasite

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Transmission of malaria
Reservoir of Malaria Parasite (P. knowlesi) – Zoonotic malaria
The natural hosts of P. knowlesi that were initially identified were long-tailed (M. fascicularis)
and pig-tailed (Macaca nemestrina) macaques from Singapore and Peninsular Malaysia, and
there has also been a report of a single P. knowlesi isolation from a leaf monkey (Presbytis
melalophos) from Peninsular Malaysia. Subsequently, P. knowlesi infections were detected in
macaques from Cebu and Palawan Island, Philippines. More recent reports, using molecular
detection methods and sequencing, have identified P. knowlesi infections in wild long-tailed
macaques in Sarawak, Malaysian Borneo; Peninsular Malaysia; Singapore; and Southern
Thailand and in wild pig-tailed macaques in Southern Thailand and Sarawak. These two
macaque species are distributed throughout Southeast Asia and are the most common
nonhuman primates in this region. The observation that peridomestic long-tailed macaques in
Singapore and macaques living close to a temple in Thailand did not harbor P. knowlesi or
other simian malaria parasites is a reflection of the absence of a competent mosquito vector for
parasite transmission.

The highest prevalence of P. knowlesi has been observed in wild macaques of the Kapit
Division in Sarawak, Malaysian Borneo, where 87% of 83 long tailed-macaques and 50% of 26
pig-tailed macaques were P. knowlesi positive. The very high prevalence of P. knowlesi and
other malaria parasites in these macaques (94% were malaria positive) from 17 locations
indicates that malaria transmission is intense among the wild-macaque population in the Kapit
Division of Malaysian Borneo.

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Mouth part:
· Anopheles mosquitoes have a pair of mouthpart palps that are about the same length as
the proboscis.

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Normal morphology of red blood cell

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➢The shape is uniformly discoid shape or biconcave disc

➢No nucleus, no organelles
➢Red colour with central area of pallor, 1/3 of the entire erythrocytes

How malaria parasite affect red blood cell ?

➢When parasite invade RBC, outer membrane of RBC forms a vacuole
around the parasite
➢Parasite makes and transports proteins out into RBC to remodel it
➢These proteins pass through a membrane in the vacuole called PTEX
➢PTEX is essential for parasite to live

Transmission of malaria
Mode of transmission
Bites from mosquitoes
In most cases, malaria is transmitted through the bites of female Anopheles mosquitoes. There
are more than 400 different species of Anopheles mosquito; around 30 are malaria vectors of
major importance. All of the important vector species bite between dusk and dawn. The
intensity of transmission depends on factors related to the parasite, the vector, the human host,
and the environment.

Anopheles mosquitoes lay their eggs in water, which hatch into larvae, eventually emerging as
adult mosquitoes. The female mosquitoes seek a blood meal to nurture
their eggs. Each species of Anopheles mosquito has its own preferred aquatic habitat; for
example, some prefer small, shallow collections of fresh water, such as puddles and hoof prints,
which are abundant during the rainy season in tropical countries.

Transmission is more intense in places where the mosquito lifespan is longer (so that the
parasite has time to complete its development inside the mosquito) and where it prefers to bite
humans rather than other animals. The long lifespan and strong human-biting habit of the
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African vector species is the main reason why approximately 90% of the world's malaria cases
are in Africa.

Transmission also depends on climatic conditions that may affect the number and survival of
mosquitoes, such as rainfall patterns, temperature and humidity. In many places, transmission is
seasonal, with the peak during and just after the rainy season. Malaria epidemics can occur
when climate and other conditions suddenly favour transmission in areas where people have
little or no immunity to malaria. They can also occur when people with low immunity move
into areas with intense malaria transmission, for instance to find work, or as refugees

Blood
• Blood transfusion
• Needle stick injuries
• Organ transplant
• The shared use of needles or syringeCongenital malaria
• From a mother to her child during pregnancy before or during delivery

Human immunity is another important factor, especially among adults in areas of moderate or
intense transmission conditions. Partial immunity is developed over years of exposure, and
while it never provides complete protection, it does reduce the risk that malaria infection will
cause severe disease. For this reason, most malaria deaths in Africa occur in young children,
whereas in areas with less transmission and low immunity, all age groups are at risk.

