Malaria

This nursing study guide provides an overview of malaria including the five species of the malaria parasite, treatment, preventive options, nursing interventions, and nursing care planning, nursing diagnosis, and management.

Malaria is one of the most common infectious diseases known to mankind and is among the leading causes of morbidity and mortality in the world. It predominantly occurs in tropical and subtropical areas such as in sub-Saharan Africa, Asia, and Latin America where the mosquitos that carry the parasite live.

Table of Contents

• What is Malaria?
• Types
• Pathophysiology
• Statistics and Incidences
• Causes
• Clinical Manifestations
• Assessment and Diagnostic Findings
• Medical Management
  • Pharmacologic Management
• Nursing Management
  • Nursing Assessment
  • Nursing Diagnosis
  • Nursing Care Planning and Goals
  • Nursing Interventions
  • Evaluation
  • Documentation Guidelines
• Practice Quiz: Malaria
• References

What is Malaria?

Malaria, is a potentially life-threatening disease caused by infection with Plasmodium protozoa transmitted by an infective female Anopheles mosquito vector.

• Malaria is a serious and sometimes fatal disease caused by a parasite that commonly infects a certain type of mosquito which feeds on humans.
• People who get malaria are typically very sick with high fevers, shaking chills, and flu-like illness.
• The 5 Plasmodium species known to cause malaria in humans are P falciparum, P vivax, P ovale, P malariae, and P knowlesi.
• Timely identification of the infecting species is extremely important, as P falciparum infection can be fatal and is often resistant to standard chloroquine treatment.
• Plasmodium falciparum is distinguished from the rest of the plasmodia by its high level of parasitemia and the banana shape of its gametocytes.

Types

The types (species) of Anopheles present in an area at a given time will influence the intensity of malaria transmission.

• Plasmodium falciparum. The most malignant form of malaria is caused by this species; P falciparum is able to infect RBCs of all ages, resulting in high levels of parasitemia; sequestration is a specific property of P falciparum; as it develops through its 48-hour life cycle, the organism demonstrates adherence properties, which result in the sequestration of the parasite in small postcapillary vessels.
• Plasmodium vivax. If this kind of infection goes untreated, it usually lasts for 2-3 months with diminishing frequency and intensity of paroxysms; of patients infected with P vivax, 50% experience a relapse within a few weeks to 5 years after the initial illness;P vivax infects only immature RBCs, leading to limited parasitemia.
• Plasmodium ovale. These infections are similar to P vivax infections, although they are usually less severe; P ovale infection often resolves without treatment; similar to P vivax, P ovale infects only immature RBCs, and parasitemia is usually less than that seen in P falciparum.
• Plasmodium malariae. Persons infected with this species of Plasmodium remain asymptomatic for a much longer period of time than do those infected with P vivax or P ovale; recrudescence is common in persons infected with P malariae. 
• Plasmodium knowlesi. Autochthonous cases have been documented in Malaysian Borneo, Thailand, Myanmar, Singapore, the Philippines, and other neighboring countries; it is thought that simian malaria cases probably also occur in Central America and South America; patients infected with this, or other simian species, should be treated as aggressively as those infected with falciparum malaria, as P knowlesi may cause fatal disease. 

Pathophysiology

The natural history of malaria involves cyclical infection of humans and female Anopheles mosquitoes.

• In humans, the parasites grow and multiply first in the liver cells and then in the red cells of the blood.
• In the blood, successive broods of parasites grow inside the red cells and destroy them, releasing daughter parasites (“merozoites”) that continue the cycle by invading other red cells.
• The blood-stage parasites are those that cause the symptoms of malaria; when certain forms of blood stage parasites (gametocytes, which occur in male and female forms) are ingested during blood feeding by a female Anopheles mosquito, they mate in the gut of the mosquito and begin a cycle of growth and multiplication in the mosquito.
• After 10-18 days, a form of the parasite called a sporozoite migrates to the mosquito’s salivary glands.
• When the Anopheles mosquito takes a blood meal on another human, anticoagulant saliva is injected together with the sporozoites, which migrate to the liver, thereby beginning a new cycle.
• Thus the infected mosquito carries the disease from one human to another (acting as a “vector”), while infected humans transmit the parasite to the mosquito.
• In contrast to the human host, the mosquito vector does not suffer from the presence of the parasites.

