Progress in Reaching GMAP targets in

India

National Vector Borne Disease Control ProgrammeIndia

Objectives

• Prevention of deaths due to malaria

• Prevention of morbidity due to malaria

• Maintenance of ongoing socioeconomic development

Specific Objectives

• API 1.3 or less by 2012

• 50% reduction of morbidity and mortality due to malaria by 2010 (National Health Policy- 2002)

• To halt and reverse the incidence of malaria by 2015 (MDGs)

GMAP Targets

• Reduce global malaria cases from 2000 levels by 50% in 2010 and by 75% in 2015 (GMAP)

• Reduce global malaria deaths from 2000 levels by 50% in 2010 and to near zero preventable deaths in 2015 (GMAP)

Country Profile• Population: 1065 Million

(95% of Country’s Population lives in Malaria Transmission Risk Areas)

• States & UTs: 35

• Districts: 628

• PHCs: 22669

• Microscopy Centres: 22669

• Sub-centres: 144988

• MPW (M): 65511

• MPW (F):149695

• ASHAs: 481308

Malaria Disease Burden • 1953 - Estimated Malaria - 75 Million

Estimated Deaths Due to Malaria – 0.8 Million Launching of NMCP

• 1958 - Launching of NMEP

• 1966 - Cases Reduced to 0.1 Million

• Early 70’s - Resurgence of Malaria

• 1976 -Malaria Cases 6.46 Million and 59 Deaths

• 1977 - Modified Plan of Operations Introduced

• 1984 - Annual Malaria Incidence Reduced to 2.2. Million Cases

0-22-55-10>10

MALARIA ENDEMIC AREASMALARIA ENDEMIC AREAS

APIAPI

PERCENTAGE CONTRIBUTION OF PERCENTAGE CONTRIBUTION OF POPULATION, MALARIA CASES, PF POPULATION, MALARIA CASES, PF

CASES AND DEATHSCASES AND DEATHS

(Compared to the country total)(Compared to the country total)

StatesStates% %

PopulPopulationation

% % Malaria Malaria casescases

%%

Pf Pf casescases

% % DeathDeath

N.E. N.E. StatesStates 44 1313 1717 4646

Other Other high high endemic endemic states*states*

4242 6767 7777 4343

OtherOther 5454 2020 66 1111

*Andhra, Chhattisgarh, Gujarat, *Andhra, Chhattisgarh, Gujarat, Jharkhand, MP, Jharkhand, MP,

Maharashtra, Orissa, RajasthanMaharashtra, Orissa, Rajasthan

Distribution of Districts by API

API Districts Nos. Population ‘000

%

Less than 0.5

279 531051 50.0

0.5 – 1 111 219943 20.7

1 – 2 72 123918 11.7

2 – 5 79 110015 10.4

More than 5 86 77580 7.3

Total 628 1062508 100.0

India - Malaria Control Strategies

The three pronged strategy for prevention and control of malaria is:

1.Early Diagnosis and Prompt Treatment

a. Disease Surveillance – through MPWs & ASHAs

b. Case Detection & management

c. Epidemic Preparedness and Response

Malaria Control Strategies Cont…

2. Integrated Vector Control

a. Indoor Residual Spray

b. Insecticide treated Bednets (ITNs) & Long Lasting Insecticide Treated Nets (LLINs)

c. Source Reduction

Malaria Control Strategies Contd…

3. Supportive interventions

a. Training & Capacity Building

b. Behaviour Change Communication

c. Intersectoral Collaboration

d. Community Participation

d. Public Private Partnership (eg. NGO/ CBOs/ IMA etc.)

e. Monitoring, Evaluation & Supportive Supervision

f. Legislation

Early Diagnosis and Prompt Treatment

a. Disease Surveillance Conducted through:

A.Passive and active surveillance for case Detection B. Sentinel Surveillance for severe cases and deaths

b. Malaria Diagnosis Microscopy Rapid Diagnostic Tests

c. MicroscopySlides collected by MPWsSlides examined in microscopy centers in PHCs95 million slides were examined in 2007

d. Rapid Diagnostic TestsMPWs/ ANMs /ASHAs trained on RDTsTest in remote inaccessible areas endemic for P.falciparum

Scaling up of Service Delivery

• Engaging 9655 contractual MPWs against vacancies for surveillance

• Vacancies of LTs: 6822 (Sanctioned – 23236)

• Engaging LTs against vacancies under Global Fund, WB Project and also through NRHM

