Control of Malaria in India

Dr.M.Vijay KumarM.D.(Community Medicine)

Outline of the Presentation

• Introduction• Burden of Malaria at State, National and

International level.• Historical aspect of Malaria Control in India• Malaria Control Strategies at State and National level• Surveillance in Malaria• Recent advances• Monitoring and Evaluation• SWOT Analysis

Historical Perspective

• Intermittent fever, with high incidence during the rainy season, coinciding with agriculture, sowing and harvesting, was first recognized by Romans and Greeks who associated it with swampy areas.

• They postulated that intermittent fevers were due to the 'bad odour' coming from the marshy areas and thus gave the name 'malaria' ('mal'=bad + 'air') to intermittent fevers.

• In spite of the fact that today the causative organism is known, the name has stuck to this disease.

Introduction

- Malaria is one of the major public health problems of the country.

-Around 1.5 million confirmed cases are reported annually by the National Vector Borne Disease Control Programme (NVBDCP).

-Malaria is curable if effective treatment is started early. Delay in treatment may lead to serious consequences including death.

Burden of Malaria Globally

• In 2010 there were an estimated 216 million cases of malaria of which 91% were due to P.falciparum.

• The vast majority of cases (81%) were in the African Region followed by the South-East Asia (13%) and Eastern Mediterranean Regions (5%).

• There were an estimated 6,55,000 malaria deaths worldwide in 2010

World Malaria Report 2011:http://www.who.int/malaria/world_malaria_report_2011/WMR2011_noprofiles_lowres.pdf

SEARO website: http://www.searo.who.int/en/Section10/Section21/Section340_4018.htm

SEARO (South East Asia Regional Office) website: http://www.searo.who.int/en/Section10/Section21/Section340_4018.htm

Burden of Malaria in India

National Vector Borne Disease Control Project (NVBDCP) official website: http://www.nvbdcp.gov.in/malaria9.html

Malaria Situation in Andhra Pradesh (2011)

Blood Slide Examination 9368740Total Malaria Cases 34949Plasmodium falciparum(Pf) cases

24089

P.f. % 69%Slide Positivity Rate(SPR) 0.49Slide falciparum Rate(SfR) 0.36Deaths 05

NVBDCP website: Malaria situation in India PDF file http://www.nvbdcp.gov.in/Doc/malaria-situation-august12.pdf

Prior to 1940 - No organized National Malaria Control Programme1945 -Insecticide properties of DDT identified

Prior to 1953 - Estimated malaria cases in India - 75 million estimated Deaths due to malaria – 1 million

1953 -Launching of National Malaria Control Programme

1958 - Launching of National Malaria Eradication Programme

Early 70’s - Resurgence of malaria

1976 - Malaria cases 6.46 million highest in post DDT era (one of the reasons for resurgence was insecticide resistance in malaria vectors)

History of Malaria control in India

History -- Cont..• 1977 - Modified Plan of Operations Implemented• 1997 - World Bank Assisted Enhanced Malaria Control Project

(EMCP)• 1999 - Renaming of programme to National Anti Malaria

Programme (NAMP)• 2002 - Renaming of NAMP to National Vector Borne Disease

Control Programme• 2005 – i) The NVBDCP became an integral part of the NRHM ii) Global Fund assisted Intensified Malaria Control Project

(IMCP) launched 2008 - i) ACT extended to high Pf predominant districts covering

about 95% Pf cases ii) NMCP launched

Strategic Action Plan of Malaria Control in India(2007-2012)

1. Surveillance and case management: Case detection (passive and active) Early Diagnosis and Complete Treatment Sentinel surveillance2. Integrated Vector Management (IVM) Indoor Residual Spray (IRS) Insecticide Treated bed Nets (ITNs) / Long Lasting Insecticide treated Nets (LLINs) Antilarval measures including source reduction3. Epidemic preparedness and early response4. Supportive Interventions Capacity building Behaviour Change Communication (BCC) Intersectoral collaboration Monitoring and Evaluation (M & E) Operational research and applied field research

Diagnosis

• Microscopy: Stained thick and thin blood smears remains the gold standard for confirmation of diagnosis of malaria.

