malaria program
TRANSCRIPT
MALARIA PROGRAM
Dr. Mihir RupaniAssistant Professor
Dept. of Community MedicineGovernment Medical College,
Bhavanagar
Burden Globally, 207 million estimated
cases reported in 2012 with 6.2 lakh deaths (Source: World Malaria Report 2013)
SEAR estimated 27 million cases with 42000 deaths in 2012 (Source: World Malaria Report 2013)
Burden India population wise
distribution (Source: World Malaria Report 2013, total population of India 1237 million)
Transmission area
Cases Percentage
High transmission
> 1 case per 1000
population
22%
Low transmission
0-1 case per 1000
population
67%
Malaria free 0 cases 11%
Year Population (in ‘000)
Total Malaria Cases
(million)
P.falciparum cases (million)
Pf % API Deaths due to malaria
1995 888143 2.93 1.14 38.84 3.29 11511996 872906 3.04 1.18 38.86 3.48 10101997 884719 2.66 1.01 37.87 3.01 8791998 910884 2.22 1.03 46.35 2.44 6641999 948656 2.28 1.14 49.96 2.41 10482000 970275 2.03 1.05 51.54 2.09 9322001 984579 2.09 1.01 48.2 2.12 10052002 1013942 1.84 0.9 48.74 1.82 9732003 1027157 1.87 0.86 45.85 1.82 10062004 1040939 1.92 0.89 46.47 1.84 9492005 1082882 1.82 0.81 44.32 1.68 9632006 1072713 1.79 0.84 47.08 1.66 17072007 1087582 1.51 0.74 49.11 1.39 13112008 1119624 1.53 0.77 50.81 1.36 10552009 1150113 1.56 0.84 53.72 1.36 11442010 1167360 1.6 0.83 52.12 1.37 10182011 1194901 1.31 0.67 50.74 1.1 754
2012(Prov.) 1211509 1.06 0.53 50.01 0.88 519
Burden in India (Source: NVBDCP)
YearPopulatio
n in thousand
Blood Smear Examined
Positive cases Pf Cases ABER API SPR SFR Deaths
2001 984579 9,03,89,019 20,85,484 10,05,236 9.18 2.12 2.31 1.11 10052002 1013942 9,16,17,725 18,41,229 8,97,446 9.04 1.82 2.01 0.98 9732003 1027157 9,91,36,143 18,69,403 8,57,101 9.65 1.82 1.89 0.86 10062004 1040939 9,71,11,526 19,15,363 8,90,152 9.33 1.84 1.97 0.92 9492005 1082882 10,41,43,80
6 18,16,569 8,05,077 9.62 1.68 1.74 0.77 963
2006 1072713 10,67,25,851 17,85,129 8,40,360 9.95 1.66 1.67 0.79 1707
2007 1087582 9,49,28,090 15,08,927 7,41,076 8.73 1.39 1.59 0.78 13112008 1119624 9,73,16,158 15,26,210 7,75,523 8.69 1.36 1.57 0.8 10552009 1150113 103396076 15,63,574 8,39,877 8.99 1.36 1.51 0.81 11442010 1167360 106040223 1495817 779549 9.21 1.37 1.41 0.74 10182011 1194901 109313294 1310656 665004 9.12 1.1 1.2 0.61 754
2012(P) 1211509 108989326 1066981 533535 9 0.88 0.98 0.49 519
Burden in India (Source: NVBDCP)
Trend of malaria cases and deaths 2001-12
Lancet study claims: malaria toll 40 times the govt. count
Malaria killed an estimated 46,800 Indians in 2010
• Source: Murray Christopher, et al. Global malaria mortality between 1980 and 2010: a systematic analysis. The Lancet, Vol. 379 No. 9814 pp 413-431
Magnitude of problem
Vectors of Malaria Anopheles culicifacies is the main
vector of malaria 1. Feeding habits
It is a zoophilic species When high densities build up
relatively large numbers feed on men
2. Resting habits Rests during daytime in human
dwellings and cattle sheds
Vectors of Malaria (contd.) Breeding places
Breeds in rainwater pools and puddles, borrow pits, river bed pools, irrigation channels, seepages, rice fields, wells, pond margins
Extensive breeding is generally encountered following monsoon rains.