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Clinical
 Type of antimalaria drugs for treatment
 Procedures to detect malaria
 Sign and Symptoms of malaria

Anti-malaria drug:
1. Atovaquone/Proguanil (Malarone)

2. Chloroquine

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3. Doxycycline

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4. Mefloquine

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5. Primaquine

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6. Tafenoquine

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Procedures to detect malaria
Diagnosis of Malaria Infection
Microscopic blood test:
Peripheral smear study for malarial parasites – The MP test

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Serological tests: detects antibodies against asexual blood stage malaria

parasites
Malaria antibody detection is performed using the indirect fluorescent antibody (IFA) test. The
IFA procedure can be used to determine if a patient has been infected with Plasmodium.
Because of the time required for development of antibody and also the persistence of
antibodies, serologic testing is not practical for routine diagnosis of acute malaria. However,
antibody detection may be useful for:

• Screening blood donors involved in cases of transfusion-induced malaria when the donor’s
parasitemia may be below the detectable level of blood film examination
• Testing a patient, usually from an endemic area, who has had repeated or chronic malaria
infections for a condition known as tropical splenomegaly syndrome
• Testing a patient who has been recently treated for malaria but in whom the
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diagnosis is questioned.

Non-microscopic test:
Rapid Diagnostic Tests (RDTs)
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Detect species-specific circulating parasite antigens targeting either the histidine

rich protein-2 of P. falciparum or a parasite-specific lactate dehydrogenase.
Although the dipstick tests may enhance diagnostic speed, microscopic examination
remains mandatory in patients with suspected malaria, because occasionally these
dipstick tests are negative in patients with high parasitaemia, and their sensitivity
below 100 parasites/μl is low.

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Sign and Symptoms of Malaria Infection

Signs and symptoms of malaria may include:
· Fever
· Chills
· General feeling of discomfort
· Headache
· Nausea and vomiting
· Diarrhea
· Abdominal pain
· Muscle or joint pain
· Fatigue
· Rapid breathing and heart rate
· Cough

 Some people who have malaria experience cycles of malaria “attacks” (fever
paroxysm). An attack usually starts with shivering and chills, followed by a
high fever, followed by sweating and a return to normal temperature.

 Malaria signs and symptoms typically begin within a few weeks after being
bitten by an infected mosquito. However, some types of malaria parasites can
lie dormant in your body for up to a year.

 Malaria is known for its fever paroxysm, starting with chills, rigors, high
grade fever, followed by sweating as the fever declines.

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Behavioral
-Risk factor of Malaria
-Prevention of Malaria

Risk factor of Malaria

What causes malaria?
Malaria is caused by one of four species of the protozoan Plasmodium : P.
falciparum , P. vivax , P. ovale , and P. malariae . Malaria is usually acquired by the
bite of a protozoan-infected Anopheles mosquito, but it also may be transmitted by
transfusion of infected blood or from mother to child in utero. P. falciparum , the
most common and most life-threatening type, causes virtually all of the 1 million
annual malaria deaths worldwide.

Who is most at risk of getting very sick and dying from malaria?
 P. falciparum is the type of malaria that most often causes severe and life-
threatening malaria; this parasite is very common in many countries in Africa
south of the Sahara Desert.

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 People who are heavily exposed to the bites of mosquitoes infected with P.
falciparum are most at risk of dying from malaria.
 People who have little or no immunity to malaria, such as young children and
pregnant women or travelers coming from areas with no malaria, are more
likely to become very sick and die.
 Poor people living in rural areas who lack access to health care are at greater
risk for this disease.
 As a result of all these factors, an estimated 90% of deaths
 due to malaria occur in Africa south of the Sahara; most of these deaths occur
in children under 5 years of age.
 However, newborn are protected from falciparum malaria because of high
concentration of foetal haemoglobin in first few months of life.

Deforestation linked with malaria:

• Pools of water being exposed to sunlight. This increases temperatures, promoting
more ideal breeding grounds
• Creating ditches and puddles which are more likely to pool less acidic water. This
is more conducive to Anopheles larvae development
• Reducing the absorption of water – primary growth forests tend to be heavily
shaded with thick debris on the ground. This absorbs water and often leaves any
standing water acidic, and creating “tree bowls” where stumps are left behind and
gather pool water.

