2 Global Distribution of Malaria Slide 6. Global Distribution of MalariaThis slide shows the global distribution of malaria.Malaria is found in places where Anopheles mosquitoes can survive and the malaria parasites can complete their life cycle within the host. Climatic factors such as temperature, humidity, and rainfall are especially important, with the highest transmission rate found in Africa South of the Sahara.Economic development and public health measures have succeeded in eliminating malaria in many temperate areas, such as western Europe and the United States. Many of these areas have Anopheles mosquitoes that can transmit malaria, and reintroduction of the disease remains a risk.CDC. Available at Accessed October 17, 2004.Accessed October 17, 2004CDC. Available at
3 Global Burden Malaria is a global disease. 40% world pop. lives in malarious areas.m malaria cases annually.2– 3m death an average of one person every 12 seconds. Mostly children (<5 yrs).India contribute 23% of clinical cases of Pf.1.2 billion PAR P. vivax which is 42% of the global PAR.Hay et al., Lancet. 7(6):eContd…
4 Burden in Asia and India 2.4m malaria cases reported from South Asia.Of which 75% are in India alone.Five states responsible >60% malaria.Orissa, CG, MP, Jharkhand & WB.Malaria infect human at conception till adult.Patients survive if they timely access to medicines.Malaria present a diagnostic challenge.World Malaria Report World Health Organization
10 Blood Smear! The quantity of blood is very important for the thick smear! Not enough blood may lead to a WRONG NEGATIVE RESULT.Too much blood cannot be stained properly and CANNOT BE EXAMINED
11 FLUORESCENCE MICROSCOPY Fluorescent dyes have an affinity for nuclic acid in the parasite nucleus.They attach to the nuclei.Under UV light, the nucleus fluorecence strongly (490nm).Two fluorochromes used,Acridine Orange (AO) Benzothio Carboxypurine (BCP)Green/Yellow fluorescence
12 Quantitative Buffy Coat (QBC) (Becton Dickingson Franklin Lakes N.J.) QBC combines an AO coated capillary tube.Centrifuged Parasite concentrate below layer of cells.In the upper layer of RBCBetween layers of Platelets and WBC.Parasite can be viewed through the capillary tube using focal length objective (Paralens)
13 LimitationsQBC, BCP and AO are rapid and easy when parasitaemia >100 parasites/l.Inability to differentiate between Plasmodium species (AO/BCP)AO hazardous has special disposal requirementsQBC/BCP more demanding technically than AOQBC requires a particular centrifuge and its tubes. This increase costs to about US$1.7/sample.
14 PCRNested PCR and reverse transcription PCR enable all four species to be identified.P.falciparumP.vivaxLane 1-11 :Samples, Lane 12 & 13: positive & negative control, Lane 14: 100 bp DNA ladderLane 2-12 :Samples, Lane 1 & 13: positive & negative control, Lane 14: 100 bp DNA ladder
15 Limitations Advantages Expensive, extensive technical expertiseLabour intensive involved multiple stepsHigh cost of the enzymes and primersAbility to detect low level parasitaemia5 parasites/µl can be detected (100% Sen/Sp.)Strain variations, mutations and drug resistanceMixed infection
16 Why use RDT? Early diagnosis and prompt treatment. Rapid, reliable and simple to perform-RDTs an alternative to microscopy.With New Expensive ACT, RDT is must.
17 RDTs Three type of Antigen detection tests common. Histidine rich Protein 2 (HRP-2).Plasmodium Lactate dehydrogenase (pLDH) test usually detects falciparum and non falciparum.Combo testHRP-2 + pLDH based - First ResponseHRP-2 + Aldolase ICT Combo
18 PrincipleDiagnosis is based on Detection of HRP-2 released from infected erythrocytes with P. falciparum monoclonal antibodies against HRP-2 fixed in the test strip that reacts with heamolyzed blood samples from positive patients. The antigen/antibody reaction is revealed by the addition of a detector reagent. A solid pink line on the strip indicates a positive test.
22 Advantages (RDTs)Do not require extensive training or good infrastructure or electricity.Simple to perform.Easy to learn.Ideal on the spot diagnosis and treatment.No supervision required.Simple to carry in the field.
23 Limitations (RDTs) Expensive Low sensitivities in low parasitaemia Persistent positivity upto 2 weeks after medicationMay not be used for identification of drug resistanceFalse positives rheumatoid factor/ heterophile antibodyIt can not different between current/ recent parasitaemiaCan not quantify the parasitaemiaCan not differentiate between sexual and asexual
24 Assisting staff fills consent form Collection of blood sample for RDT Interpretation of Rapid Diagnostic Test KitMedical Officer provides medicine
25 Molecular Diagnostics GENOMIX reader for Point-of-Care DiagnosticsMolecular DiagnosticsPortable ReaderHandheldReaderA functional Genomics Company
27 Major Vectors in India Anopheles fluviatilis Anopheles culicifacies Anopheles stephensiAnopheles sundaicusAnopheles minimusAnopheles dirus
28 Monitoring of insecticide resistance of An Monitoring of insecticide resistance of An. culicifacies, malaria vector in district Balaghat, Dindori, Mandla, Sidhi, Jhabua and Shahdol of MPInsecticide MortalityDDT 4% 6.7 – 11.2%Malathion 5% 77.3 – 83.5%Deltamethrin – 97.0%0.05%Alphacypermethrin %
29 DYNAMICS OF P.vivax & P.falciparum RATIO IN STUDY AREA SHOWING SHIFTING TREND Singh et al., Trop Med Int Hlth
30 Aims of National Drug Policy on Malaria (2010) Providing complete cure of malaria cases.Prevention of progression of uncomplicated malaria to severe malaria.Prevention of relapses by administration of radical treatment.Interruption of transmission by the use of gametocytocidal drugs.Preventing development of drug resistance by early treatment of malaria.
31 Treatment of MalariaAll fever cases should be tested by microscopy/ RDTNo presumptive treatmentP. vivax - CQ (3 days) PQ for 14 daysP. falciparum - ACT 3 days- PQ single doseCases not responding to ACT should be treated with oral quinine with Tetracycline/ Doxycycline
32 National Drug Policy During Pregnancy Pregnant women with Pf (uncomplicated)1st Trimester – Quinine2nd & 3rd Trimester – ACT(Artesunate + Sulphadoxine-Pyrimethamine)