Vectors of Malaria (contd.) Biting time
Most of the vectors, including Anopheles culicifacies, start biting soon after dusk.
Therefore, biting starts much earlier in winter than in summer
History of Malaria control Bhore Committee (1946)
National Malaria Control Program (1953)
National Malaria Eradication Program (1958)
Urban Malaria Scheme (1971)
Modified Plan of Operation (1977)
Malaria Action Program (1995)
Enhanced Malaria Control Program (1997)
History of Malaria control (contd.)
National Anti Malaria Program (1999)
National Health Policy (2002)
National Vector Borne Disease Control Program (2004)
History of Malaria control (contd.)
Intensified Malaria Control Project (2005)
National Rural Health Mission (2005)
History of Malaria control (contd.)
Bhore Committee (1946) Country wide comprehensive
program to control malaria recommended
Endorsed by Planning Commission in 1951
National Malaria Control Programme (1953) Objectives:1. To bring down malaria transmission to a
level at which it would cease to be a major public health problem
2. Thereafter an achievement was to be maintained by each state to hold down the malaria transmission at low level indefinitely
Strategies:1. Residual insecticide spray of human
dwelling and cattle sheds2. Malaria control teams to carry out
surveys and to monitor the malaria incidence in the control areas
3. Anti-malarial drugs were made available for patients reporting to an Institution
National Malaria Control Programme (1953)
Impact:
Number of malaria cases and deaths had decreased significantly
National Malaria Control Programme (1953)
Change in concept from control to eradication
Objective: eradicate malaria in 7-9 years
Impact: spectacular reduction in cases and nil death reported in 1965
National Malaria Eradication Programme (1958)
Setback: financial, logistic, administrative and technical constraints
Result: resurgence of malaria during 1970’s
Way forward: urban areas had not received special attention
National Malaria Eradication Programme (1958)
Urban Malaria Scheme (1971) Cause of concern:
urban malaria
proliferation of malaria from urban
to rural
Presently covering 131 towns
NORMS for selection of town: The towns should have a minimum
population of 50,000
Urban Malaria Scheme (under NVBDCP)
NORMS for selection of town:
The API should be 2 or above
Towns should promulgate and strictly implement the civic by-laws to prevent/ eliminate domestic and peri-domestic breeding places
Urban Malaria Scheme (under NVBDCP)
The Municipal areas are divided into wards of 25.6 sq. km;
each ward divided into 10 sectors of 2.56 sq. km
Urban Malaria Scheme (under NVBDCP)
Staffing pattern for each ward: 1 malaria officer and 1 insect collector
Staffing pattern for each sector: 1 superior field worker, 2 field workers
1 additional field worker for de-silting, de-weeding and minor levelling
Urban Malaria Scheme (under NVBDCP)
From the year 2009, procurement and supply of larvicides has been decentralized,
which means that the states will procure themselves as per approved norms from the cash provided by GoI
Urban Malaria Scheme (under NVBDCP)
Malaria – problematic states (under UMS)
The strategies include:
Early case Detection and Prompt Treatment (EDPT) through passive surveillance institutions such as hospitals, dispensaries and malaria clinics.
Urban Malaria Scheme (under NVBDCP)
Recurrent anti-larval measures through larvicides in towns reporting malaria.
Minor engineering methods like source reduction, canalization, de-weeding etc.
Biological control using larvivorous fish at appropriate breeding sites.
Urban Malaria Scheme (under NVBDCP)
IEC campaigns for community awareness and their involvement.
Space spray as emergency response to control vector mosquitoes and their rapid reduction in domestic and peri domestic situations.
Legislative measures.
