Malaria program

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

Low transmission

0-1 case per 1000

population

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)

Intensified Malaria Control Project (2005)

National Rural Health Mission (2005)

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

The Municipal areas are divided into wards of 25.6 sq. km;

each ward divided into 10 sectors of 2.56 sq. km

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

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

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.

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.

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.

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

Strategies: to divide area in 2 groups

API 2 and above

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

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

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

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

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

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

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 >

2. All areas reporting > 5% SPR, if ABER < 10%

3. P falciparum > 50%

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

Criteria:5. Provision of insecticidal spraying in

epidemic situation

6. Other parameters including entomological, ecological, etc. also considered while prioritizing areas

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%

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

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

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

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

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

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

Epidemic prone areas

• Climatic zones with annual rainfall up to 100 mm

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

Project areas• Non-immune population of laborer to

endemic areas

• Prolific increase in vector breeding places

• Increased man-mosquito contact

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

Project areas Disease management

• Alternative drug in chloroquine resistant of Pf areas

Urban areas

15 cities are accountable for nearly 80% of Pf malaria cases

Urban areas Disease management• Active surveillance in slum areas

weekly• Passive surveillance in hospitals• Presumptive treatment• Radical treatment with priority to Pf

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

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

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;

Strategies3. Health Education and community

participation

Components of EMCP 1. Early case detection and prompt treatment

2. Selective Vector Control

3. Legislative Measures

4. Personal Protective Measures

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) 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

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

1. Early case detection and prompt treatment:Drugs in sufficient quantity made availableArtemisinine derivatives also introducedInvolvement of private sectors in case detection and treatment

2. Selective Vector ControlBioenvironmental MethodsIntroduction of Larvivorous fishes

Use of biocides: bacillus thuringiensis H-14 in selected urban areas

Environmental management methods

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

The incubation

Adding to

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)

3. Legislative Measures

Byelaws for control of mosquitoes (as in Delhi and Mumbai) would be extended to cover whole country

4. Personal Protective Measures

Bednet program

5. Epidemic Planning and Rapid Response and Intersectoral Coordination

Sector like agriculture, environment, education and so on are sensitized to malaria problem

6. Institutional and Management Capacities Strengthening

Management Information System (MIS)

Health seeking behaviour especially of malaria patientsEconomic analysis of various interventionsAlternative drug regimens and introduction of artesunate

Evaluation of bednets and curtainsTrial with biolarvicidal agentsEntomological monitoringMigratory patterns leading to malaria outbreaks

8. Community Participation

“Bottom up” planning, in which village Panchayat would be responsible for all matters related to health and development

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.

PROGRESS:

In addition 19 cities/town in these states and in TN, Karnataka, and WB

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

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

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

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

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.

The sensors are sensitive to different bands of EMS. The sensors convert the light energy into electrical voltages produces two-dimensional discrete pictures.

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.

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

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 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

THANK YOU

Malaria program

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