• Advantages- 1) The sensitivity is high. 2) It is possible to distinguish the various

species of malaria parasite and their different stages

Cont..

• Rapid Diagnostic Test(RDT): Rapid Diagnostic Tests are based on the detection of circulating parasite antigens.

• Presently, NVBDCP supplies RDT kits for detection of P. falciparum at locations where microscopy results are not obtainable within 24 hours of sample collection.

Chemoprophylaxis

• Chemoprophylaxis is recommended for travellers, migrant labourers and military personnel exposed to malaria in highly endemic areas.

• Short-term chemoprophylaxis (less than 6 weeks) Doxycycline: 100 mg daily in adults and 1.5 mg/kg body weight for children more than 8 years old. The drug should be started 2 days before travel and continued for 4 weeks after leaving the malarious area.

• Note: Doxycycline is contraindicated in pregnant and lactating women and children less than 8 years.

Cont..

Long-term chemoprophylaxis (more than 6 weeks) • Mefloquine: 5 mg/kg body weight (up to 250 mg)

weekly and should be administered two weeks before, during and four weeks after leaving the area.

• Note: Mefloquine is contraindicated in cases with history of convulsions, neuropsychiatric problems and cardiac conditions.

Integrated Vector Management

Measures for vector control and protection include:

1) Indoor Residual Spray(IRS) 2) Insecticide Treated Bed Nets(ITN’s)/ Long

Lasting Insecticidal Nets(LLIN’s) 3) Antilarval measures including source

reduction

BREEDING HABITATS OF ANOPHELES MOSQUITOES

Indoor Residual Spray(IRS)• Indoor residual spraying or IRS is the process of spraying the

inside of dwellings with an insecticide to kill mosquitoes that spread malaria.

• The main purpose of IRS is to reduce transmission by reducing the survival of malaria vectors entering houses or sleeping units.

• IRS remains a valuable intervention in malaria control when certain conditions are met.

Cont.. Effectiveness of IRS depends on:• Target area• Selection of Insecticides• Change of Insecticide• Insecticide formulations used under NVBDCP 1. DDT( Dichloro-diphenyl-trichloroethane) 2. Organophosphorus (OP) compounds 3. Synthetic Pyrethroids Strategies of Delay the onset of ResistanceNote: Recently GHMC in Hyderabad have introduced Synthetic

Pyrethroid for IRS

Insecticide Treated Bed Nets(ITN’s)/(LLIN’s)

• An insecticide-treated net is a mosquito net that repels, disables and/or kills mosquitoes coming into contact with insecticide on the netting material. There are two categories of ITNs:

• A conventionally treated net is a mosquito net that has been treated by dipping in a WHO-recommended insecticide. To ensure its continued insecticidal effect, the net should be re-treated after three washes, or at least once a year.

• A long-lasting insecticidal net is a factory-treated mosquito net made with netting material that has insecticide incorporated within or bound around the fibres..

Cont..

• Specific Objectives: Reduce Human contact, Reduce morbidity, Prevent deaths, Promote Community participation, Modalities for social marketing trough Public-Private Partnership.

• Assessment of community needs by rapid surveys, size of the nets and number of nets according to size.

Synthetic Pyrethroids mainly two Deltamethrin(2.5%) at a dosage of 25mg/m2 and cyfluthrin (5%) at 50mg/m2.

Anti-larval Measures

1) Environmental control: Good water management practices are best. Could be Temporary and Permanent.

2) Biological control: Fishes, Insects, Protozoans, Arthropods, Bacteria, Fungi & viruses.

3) Genetic control: Genetic Engineering like Transgenic Mosquito

4) Chemical control: Given high priority in Operational Measures.

Biological Control

Biological Agents that work well:

1. Mosquito fish: Gambusia and Guppy2. Bacteria: Bacillus thuringiensis and B. sphaericus

Other Biological Agents:

- Predatory mosquito larvae (Toxorhynchites)

- Copepods (Macrocyclops albidus)

Use of Biological Agents to control

of vector populations

Urban Malaria Scheme(UMS)• OBJECTIVES: The main aim is the reduction of the disease to a

tolerable level in which the human population can be protected from malaria transmission with the available means.