Urban Malaria Scheme (under NVBDCP)
Intensive anti larval measures and drug treatment were the mainstay of UMS in 1971
Setback: high number of cases recorded in 1976
Urban Malaria Scheme (1971)
Modified Plan of Operation (1977) Attempts at malaria eradication
were given up
MPO adopted
Objectives
Elimination of malarial deaths
Reduction of malaria morbidity
Maintenance of gains achieved to stop further transmission
Modified Plan of Operation (1977)
Strategies: to divide area in 2 groups
API 2 and above
API less than 2
Modified Plan of Operation (1977)
API less than 2
• Focal Spray of DDT (BHC or malathion)
• Surveillance and treatment: active and passive surveillance should be carried out and presumptive treatment is given to all the fever suspected cases
Modified Plan of Operation (1977)
API less than 2
• Epidemiological investigation of a malaria case to determine the causative factors
• Ensuring radical treatment of those patients who are found positive in their blood smear
Modified Plan of Operation (1977)
API 2 and above• Insecticidal spray• Entomological studies• Malaria surveillance• Treatment of cases• Decentralization of laboratory services
to PHC level• Establishment of DDC and FTD
Modified Plan of Operation (1977)
API 2 and above
• Attempts were made to intensity the efforts in rural areas with assistance of the Swedish International Development Agency (SIDA) by providing input under P falciparum Containment Program
Modified Plan of Operation (1977)
API 2 and above• Regular 2 rounds of insecticidal spray
with DDT/ Malathion / Synthetic Pyrethroids at the dose of 1, 2, 0.5 mg/sq meter respectively.
• Entomological assessment for vector behavior and development of insecticidal resistance
Modified Plan of Operation (1977)
API 2 and above
• Active and passive surveillance is carried out on regular basis every fortnight
• Presumptive Treatment to all fever cases and radical treatment to all slide positive cases is given
Modified Plan of Operation (1977)
Technical Advisory Committee on Malaria further prioritized the criteria for undertaking IRS in 2002
Modified Plan of Operation (2002 recommendations)
Criteria:1. All areas with > 5 API where ABER is >
10%
2. All areas reporting > 5% SPR, if ABER < 10%
3. P falciparum > 50%
Modified Plan of Operation (2002 recommendations)
Criteria:4. API < 5 or SPR < 5% • in case of drug resistant foci; • project areas with population migration;• and aggregation or other vulnerable factors including peri-contonment areas
Modified Plan of Operation (2002 recommendations)
Criteria:5. Provision of insecticidal spraying in
epidemic situation
6. Other parameters including entomological, ecological, etc. also considered while prioritizing areas
Modified Plan of Operation (2002 recommendations)
High risk areas and populations will be re-defined at least annually
High risk areas protected by IRS and ITNs and coverage will be more than 80%
Modified Plan of Operation (2002 recommendations)
API > 5: • Areas are planned to be covered by LLINs API > 2:• Conventional net treated with
insecticides and IRS API 2-5:• Conventional net treated with
insecticides
Modified Plan of Operation (2002 recommendations)
Impact: MPO was able to control malaria deaths, but during 1994, resurgence of malaria was observed in some states
Outbreaks were reported from Rajasthan, Manipur and Nagaland
During 1995 from Assam, Maharashtra and West Bengal
1996: Rajasthan and Haryana
Modified Plan of Operation (1977)
Malaria Action Programme (1995) Malaria control was made 100%
centrally sponsored scheme since December 1994 for seven North-eastern states and states like Andhra Pradesh, Bihar, Gujarat, Maharashtra, Orissa and Rajasthan
Problem areas:A. Hardcore areas (Tribal Areas)
B. Epidemic Prone AreasC. Project AreasD. Triple Insecticide resistant AreasE. Urban Areas
Malaria Action Programme (1995)
Hardcore (tribal areas)• Difficult terrain areas• Predominantly tribal• Predominantly P falciparum• Stable malaria with transmission period
extending up to 9 months or more• Predominantly have more deaths due
to malaria
Malaria Action Programme (1995)
Hardcore (tribal areas) Disease management• IEC and intensified IEC• Case detection and presumptive
treatment of fever• Radical treatment with priority to
Pf cases within 48 hours
Malaria Action Programme (1995)
Hardcore (tribal areas)• MPW should be able to identify
severe cases of malaria requiring referral
• PHC well-equipped to tackle severe malaria
• Alternative drug in chloroquin resistant Pf areas
Malaria Action Programme (1995)
Hardcore (tribal areas) Action required• Link worker: one for 2000 population• Also work as FTD and carry all blood