• 117 thousand ASHAs trained with special focus on use of RDTs for diagnosis and ACT for treatment

8130

15000

0

2000

4000

6000

8000

10000

12000

14000

16000

Nos

Actual (2006) Need (2010)

RDKs in '000

• At Present 100 million slides collected

• Pf Specific RDT in Use

• 50% of cases are Pf

• Pf cases are mostly confined to 250 million population

• 40 % of Pf cases are in remote areas

RDT Supply vs. Need

Scaling up RDTs

• Introduced in 2003-04 and gradually scaled up

• Used in inaccessible and remote areas

• At Present monovalent RDTs ( only for PF) are being used

• Training of community volunteers in RDT and drug delivery

907 1200

6427

8130

12040

0

2000

4000

6000

8000

10000

12000

14000

2003-04 2004-05 2005-06 2006-07 2007-08

RDKs in '000

Treatment of Cases

• Chloroquine was the Drug of Choice for both Pv & Pf till emergence of

resistance in Pf

• Pf Monitoring (Parasite Sensitivity of anti-malarials) started in 1977

• SP adopted as 2nd line treatment for treatment of Pf cases in CQ resistant areas in 1982.

• Combination therapy of Artesunate plus SP adopted in 2004 for treatment of Pf cases in CQ resistant areas.

• Use of ACT extended to cluster of blocks and 7 pilot districts under the programme since 2007

• According to Revised Drug Policy (2008) ACT is 1st line drug for Pf in all high endemic areas in addition to CQ resistant and surrounding blocks.

• 1.8 Million Total Malaria Cases

• 50 % Pf Proportion

• ACT rolled out as first line treatment of Pf cases in 117 districts

• Eventually will cover 95% of Pf cases

2.42

9

0

1

2

3

4

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6

7

8

9

Actual (2006) Need (2010)

COMBI IN LAKHS

ACT Supply vs. Need

2.42

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1

2

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4

5

6

7

8

9

Actual (2006) Need (2010)

COMBI IN LAKHS

Scaling up ACT

3.05

7.38

10.66

0

2

4

6

8

10

12

2005-06 2006-07 2007-08 2008-09

COMBI IN LAKHS

Integrated Vector Control

a. Indoor Residual Spray• 1953 – entire country uniformly sprayed

• 1977 - MPO adopted (areas with API > 2 covered with IRS)

• Currently high risk areas API > 3 covered with IRS during the transmission season

• 90 Million of Country’s population targeted annually and coverage is 80%

• Insecticide used: DDT, Malathion, Synthetic Pyrethroids

b. Insecticide treated Bednets (ITNs) & Long Lasting Insecticide Treated Nets (LLINs)

• Introduced in high risk areas in 2001

• Plain Bed-nets procured so far are mainly used in - GFATM Project - WB Project

• Efforts are on to introduce LLIN

• Use guided by epidemiological and entomological parameters or IRS operational difficulty

ITNs Actual vs. Need

Actual (2006) Need

8

22

2

8

0

5

10

15

20

25

30

Comm ITNs in Million Prog ITNs in Millions

Scaling up ITNs

0.09 0.23

1.2

2.52.75

33.2

3.5

0

0.5

1

1.5

2

2.5

3

3.5

2001-02 2002-03 2003-04 2004-05 2005-06 2006-07 2007-08 2008-09

ITNs in Million

GIS Mapping Based identification of High Risk Areas GIS Mapping Based identification of High Risk Areas Eg. Problematic Villages Identified through GIS for Eg. Problematic Villages Identified through GIS for Focus Intervention in District Nalbari, Assam (2006)Focus Intervention in District Nalbari, Assam (2006)

Priority API Pf% No. of Villages1 > 5 > 50 1062 > 5 > 30 & <= 50 53 >3 & <= 5 > 50 54 >3 & <= 5 > 30 & <= 50 1

117Total Villages

No. of Malarious Villages in Nalbari = 271 (Total Villages -800)

Other Vector Control Methods LARVICIDING & ADULT CONTROL

• Undertaken in urban set up with temephos, pirimiphos methyle & Biological larvicide (Bti) & pyrethrum extract 2% as adulticide

• 131 major towns are covered

• Target population is 112.6 million

LARVIVOROUS FISH

• Cost effective & environment friendly method

• Emphasis on perennial water bodies as hatcheries

• Over 2191 district level & 19023 Block/ PHC level hatcheries established

• No of water bodies seeded are 192,781

Improving Access to & Use of Malaria Prevention and control Services

WORLD BANK PROJECT TARGETS

• > 80% of population in high-risk project areas protected by ITNs or IRS

• > 80% of RDT positive cases among adults receiving ACT no later than the day after the first contact

