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Malaria infection

Background

Overview

Definition
Malaria is mosquito-borne parasitic disease that is endemic to tropical and subtropical countries.
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Pathophysiology
Malaria is caused by single-celled microorganisms of the Plasmodium group, predominantly P. falciparum, P. vivax, P. ovale, P. malariae, and P. knowlesi. The parasite is most commonly spread by an infected female Anopheles mosquito.
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Epidemiology
In the US, the incidence of malaria requiring hospitalization is estimated at 0.5 per 100,000 population.
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Disease course
Replication of parasites cause the infectious syndrome associated with malaria. Severe complications of malaria include respiratory failure, severe anemia, increased risk of abortion in pregnant women, confusion, convulsions, shock, jaundice, pulmonary edema, AKI, and death.
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Prognosis and risk of recurrence
Malaria, when treated with standard artemisin-based therapy, is associated with a disease-specific mortality rate of 0.32%. Infection with P. vivax can relapse weeks to months following an initial infection in up to 50-80% of cases.
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Guidelines

Key sources

The following summarized guidelines for the evaluation and management of malaria infection are prepared by our editorial team based on guidelines from the Infectious Diseases Society of America (IDSA/CDC/NIH/HIVMA 2024,2013), the British Society for Haematology (BSH 2022), the World Health Organization (WHO 2022), the Royal College of Ophthalmologists (RCOphth 2020), the Committee to Advise on Tropical Medicine and Travel (CATMAT ...
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Screening and diagnosis

Indications for screening: as per WHO 2022 guidelines, do not obtain mass testing and treatment to reduce transmission of malaria,
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including in patients with an increased risk of infection relative to the general population.
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Classification and risk stratification

Severity grading: as per CATMAT 2014 guidelines, classify patients as having severe malaria in the presence of ≥ 1 of the following criteria:
prostration/impaired consciousness
multiple convulsions
respiratory distress
pulmonary edema
circulatory collapse
abnormal bleeding
jaundice
hemoglobinuria.
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Diagnostic investigations

Laboratory tests: as per BSH 2022 guidelines, assess good-quality thick and thin films for diagnosis of malaria. Stain thin films with a Giemsa stain and thick films with either a Giemsa or a Field stain. Use Giemsa at pH 7.2.
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Medical management

Management of uncomplicated P. falciparum malaria: as per WHO 2022 guidelines, administer any of the following artemisinin-based combination therapies for 3 days for the treatment of adult patients with uncomplicated P. falciparum malaria:
artemether-lumefantrine
artesunate-amodiaquine
artesunate-mefloquine
dihydroartemisinin-piperaquine
artesunate plus sulfadoxine-pyrimethamine
artesunate-pyronaridine.
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  • Management of uncomplicated P. vivax, P. ovale, P. malariae, or P. knowlesi malaria

  • Management of severe malaria (antimalarial treatment)

  • Management of severe malaria (corticosteroids)

Therapeutic procedures

Exchange transfusion: as per CATMAT 2014 guidelines, consider administering exchange transfusion in patients with hyperparasitemic P. falciparum malaria.
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Specific circumstances

Pediatric patients, prevention: as per WHO 2022 guidelines, offer RTS, S/AS01 malaria vaccination to prevent P. falciparum malaria in children living in regions with moderate-to-high transmission, as defined by the WHO.
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  • Pediatric patients (management of uncomplicated P. falciparum malaria)

  • Pediatric patients (management of uncomplicated P. vivax, P. ovale, P. malariae, or P. knowlesi malaria)

  • Pediatric patients (management of severe malaria)

  • Pregnant patients (diagnosis)

  • Pregnant patients (counseling)

  • Pregnant patients (primary chemoprevention)

  • Pregnant patients (general principles of management)

  • Pregnant patients (antimalarial treatment)

  • Pregnant patients (management of complications)

  • Pregnant patients (obstetric care)

  • Patients with HIV (primary prevention)

  • Patients with HIV (antimalarial treatment)

  • Patients with HIV (pediatric patients)

  • Patients returning from travel

Preventative measures

Insecticide-treated nets: as per WHO 2022 guidelines, deploy pyrethroid-only long-lasting insecticidal nets for the prevention and control of malaria in children and adults living in areas with ongoing malaria transmission.
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  • Insecticide-treated clothes

  • Indoor residual spraying

  • Space spraying

  • Insect repellents

  • Environmental measures

  • House screening

  • Immunization

  • Mass drug administration

  • Primary chemoprevention (family relatives)

  • Primary chemoprevention (pediatric patients)

  • Primary chemoprevention (pregnant patients)

Follow-up and surveillance

Monitoring for chloroquine/hydroxychloroquine retinopathy: as per RCOphth 2020 guidelines, obtain annual monitoring for retinopathy in all patients receiving hydroxychloroquine for > 5 years or chloroquine for > 1 year.
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Quality improvement

Elimination programs: as per WHO 2022 guidelines, do not obtain routine malaria testing and treatment in persons arriving at points of entry (land, sea, or air) to reduce importation.
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  • National/regional quality control

  • Laboratory quality control