3. Phylum: Apicomplexa
Class: Sporozoea
Sub-class: Coccidia
Order: Eucoccidia
Sub-order: Haemosporina
Family: Plasmodidae
Genus: Plasmodium
Sub-genus: Plasmodium Laverania Vinckeia …....
Species: vivax falciparum berghei
malariae
ovale

5. Causal Agents:
There are approximately 156 named species of Plasmodium which infect various species of vertebrates. 
Four are known to infect humans:. 
P. falciparum, P. vivax , P. ovale  and P. malariae.

6. Distribution of Malarial Parasites
P. vivax
most widespread
P. falciparum
primarily tropics and subtropics
P. malariae
similar range as P. falciparum
P. ovale

8. Malaria types Malignant Tertian Malaria Benign Tertian Malaria
Benign QuartanMalaria

9. Anopheles mosqouite

10. Vectores in Iran An. Stephenciمهمترین و پایدارترین ناقل در ایران
An. Superpictus فراگیرترین آنوفل در ایران
An. Dethaliکوچکترین آنوفل در جنوب شرق ایران
An. Culicifacies
An. Fluviatilisخطرناکترین ناقل فالسیپاروم
An. Maculipennisناقل اصلی درشمال و شمال غرب کشور
An. Sacharovi ناقل اصلی درشمال و شمال غرب کشور

12. Life Cycle:
                                                                                 
Life Cycle

14. Geographic Distribution

17. شیوع مالاریا در ایران در سال 1381: 15378 مورد مثبت در کشور
24/0 در هزار نفر جمعیت:API
68/14درصد آن مربوط به پلاسمودیوم فالسیپاروم
در سال 1380: مورد بیماری در منطقه جنوب شرقی کشور گزارش شده است.

18. Malaria Transmission natural (sporozoites/Anopheles)
blood transfusions
shorter incubation period
fatality risk (P. falciparum)
no relapses possible (vivax/ovale)
syringe sharing
congenital
relatively rare although placenta is heavily infected

21. Clinical features 2-Fever ( Hot stage) 3- Sweating stage
History of exposure:
(mostly: past travel or residence in disease-endemic areas). 
Since untreated malaria can progress to severe forms that may be rapidly (<24 hours) fatal, malaria should always be considered in patients who have a
Paroxsym:
1-Chills ( Cold stage)
2-Fever ( Hot stage)
3- Sweating stage
Other clinical features:
splenomegaly, anemia, thrombocytopenia, hypoglycemia, pulmonary or renal dysfunction, and neurologic changes.

22. cold stage feeling of intense cold vigorous shivering, rigor
lasts min

24. hot stage intense heat dry burning skin throbbing headache
lasts 2-6 hours

26. sweating stage profuse sweating declining temperature
exhausted, weak  sleep
lasts 2-4 hours

28. Malaria Paroxysm
paroxysms associated with synchrony of merozoite release
temperature is normal and patient feels well between paroxysms
falciparum may not exhi-bit classic paroxysms
continuous fever
24 hr periodicity
tertian malaria
quartan malaria

29. توضیح واژه ها Relapse Hypnozoite (Resting stage) Recrudescence
Induced malaria
Hemozoin

30. Stippling dots 1) Schuffner’s dots 2) Maurer’s dots 3) Ziemann’s dots
4) Jame’s dots
Sticky phenomen( knobs)

32. Malignant Tertian Malaria
Infections caused by P. falciparum can progress to severe;
1-Cerebral malaria
2-Black water fever ( severe anemia)
3-Acute renal failure
4- Algid malaria
5- Respiratory distress syndrome (pneumonic malaria)
6- Gastro-intestinal mlaria
Complications of P. vivax malaria include splenomegaly (with, rarely, splenic rupture),
and those of P. malariae include nephrotic syndrome.

33. Karunaweera et al (1992) PNAS 89:3200
sweating
rigor
TNF = tumor necrosis factor-a ()
proinflammatory cytokine (produced in response to malarial antigens?)

34. Immunity Anti-Parasite Immunity
slow to develop
short lived
‘premunition’
non-sterilizing
lower parasitemia
less symptoms
Anti-Parasite Immunity
immune response prevents merozoite invasion, eliminates infected erythrocytes, etc.
Anti-Disease Immunity
eg., neutralization of exo-antigens or toxic effects

35. Immunity in Malaria A) Natural immunity 1-Innate immunity
2- Genetic immunity
B) Acquired immunity
1-Exo-Erythrocytic stage
Premonition: prevents of super-infection no re-infection (stage specific).
2- Erythrocytic stage
concomitant immunity (stage specific & strain specific ):
Ab mediated immunity
Ab dependent cell cytotoxicity (ADCC)
Ab dependent phagocytosis
Cellular immunity

36. Malaria Epidemiology Stable or Endemic Malaria
~constant incidence over several years
includes seasonal transmission
immunity and disease tolerance correlates with level of endemicity (especially adults)
Unstable or Epidemic Malaria
periodic sharp increase in malaria
little immunity
high morbidity and mortality
Endemicity
Levels:
holo-
hyper-
meso-
hypo-