Prevention of Malaria

Can malaria be prevented?

Although no one method of protection is 100% effective, proper use of prophylactic
drugs, bed nets, and insect repellent, as well as proper patient education, can
prevent most cases of traveler’s malaria seen in the United States.

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Treatment :
A. Suppressive treatment/chemoprophylaxis:
Kills sporozoites before they infect hepatocytes
Usually given to travelers that are headed to a country with endemic malaria.

B. Therapeutic treatment:
Aimed at eliminating merozoites in the erythrocytic phase
Given during an acute infection

C. Gametocidal treatment
Aimed at killing gametocytes
Prevents spread of disease and creation of resistant forms of parasite

D. Radical treatment
Aimed to killing hypnozoites in the liver from P.vivax /P.ovale to prevent relapses

Prevention
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Vector control
WHO recommends protection for all people at risk of malaria with effective malaria
vector control. Two forms of vector control – insecticide-treated mosquito nets and
indoor residual spraying – are effective in a wide range of circumstances. Sleeping
under an insecticide-treated net (ITN) can reduce contact between mosquitoes and
humans by providing physical barrier and an insecticidal effect. Indoor residual
spraying (IRS) with insecticides is another powerful way to rapidly reduce malaria
transmission. It involves spraying the inside of housing structures with an
insecticide, typically once or twice per year.

Vaccines against malaria

RTS,S/AS01 (RTS,S) is the first and, to date, the only vaccine to show that it can
significantly reduce malaria, and life-threatening severe malaria, in young African
children. It acts against P. falciparum, the most deadly malaria parasite globally and
the most prevalent in Africa. Among children who received 4 doses in largescale
clinical trials, the vaccine prevented approximately 4 in 10 cases of malaria over a
4-year period.

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Population:
-Malaria Screening in Sabah & Sarawak
-Awareness of Malaria in Malaysia
-The Law used regarding infectious disease
-Control of infectious disease

Malaria Screening in Sabah & Sarawak

List of Notifiable Disease in Malaysia (Notification Form)
Why do we need to do mandatory reporting?
The information collected on notifiable diseases from doctors and laboratories is used to detect
and investigate outbreaks, and prevent spread of infection, hence reducing further cases of
disease. It is also used to examine disease epidemiology, and implement and monitor
interventions such as immunisation to protect public health.

Prevalance of Malaria in Sarawak and Sabah

https://malariajournal.biomedcentral.com/articles/10.1186/s12936-020-3135-x

Majority of the patients were male (13,552; 82.1%). The most common age group in Sabah and
Sarawak reported highest number of malaria cases in age group of 30
to 39 years (2776; 21.6%). The top two races with malaria in Sabah and Sarawak
were Bumiputera Sabah (5613; 43.7%) and Bumiputera Sarawak (4512; 35.1%).
The highest number of P. knowlesi in Malaysia was contributed mainly from
P. knowlesi cases notified in Sabah and Sarawak which was 9902 (77.1%). Other types of
Plasmodium species only accounted for less than 10% of the total malaria
cases. There were 1177 (9.2%) P. vivax, 1011 (7.9%) P. falciparum, 542 (4.2%) P.
malariae, 62 (0.5%) P. ovale, and 141 (1.1%) mixed infection.

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The commonest type of Plasmodium species reported in Sabah and Sarawak was P. knowlesi
with a sharp increase for 2017. There were 1468 cases in 2013 and it increased to 2252 cases in
2014. Then it reduced to 1527 cases in 2015 and 1464 cases in 2016 and eventually rose to
3191 cases in 2017. The other four types of Plasmodium reported fewer than 500 cases per year
and showed decreasing trend year by year.

Incidence rate

Mortality rate

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Support group

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What is travel medicine?

 Travel medicine refers to the prevention and management of health problems in travelers.

 A pre-travel consultation should include a health assessment, interventions and counseling to

decrease travel-related risks and improve the likelihood of a safe and enjoyable travel
experience.

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