Statistics and Incidences

Malaria is one of the most severe public health problems worldwide

• Almost all US cases of malaria are imported from patients traveling from endemic areas.
• Outbreaks of locally transmitted cases of malaria in the United States have been small and relatively isolated, but the potential risk for the disease to re-emerge is present due to the abundance of competent vectors, especially in the southern states.
• In 2016, an estimated 445,000 people died of malaria—most were young children in sub-Saharan Africa.
• Within the last decade, increasing numbers of partners and resources have rapidly increased malaria control efforts.
• his scale-up of interventions has saved millions of lives globally and cut malaria mortality by 25% from 2010 to 2016, leading to hopes and plans for elimination and ultimately eradication.
• In areas with high transmission, the most vulnerable groups are young children, who have not developed immunity to malaria yet, and pregnant women, whose immunity has been decreased by pregnancy.
• Nearly half the world’s population lives in areas at risk of malaria transmission in 91 countries and territories.
• In 2016, malaria caused an estimated 216 million clinical episodes, and 445,000 deaths; an estimated 90% of deaths in 2016 were in the WHO African Region.

Causes

Causes of malaria may include the following:

• Endemic areas. Individuals with malaria typically acquired the infection in an endemic area following a mosquito bite. 
• Transfusion. Cases of infection secondary to transfusion of infected blood are extremely rare.
• Poor immunity. The outcome of infection depends on host immunity; individuals with immunity can spontaneously clear the parasites; in those without immunity, the parasites continue to expand the infection. 
• Climate. Climate is a key determinant of both the geographic distribution and the seasonality of malaria; without sufficient rainfall, mosquitoes cannot survive, and if not sufficiently warm, parasites cannot survive in the mosquito.

Clinical Manifestations

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

• Cold stage. A sensation of cold and shivering.
• Hot stage. There is fever, headaches, vomiting; and seizures in young children.
• Sweating stage. Patient experiences sweat, return to normal temperature, and tiredness. 

Assessment and Diagnostic Findings

Rapid and accurate diagnosis of malaria is integral to the appropriate treatment of affected individuals and in preventing the further spread of infection in the community.

• Blood smears. A diagnosis of malaria should be supported by the identification of the parasites on a thin or thick blood smear; thick smears are 20 times more sensitive than thin smears, but speciation may be more difficult; thin smears are less sensitive than thick smears, but they allow identification of the different species. 
• Rapid diagnostic tests. Immunochromatographic tests based on antibody to histidine-rich protein-2 (PfHRP2), parasite LDH (pLDH), or Plasmodium aldolase appear to be very sensitive and specific; some RDTs may be able to detect P falciparum in parasitemias that are below the threshold of reliable microscopic species identification; only one RDT (BinaxNOW) has been approved to date for the diagnosis of malaria in the United State
• Other tests. In addition to the RDT listed above, new molecular techniques, such as PCR assay testing and nucleic acid sequence-based amplification (NASBA), are also available for diagnosis; they are more sensitive than thick smears but are expensive and unavailable in most developing countries.

Medical Management

Treatment of malaria depends on many factors including disease severity, the species of malaria parasite causing the infection, and the part of the world in which the infection was acquired.

• Inpatient. Patients with elevated parasitemia (>5% of RBCs infected), CNS infection, or otherwise severe symptoms and those with P falciparum infection should be considered for inpatient treatment to ensure that medicines are tolerated; obtain blood smears every day to demonstrate a response to treatment. 
• Prevention. Avoid mosquitoes by limiting exposure during times of typical blood meals (ie, dawn, dusk); wearing long-sleeved clothing and using insect repellants may also prevent infection; avoid wearing perfumes and colognes.
• Consultations. Consider consulting an infectious disease specialist for assistance with malaria diagnosis, treatment, and disease management.

Pharmacologic Management

The 4 major drug classes currently used to treat malaria include quinoline-related compounds, antifolates, artemisinin derivatives, and antimicrobials; no single drug that can eradicate all forms of the parasite’s life cycle has been discovered or manufactured yet.

• Antimalarials. These agents inhibit growth by concentrating within acid vesicles of the parasite, increasing the internal pH of the organism; they also inhibit hemoglobin utilization and parasite metabolism.

Nursing Management

The nursing management of a patient with malaria may include the following:

Nursing Assessment

Assessment of a patient with malaria include:

• History. In patients with suspected malaria, obtaining a history of recent or remote travel to an endemic area is critical; asking explicitly if they traveled to a tropical area at anytime in their life may enhance recall; maintain a high index of suspicion for malaria in any patient exhibiting any malarial symptoms and having a history of travel to endemic areas.
• Demographic data. Also determine the patient’s immune status, age, and pregnancy status; allergies or other medical conditions that he or she may have; and medications that he or she may be using.