• The Urban Malaria Scheme aims at :a) To prevent deaths due to malaria.b) Reduction in transmission and morbidity.

• NORMS :

Cont..

Control Strategies under Urban Malaria Scheme: Vector Control – 1) Source Reduction 2) Anti-larval methods- Chemical

Recurrent anti-larval measures at weekly intervals with approved chemical larvicides like Temephos.

3) Use of larvivorous fish like gambusia and guppy 4) Aerosol space spray – 5) Minor engineering&Legislative measures

Epidemic Preparedness and Early Response

• Confirmation of an Outbreak• Preparatory aspects like Constitution of Rapid

Response Team(RRT) and Logistics• Control of malaria epidemic by 1. Delineation of the affected area 2. Estimation of population involved 3. Measures for liquidation of foci 4. Follow-up Action

Surveillance in Malaria

• Monitoring Malaria incidence trends and geographic distribution.

1) Active Surveillance(Active case detection)

2) Passive Surveillance(PCD)

3) Sentinel Surveillance

IDSP in Malaria

• Malaria is under Regular Surveillance in Integrated Disease Surveillance Project(IDSP).

• Case Classification: Suspect case- Any case of fever(in an endemic

area). Probable case- A case that meets the clinical case

description. Confirmed case- A suspect case with malaria

parasites in blood film.

INTEGRATION UNDER NRHM

At Village LevelMonthly meetings of Village Health & Sanitation Committee serve

as a platform for health education and counseling of community. Involvement of ASHA as-surveillance worker to inform any increase in fever cases

including Dengue/ Chikungunya and J.E.FTD for early detection of suspected malaria cases and treatment linkage between ANC services and prevention & treatment of

malaria organizer, motivator and trainer in village level meetings/training

workshops.

Interaction of Malaria Control with the Other health programmes

• Integrated Disease Surveillance Project(IDSP) - The Project with weekly fever alerts is increasingly providing early warning signals on malaria outbreaks.

• Other Vector borne diseases - Dengue & malaria control activities overlap in many Urban areas, Malaria & kala-azar in few districts of Jharkhand.

• Reproductive and Child Health - ANC services utilized in distribution of LLINs to pregnant women.

Major Externally Supported Projects

• Global Fund for AIDS TB & Malaria(GFATM) supported Intensified Malaria Control Project(IMCP):

• It was for a period of 5years from July 2005 to June 2010. Implemented in 106 districts in 10 states.

• It helped to achieve 23.4% decline in Malaria Incidence.

• IMCP-II has been initiated for a period of five years (2010-2015).

World Bank Supported Project on Malaria Control

• Approved for 5years(March 2009-Dec 2012). Total financial outlay Rs.1000 Crore.

• Being implemented in 93 malarious districts of eight states including Andhra Pradesh.

• Provides additional Support for procuring ACT, Long Lasting Insecticidal Nets(LLIN’s), Provision of additional manpower.

Elimination & Eradication of Malaria

• Malaria control: reducing the malaria disease burden to a level at which it is no longer a public health problem.

• Malaria elimination: the interruption of local mosquito-borne malaria transmission; reduction to zero of the incidence of infection caused by human malaria parasites in a defined geographical area as a result of deliberate efforts.

Cont..• Certification of malaria elimination: the chain of local human

malaria transmission by Anopheles mosquitoes has been fully interrupted in an entire country for at least 3 consecutive years.

• Malaria eradication: permanent reduction to zero of the worldwide incidence of infection caused by a particular malaria parasite species.

Cont..

• Key factors proposed for eradicating malaria: 1) Reducing Malaria Burden 2) Vector Control 3) Malarial Vaccine

Malarial Vaccine

• Vaccines developed are basically of three types: Pre-erythrocytic stage vaccine Blood stage vaccine and Transmission blocking vaccine SPf-66—1st malaria vaccine that was tried in clinical

trials in 1990s. RTS,S--Most successful vaccine candidate, currently

in Phase IIIChallenges facing vaccine development

Remote Sensing

• Remote Sensing is a tool for surveillance of habitats, density of vector species and prediction of Incidence of diseases.