To be adopted in all high endemic areas

Meeting the Gaps

Additional inputs provided through Global fund & World Bank Projects

A. HUMAN RESOURCE• PMUs at National, State Level• District Level – DVBDC Consultant, MTS

B. COMMODITIES• ITNs/ LLIns• Synthetic pyrethroids• RDT• ACT

RBM Partnership’s vision

Substantial and sustained reduction in the burden of malaria in the near and mid-term, and the eventual global eradication of malaria in the Long term, when new tools make eradication possible.

Targets of the GMAP :

•Achieve universal coverage, for all populations at risk with locally appropriate interventions for prevention and case management by 2010 and sustain universal coverage until Local field research suggests that coverage can gradually be targeted to high risk areas and seasons only, without risk of a generalized resurgence;

•Reduce global malaria cases from 2000 Levels by 50% in 2010 and by 75% in 2015;

•Reduce global malaria deaths from 2000 Levels by 50% in 2010 and to near zero preventable deaths in 2015;

•Eliminate malaria in 8-10 countries by 2015 and afterwards in all countries in the pre-elimination phase today; and

•In the long term, eradicate malaria world-wide by reducing the global incidence to zero through progressive elimination in countries.

India’s Progress

• The programme adopted universal coverage during 1960’s when eradication was contemplated.

• Subsequent resurgence in certain areas resulted in adoption of targeted approach in high risk areas

• Country on track for SUFI & Universal Coverage of control interventions in these areas

• Partnerships forged with WHO, Global Fund, World Bank & Private Partners

• 28% reduction in Malaria Morbidity from baseline of 2000

• Around 70% of country’s population under sustained control

THANK YOU

GMAP Vision Vision is of a world free from the burden of malaria.

By 2015: the malaria-specific MDG is achieved, and malaria is no longer a major cause of mortality and no longer a barrier to social and economic development and growth any where in the world.

Beyond 2015:all countries and partners sustain their political and financial commitment to malaria control efforts. The burden of malaria never rises above the 2015 level, ensuring that malaria does not re-emerge as a global threat.

In the long term:global malaria eradication is achieved. There is no malaria infection in any country. Malaria control efforts can be stopped.

Targets

By 2010, through targeting universal coverage:

• 80% of people at risk from malaria are using locally appropriate vector control methods such as long-lasting insecticidal nets (LLINs), indoor residual spraying (IRS) and, in some settings, other environmental and biological measures

• 80% of malaria patients are diagnosed and treated with effective anti-malarial treatments; in areas of high transmission,

• 100% of pregnant women receive intermittent preventive treatment (IPTp);

and

• the global malaria burden is reduced by 50% from 2000 levels: to less than 175-250 million cases and 500,000 deaths annually from malaria.

• By 2015:

− universal coverage continues with effective interventions;

− global and national mortality is near zero for all preventable deaths;

− global incidence is reduced by 75% from 2000 levels: to less than 85-125 million cases per year;

− the malaria-related Millennium Development Goal is achieved: halting and beginning to reverse the incidence of malaria by 2015;

and

− at least 8-10 countries currently in the elimination stage will have achieved zero incidence of locally transmitted infection.

• Beyond 2015:

− global and national mortality stays near zero for all preventable deaths;

− universal coverage (which translates to ~80% utilization) is maintained for all populations at risk until local field research suggests that coverage can gradually be targeted to high risk areas and seasons only, without risk of a generalized resurgence; and

− countries currently in the pre-elimination stage will achieve elimination.

Scaling up ACT

0.57

2.42

4

9

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4

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8

9

2005-06 2006-07 2007-08 2008-09

COMBI IN LAKHS

Plan for Scaling Up For ImpactPlan for Scaling Up For Impact

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25

30

2008

-09

2009

-10

2010

-11

2011

-12

2012

-13

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-14

2014

-15

2015

-16

2016

-17

2017

-18

Mil

lio

n

Total Available Bednets LLINs through Programme

Community Owned Nets

UNIVERSAL COVERAGE (100%) GF / WB Domestic Budget

Timeline for SUFI

MAX PROG CAPACITY (19 Million)

SUFI Gap

lag in SUFI

80% COVERAGE