Nursing Diagnosis

Based on the assessment data, the major nursing diagnosis for a patient with malaria may include:

• Risk for infection related to weakened immune system.
• Hyperthermia related to increased metabolic rate and dehydration.
• Impaired tissue perfusion related to a decrease in the cellular components needed for the delivery of oxygen and nutrients in the body.
• Fluid volume deficit related to excessive sweating and dehydration.
• Knowledge deficit related to lack of exposure and information about the disease process, its treatment, and prognosis.

Nursing Care Planning and Goals

The nursing care plan goals for a patient with malaria are:

• Prevent infection.
• Reduce increase in and regain normal body temperature.
• Improve tissue perfusion.
• Improve fluid volume of the body.
• Gain information on malarial disease process, treatment, and prognosis.

Nursing Interventions

Nursing interventions for a patient with malaria include the following:

• Improve body temperature. Warm water compress on forehead and both axilla (not more than 15 minutes each time); maintain warm environment by using warm blankets, adequate clothing); patient may sweat excessively, make sure to avoid exposing patient to wet clothes and linens; administration of antipyretic drugs as ordered.
• Improve tissue perfusion. Patient may need supplemental oxygen if condition is severe; maintain a well-ventilated room; head of the bed at 30º.; lessen activities that require moderate to high exertion.
• Improve fluid volume. Expect loss of fluid through sweat; provide information about fluid balance and guideline for fluid replacement; encourage increase in oral fluid intake; administer parenteral fluids as ordered.
• Educate the patient and family. Review the disease process and therapy, focusing on patient’s concerns; discuss importance of adhering to therapy; go over medication, purpose, frequency, dosage, and side effects; have a family member or trusted individual listen to and understand guideline of treatment as the patient chooses.

Evaluation

Nursing evaluation of patients with malaria includes meeting the following goals:

• Prevention of infection.
• Reduced increase in body temperature.
• Improved tissue perfusion.
• Improved fluid volume of the body.
• Gained and retained information on malarial disease process, treatment, and prognosis.

Documentation Guidelines

Nursing documentation in a patient with malaria include:

• Individual findings, including factors affecting, interactions, nature of social exchanges, specifics of individual behavior.
• Cultural and religious beliefs, and expectations.
• Plan of care.
• Teaching plan.
• Responses to interventions, teaching, and actions performed.
• Attainment or progress toward the desired outcome.

Practice Quiz: Malaria

Nursing practice questions for Malaria. For more practice questions, visit our NCLEX practice questions page.

1. The infectious agent that causes malaria is known as which of the following?

A. Protozoan parasite
B. Bacterial parasite
C. Viral parasite
D. Fungal parasite

1. Answer: A: Protozoan parasite

• Option A: Malaria is caused by members of the protozoan genus Plasmodium.

2. The malaria parasite is spread by which of the following?

A. Male mosquitoes
B. Female mosquitoes
C. Both male and female mosquitoes

2. Answer: B. Female mosquitoes

• Option B: The malaria parasite is spread by the bite of the female mosquito only.

3. Which mosquito genus is associated with spreading the human malaria parasite?

A. Culex
B. Anopheles
C. Aedes
D. Lutzia

3. Answer: B. Anopheles

• Option B: Members of the Anopheles genus are responsible for spreading the malaria parasite to humans (also known as vectors).

4. Which one of the following are NOT antimalarial compounds?

A. Quinine
B. Artemisinin
C. Chloroquine
D. Mefloquine
E. Penicillin

4. Answer: E. Penicillin

• Option E: Penicillin is an antibiotic that targets bacteria. The others are all antimalarial compounds.

5. Which of these statements is correct?

A. Malaria is a neglected tropical disease
B. If you get malaria once, you won’t get it again
C. Malaria is quite often endemic in poorer regions of the world

5. Answer: C. Malaria is quite often endemic in poorer regions of the world

• Option C: Whilst malaria is not caused by poverty itself, the ability to control and eliminate the disease is affected by socio-economic factors. A study by Xia Zhao and colleagues from the University of Oxford found that increased socio-economic improvements such as wealth, life expectancy and urbanization were the key drivers in eliminating malaria in Europe in the early 20th century.

References

Sources and references for malaria nursing study guide:

• Black, J. M., & Hawks, J. H. (2005). Medical-surgical nursing. Elsevier Saunders,. [Link]
• Kimberlin, D. W. (2018). Red Book: 2018-2021 report of the committee on infectious diseases (No. Ed. 31). American academy of pediatrics.
• Oshinsky, D. M. (2005). Polio: an American story. Oxford University Press. [Link]
• Willis, L. (2019). Professional guide to diseases. Lippincott Williams & Wilkins. [Link]
• WHO Expert Committee on Malaria, & World Health Organization. (2000). WHO expert committee on malaria: twentieth report (No. 892). World Health Organization. [Link]