• It is likely to become a rapid epidemiological tool for surveillance of vector borne diseases and Malaria in particular.

• Coupled with GIS(Geographical Information System), will play a key role in Macro stratification for Prioritizing control measures in a cost-effective way.

World Malaria Day 25th April

• World Malaria Day - which was instituted by the World Health Assembly at its 60th session in May 2007.

• World Malaria Day 2012 — “SUSTAIN GAINS, SAVE LIVES: INVEST IN MALARIA” marks a decisive juncture in the history of malaria control.

Monitoring and Evaluation• Monitoring & Evaluation will be an on-going process in the

programme.• Adoption of newer disease prevention and control instruments

like RDTs, ACTs & LLINs and recruitment of ASHA, a new frontline worker under NRHM, made it necessary to restructure the Management Information System (MIS).

• The NVBDCP also has an online system of data collection and collation called the National Anti malaria Management Information System (NAMMIS).

• Objectives - To ensure that 80% of districts in high-disease burden areas will collect, process, analyze, and effectively manage malaria data by 2010 and 100% of them by 2012.

Cont..

The following activities will be adopted in the programme to strengthen the M & E system :

• Strengthening of management information system for tracking malaria incidence and operational indicators including the revival of the National Anti Malaria Management Information System (NAMMIS).

• Sentinel surveillance to collect data on severe malaria, hospitalized malaria cases and malaria deaths from selected hospitals in each district.

• Decentralized measurement of outcomes at district and PHC levels through Lot Quality Assurance Sampling (LQAS).

Cont..• Large-scale population surveys every second year to assess

malaria prevalence and population coverage with main interventions.

• Logistic Management Information System for supply chain management.

• System to monitor the quality of RDTs and medicines to ensure their quality upon delivery and at point of use.

SWOT analysis of National Malaria Control Programme

• Strengths• Weaknesses• Opportunities• Threats

StrengthsLong experience since 1953Political commitmentMalaria Surveillance covering all blocksASHAs being utilized in all endemic villages for surveillance.

RDTs for diagnosis of Pf introducedMicroscopy available up to PHC levelACT for treatment of Pf introducedLLINs introducedResearch support from NIMR

WeaknessesRDT coverage needs to be expanded to all endemic villages.Delay in conducting microscopic examination of smears .ACT needs to be used for all Pf cases in country.Requirement of total shift from re-impregnation of plain nets to LLINs.Difficulty in distributions of ITN’s in remote areas with inhibited access.Deficiency of human resources at all levels from national to block level.

OpportunitiesNRHM strengthening the health structure and malaria control at all levels.NURM expected to be launched in 12th five year plan will strengthen UMS.Increasing commitment for funds from international agencies such as GFATM.NGOs willing to be partners.Possibility of introduction of pan-specific RDTs for both Pf & Pv soon.

ThreatsOverloading of ASHAs with many Programmes.Development of Insecticide resistance.Development and spread of drug resistance.Social and ecological constraints to effectiveness of standard interventions in some high risk populations.Social unrest in some areas.

References• Park’s Textbook of Preventive and Social Medicine, 21st Edition by

K.Park.• Health policies and Programmes in India , 10th Edition by

Dr.D.K.Taneja.• National Health Programmes of India, 10th Edition by Jugul Kishore.• World Health Organization(WHO) World Malaria report 2011,

http://www.who.int/malaria/world_malaria_report_2011/9789241564403_eng.pdf

• National Vector Borne Disease Control Project (NVBDCP) official website: http://www.nvbdcp.gov.in/malaria-new.html

• Guidelines for Diagnosis and Treatment of Malaria in India 2011 by National Ministry : http://www.mrcindia.org/Guidelines%20for%20Diagnosis2011.pdf

“ THERE IS NO LIMIT TO WHAT WE ACHIEVE

IF YOU DON’T MIND WHO GETS THE CREDIT”

….Anonymous

Thank you