slides of his area to PHC or malaria clinic twice a week
• Also bring drugs and microslides for FTDs in his area
Malaria Action Programme (1995)
Epidemic prone areas
• Climatic zones with annual rainfall up to 100 mm
Malaria Action Programme (1995)
Epidemic prone areas Disease management
• Case detection and presumptive treatment
• Blood slide collection and examination• Radical treatment with priority to Pf
cases within 48 hours
Malaria Action Programme (1995)
Project areas• Non-immune population of laborer to
endemic areas
• Prolific increase in vector breeding places
• Increased man-mosquito contact
Malaria Action Programme (1995)
Project areas Disease management• Mass screening of labor/incoming
population should be continuously done if transmigration is frequent
• All incoming persons from high risk tribals should be given presumptive treatment along with a single dose of 45mg Primaquine
Malaria Action Programme (1995)
Project areas Disease management
• Alternative drug in chloroquine resistant of Pf areas
Malaria Action Programme (1995)
Urban areas
15 cities are accountable for nearly 80% of Pf malaria cases
Malaria Action Programme (1995)
Urban areas Disease management• Active surveillance in slum areas
weekly• Passive surveillance in hospitals• Presumptive treatment• Radical treatment with priority to Pf
cases
Malaria Action Programme (1995)
Urban areas Action required• Provide adequate staff for active
surveillance in slum areas and one worker for 20000 population
• Establish one malaria clinic for 50000 population
Malaria Action Programme (1995)
Urban areas Action required
• Location of malaria clinic should be preferably adjoining slum area if possible and wherever feasible its location should be in existing dispensary
Malaria Action Programme (1995)
Enhanced Malaria Control Project (1997) Center sought external support from
World Bank Selection of PHCs is based on:
i) API > 2 for last 3 years;
ii) Pf cases are more than 30% of the malaria cases;
Enhanced Malaria Control Project (1997) Center sought external support from World Bank Selection of PHCs is based on:iii) 25% population of the PHC is tribal;
iv) The area has been reporting deaths due to malaria and also has the flexibility to direct resources to any needy areas in case of outbreak of malaria
Objectives:1. Effective control of malaria to bring
reduction in malaria morbidity
2. Prevention of death due to malaria
3. Consolidation of the gain achieved so far
Enhanced Malaria Control Project (1997)
Strategies 1. Early case detection and prompt treatment;
2. Vector control by indoor residual insecticide spray in rural areas with API of 2 and above in the preceding three years with appropriate insecticide and by recurrent anti-malaria in urban areas;
Enhanced Malaria Control Project (1997)
Strategies3. Health Education and community
participation
Enhanced Malaria Control Project (1997)
Components of EMCP 1. Early case detection and prompt treatment
2. Selective Vector Control
3. Legislative Measures
4. Personal Protective Measures
Enhanced Malaria Control Project (1997)
Components of EMCP 5. Epidemic Planning and Rapid Response
and Intersectoral Coordination
6. Institutional and Management capacities strengthening
7. Operation Research
Enhanced Malaria Control Project (1997)
Enhanced Malaria Control Project (1997) Components of EMCP 8. Community Participation
1. Early case detection and prompt treatment:Link worker in high Pf areas for a population of 2000 is appointed by Panchayat and paid rs. 500 per monthHe collects blood smears, provides presumptive treatment and forwards slides to PHC
Enhanced Malaria Control Project (1997)
1. Early case detection and prompt treatment:One microscope for every 30000 population at PHC in rural areas and for 50000 for urban areasDipstick test in selected areas1 FTD in every village
Enhanced Malaria Control Project (1997)
1. Early case detection and prompt treatment:Drugs in sufficient quantity made availableArtemisinine derivatives also introducedInvolvement of private sectors in case detection and treatment
Enhanced Malaria Control Project (1997)
2. Selective Vector ControlBioenvironmental MethodsIntroduction of Larvivorous fishes
Use of biocides: bacillus thuringiensis H-14 in selected urban areas
Environmental management methods
Enhanced Malaria Control Project (1997)
BIOLOGICAL CONTROL - Bti
The bacillus Bti (Bacillus Thuringiensis Israelensis !!!) can be incubated in coconuts, where it multiplies. The coconuts are
then broken open and thrown into pools, where the bacilli are eaten by the mosquito larvae. They kill the larvae by destroying
its gut.