37. Malaria laboratory diagnosis
1) Microscopic identification:
-preparing thick and thin biood smear
-comparison of plasmodium species
2- Quality Buffy Coat ( QBC)
3) Immunochromatographic methods
4)Antibody Detection
5) Molecular diagnosis techniques

38. Thin Blood Smear

39. Thick Blood Smear

40. A: Immature schizont in a thin blood smear. B: Mature schizont
                                                             A B

41. Multiply infected red blood cells with appliqué forms in thin blood smears
                                                             A B C

42. Ruptured schizonts in a thin blood smear.
                        
                          C D

43. Malaria antibody detection
The IFA procedure
Blood stage Plasmodium species schizonts (meronts) are used as antigen
Enzyme immunoassays have also been employed as a tool to screen blood donors,
but are not recommended for clinical diagnosis due to limited sensitivity
serologic testing is not practical for routine diagnosis of acute malaria. 

44. Antibody detection may be useful for:
1- screening blood donors
2- Fever of Unknown Origin
3- testing a patient who has been recently treated for malaria but in whom the diagnosis is questioned
Species-specific testing is available for the four human species: P. falciparum, P. vivax, P. malariae, and P. ovale. 
Cross reactions often occur between Plasmodium species and Babesia species. 

45. Usefulness of Antibody Detection in the Diagnosis of Malaria Parasites

46. Types of Serological Assays Malaria
Antibody Detection:
Indirect Fluorescent Antibody
Enzyme immunoassays
Antigen Detection:
Immunochromatographic

47. Antibody Detection + = Antigen Patient’s serum Antigen-antibody
contains specific
and non-specific
antibodies + =
Antigen-antibody
complex
Antigen

48. Antigen-antibody- *antibody complex
Antibody Detection
*-labeled antibody to
human antibody +
Antigen-antibody- *antibody complex =
Antigen-antibody
complex

49. Indirect Fluorescent Antibody (IFA)
Microscope slide

50. Enzyme Immunoassay (EIA/ELISA)
substrate
enzyme + _

51. ELISA
Eight of the 8-kDa antigens were chemically synthesized and tested with a panel of defined sera in a FAST-ELISA.
All sera were tested in triplicate against each synthetic protein.
This plate shows the substrate development for one protein.
For evaluation, the mean absorbance value for each serum was divided by the mean absorbance value for the positive reference serum to give a relative absorbance unit.

52. Antigen Detection + = Antigen-antibody complex Monoclonal antibody
Antigen in
patient’s serum

53. Antibody-antigen-antibody
Antigen Detection
Antigen-antibody
complex =
Antibody-antigen-antibody
complex +
Immobilized
monoclonal
antibody

54. Antigen Detection Malaria Immunochromatographic Dipstick
Optimal Assay
P. falciparum specific
monoclonal antibody
Control
Plasmodium pan specific
monoclonal antibody

55. Antigen Detection Malaria Immunochromatographic Dipstick
Problems:
Low sensitivity with parasites density <100/ml
Currently only useful for detection of
P. falciparum infections

56. Diagnostic Tools for Human Infections with Malaria
Blood film examination
Serology - IFA
PCR

57. Malaria IFA Test Sensitivity = 98% Specificity = 99.5%
Sulzer et al, Am J Trop Med Hyg 1969;18:
Sulzer et al, Bull Wld Hlth Org 1971;45:

58. P. malariae

59. P. malariae

60. P. malariae

61. P. falciparum

62. P. falciparum

63. P. falciparum

64. A: Positive IFA result with P. malariae schizont antigen.
                               A
A: Positive IFA result with P. malariae schizont antigen.

65. Malaria antibody detection
for clinical diagnosis is performed using the indirect fluorescent antibody (IFA) test. 
The IFA procedure can be used as a diagnostic tool to determine if a patient has been infected with Plasmodium. 
Blood stage Plasmodium species schizonts (meronts) are used as antigen
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. 
Enzyme immunoassays have also been employed as a tool to screen blood donors, but are not recommended for clinical diagnosis due to limited sensitivity

66. Antibody detection may be useful for:
1- 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
2- testing a patient with a febrile illness who is suspected of having malaria and from whom repeated blood smears are negative ( Fever of Unknown Origin)
3- testing a patient who has been recently treated for malaria but in whom the diagnosis is questioned
Species-specific testing is available for the four human species: P. falciparum, P. vivax, P. malariae, and P. ovale. 
Cross reactions often occur between Plasmodium species and Babesia species. .

67. A: Positive IFA result with P. malariae schizont antigen.
                               A
A: Positive IFA result with P. malariae schizont antigen.

68. Rapid Diagnostic Tests(dipstickor test strip) (basedon the detection of antigens malaria parasites; Histiding- rich protein II)

71. Comparison of Plasmodium Species

79. Treatment Chloroquine Sulfadoxine-pyrimethamine (Fansidar)
Mefloquine (Lariam)
Quinine
Doxycycline
Artemisin derivatives

80. Malaria Control Reduce Human-Mosquito Contact Reduce Vector
impregnated bed nets
repellants, protective clothing
screens, house spraying
Reduce Vector
environmental modificaton
larvacides/insecticides
biological control
Reduce Parasite Reservoir
diagnosis and treatment
chemoprophylaxis