Spraying Bti from a
boat
The incubation
stage
Adding to
pools
2. Selective Vector ControlSelective sprayVillage in which there is one case of Pf or more qualify for residual spray in project area.
Synthetic pyrethroids (safer)
Enhanced Malaria Control Project (1997)
3. Legislative Measures
Byelaws for control of mosquitoes (as in Delhi and Mumbai) would be extended to cover whole country
Enhanced Malaria Control Project (1997)
4. Personal Protective Measures
Bednet program
Enhanced Malaria Control Project (1997)
5. Epidemic Planning and Rapid Response and Intersectoral Coordination
Sector like agriculture, environment, education and so on are sensitized to malaria problem
Enhanced Malaria Control Project (1997)
6. Institutional and Management Capacities Strengthening
Management Information System (MIS)
IEC
Enhanced Malaria Control Project (1997)
7. Operation Research
Health seeking behaviour especially of malaria patientsEconomic analysis of various interventionsAlternative drug regimens and introduction of artesunate
Enhanced Malaria Control Project (1997)
7. Operation Research
Evaluation of bednets and curtainsTrial with biolarvicidal agentsEntomological monitoringMigratory patterns leading to malaria outbreaks
Enhanced Malaria Control Project (1997)
8. Community Participation
“Bottom up” planning, in which village Panchayat would be responsible for all matters related to health and development
Enhanced Malaria Control Project (1997)
PROGRESS: Since 1997, EMCP implemented in
1045 PHCs in 100 districts predominantly Pf malaria endemic and tribal dominated districts in AP, Jharkhand, Gujarat, MP, Chhattisgarh, Mh, Odisha and Rajasthan covering 62.2 million population.
Enhanced Malaria Control Project (1997)
PROGRESS:
In addition 19 cities/town in these states and in TN, Karnataka, and WB
Enhanced Malaria Control Project (1997)
IMPACT:
Out of 100 EMC districts, 79% have recorded decline in Malaria incidence during 2003
Number of Pf cases has declined from 0.72 million in 1997 to 0.41 million in 2004
Enhanced Malaria Control Project (1997)
National Anti-Malaria Program (1999) NMEP dropped
Soon became part of NVBDCP
National Health Policy (2002) Goal:
Reduction in mortality on account of malaria and other VBDs by 50% by 2010 and efficient morbidity control
NVBDCP (2004)1. Early case Detection and Prompt Treatment: main strategy of malaria control – radical treatment is necessary to prevent transmission of malaria
Chloroquine is the main anti-malaria drug for uncomplicated malaria
1. Early case Detection and Prompt Treatment: DDCs and FTDs have been established in the rural areas
Alternative drugs for chloroquine resistant malaria are recommended as per the drug policy of malaria
NVBDCP (2004)
2. Vector Control
(i) Chemical Control Use of IRS with insecticides
recommended under the programme Use of chemical larvicides like Abate
in potable water Aerosol space spray during day time Malathion fogging during outbreaks
NVBDCP (2004)
NVBDCP (2004)2. Vector Control(ii) Biological Control
Use of larvivorous fish in ornamental tanks, fountains etc.
Use of biocides.
2. Vector Control(iii) Personal Prophylactic MeasuresUse of mosquito repellent creams, liquids, coils, mats etc. Screening of the houses with wire mesh Use of bed nets treated with insecticide Wearing clothes that cover maximum surface area of the body
NVBDCP (2004)
3. Community Participation Sensitizing and involving the
community for detection of Anopheles breeding places and their elimination
NGO schemes involving them in programme strategies
Collaboration with private sector.
NVBDCP (2004)
4. Environmental Management & Source Reduction Methods
Source reduction i.e. filling of the breeding places
Proper covering of stored water Channelization of breeding source
NVBDCP (2004)
5. Monitoring and Evaluation of the Program
Monthly Computerized Management Information System(CMIS)
Field visits by state by State National Program Officers
Field visits by Malaria Research Centers and other ICMR Institutes
Feedback to states on field observations for correction actions
NVBDCP (2004)
Insecticide Policy
DDT should be the insecticide of choice for residual spray.
If resistance found to DDT then Malathion
is the alternative choice.
In case of resistance to both DDT and malathion then synthetic Pyrethroids is the choice.
ITMN: as a measure for protection against mosquitoes was started in general and in NE states particularly
Synthetic Pyrethroids namely Deltamarin (2.5%) at dosage of 25mg/sq m and Cyflutharin (5%) at 50mg/sq m is used to impregnate the nets
Insecticide Policy
World Bank assisted NVBDCP project On Malaria control and Kala azar
elimination effective from 6th March, 2009; though started from August 2008 for a period of 5 years
Being implemented in 2 phases in 93 districts of 10 states
Strategies :
improve case management, improving surveillance, effective vector control, m & e, program management & capacity building
World Bank assisted NVBDCP project
Global Fund supported project “Intensified Malaria Control Project”:Implemented in 106 districts of 10 states for a period of 5 years from July 2005 to June 2010
Intensified Malaria Control Project (2005)
Global Fund supported project “Intensified Malaria Control Project”:For areas under GFATM project, additional support is given for the following 5 activities:Provision of rapid diagnostic kits Provision of artemisinin combination therapy (ACT) for Pf cases
Intensified Malaria Control Project (2005)
Global Fund supported project “Intensified Malaria Control Project”:Additional manpower for strengthening supervision and monitoringProvision of ITMN to high endemic areasTreatment of community owned bed nets with insecticides
Intensified Malaria Control Project (2005)
Roll back Malaria (RBM) Is a global partnership founded in
1998 by WHO ,UNDP, UNICEF and the World bank
To halve malaria-associated mortality by 2010 and again by 2015
Malaria vaccine RTS,S malarial candidate vaccine is
only vaccine which is found to be effective in adults ,children and infants in neutral field trials ,for which Phase 3 clinical trial is planned.
It leads to formation of antibodies against AMA 1(Apical Membrane Antigen) which is present on merozoite of P.falciparum
Remote Sensing in Vector Borne Disease Control Remote Sensing (RS) technology is
a tool for the surveillance of habitat, densities of vector species and even prediction of the incidence of disease that must be considered as new invention in the epidemiology of malaria and vector-borne diseases.
Remote sensing is to sense any object from a distance
The principle of RS rests on the fact that every object absorbs some part of radiation received from sunlight.
Remote Sensing in Vector Borne Disease Control
Depending upon its physical and chemical properties, the object absorbs some part of radiation while the remaining part is reflected in specific wavelength of the electromagnetic spectrum (EMS). This reflected energy is channelised through a telescope to detectors/sensors present on board of the satellites.
Remote Sensing in Vector Borne Disease Control
The sensors are sensitive to different bands of EMS. The sensors convert the light energy into electrical voltages produces two-dimensional discrete pictures.
Remote Sensing in Vector Borne Disease Control
These are different for different objects and the satellite pass over a particular part of earth at the fixed time intervals repeatedly making it possible to monitor changes in the lad use categories viz. Water bodies, vegetation, forests, soil mapping, geology, crop estimation, detection of fire in forest, mines, oil sleek in sea, etc.
Remote Sensing in Vector Borne Disease Control
Such data is generated in National Remote Sensing Agency, Hyderabad, in India. A feasibility study using Satellite data in collaboration with the Indian Space Research Organisation in and around Delhi was carried out and correlation of changes in the areas of land use features viz. Water bodies and vegetations with mosquito density was found significant in some sites
Remote Sensing in Vector Borne Disease Control
NIMR National Institute of Malaria Research
(NIMR) was established in 1977 as 'Malaria Research Centre', which was renamed as 'National Institute of Malaria Research' in November 2005.
NIMR is one of the institutes of the ICMR
The primary task of the Institute is to find short term as well as long term solutions to the problems of malaria through basic, applied and operational field research.
The Institute also plays a key role in man power resource development through trainings/workshops and transfer of technology.
NIMR
NIMR field stations
NIMR 15 studies are conducted in a year
through Pf monitoring teams through ROH&FWs and National Institute of Malaria Research (NIMR) at different places
Based on their report, resistance areas are identified and their drug policy changed
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