Dr. Priyamadhaba BeheraJunior Resident

MALARIA CONTROL STRATEGIES IN INDIA 12/04/2013

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OUTLINE OF PRESENTATION

• EPIDEMIOLOGY• EVOLVVING MALARIA CONTROL STRATEGIES IN

INDIA• NVBDCP• GUIDELINE FOR DIAGNOSIS AND TREATMENT

OF MALARIA IN INDIA( 2011)

The World Malaria Report 2012 :104 malaria-endemic countries and territories for 2011. Ninety-nine of these countries had on-going malaria transmission.

Extends up to 40 degree north and 40 degree south of equator

219 million cases of malaria in 2010 and an estimated 660 000 deaths. Africa is the most affected continent: about 90% of all malaria deaths occur there.

Between 2000 and 2010, malaria mortality rates fell by 26% around the world. In the WHO African Region the decrease was 33%.

what factors make Africa prone for high transmission? How malaria transmission of Africa differ from India

Malaria is a public health problem in India

-About 95% population in the country resides in malaria endemic areas and 80% of malaria reported in the country is confined to areas consisting 20% of population residing in tribal, hilly, difficult and inaccessible areas

-45-50% cases are p.falciparum casesHow falciparum differs from others and why leads to various complication?

Trend of Malaria Cases And Deaths 2001-2010 in India

cases have declined from 2.08 million to 1.49 million during 2001 to 2010. Pf cases have declined from 1.0 to 0.77 million cases during the same period. Less than 2000 deaths were reported during all the years with a peak in 2006 when an epidemic was reported in NE States. SPR has declined from 2.31 to 1.41 and SFR has declined from 1.11 in 2001 to 0.74 in 2010.

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India’s contribution to Malaria in SEAR

India contributes to 71% of total malaria cases in the SEAR

How bionomics of vector help to control malaria

Indicators for

surveillance, prevalence, when ABER is low or fluctuates?

MILESTONESNMCP 1953

SPECTACULAR SUCCESS

NMEP 1958

UMS 1971

RESURGENCE

MPO 1977

MAP 1995

EMCP 1997

NAMP 1999

NVBDCP 2004

IMCP 2005

NATIONAL MALARIA CONTROL PROGRAMME 1953

OBJECTIVES

• TO BRING DOWN MALARIA TRANSMISSION• TO HOLD DOWN MALARIA TRANSMISSION AT LOW LEVEL

STRATEGIES

•INDOOR RESIDUAL SPRAY•TREATMENT OF PATIENTS REPORTING TO HEALTH

ACHIEVEMENTS

•DECLINE IN INCIDENCE FROM 75 MILLION TO ONLY 2 MILLION IN 1958

How current treatment of malaria differs from 1953 ?

NATIONAL MALARIA ERADICATION PROGRAMME1958

OBJECTIVES

TO ERADICATE MALARIA FROM INDIA IN 7 TO 9 YEARS

ACTIVITIES

SPRAYING OPERATIONFORTNIGHTLY ACTIVE CASE DETECTIONRADICAL TREATMENTINVESTIGATION OF POSITIVE CASES AND REMEDIAL MEASURES

ACHIEVEMENTS

LOWEST EVER INCIDENCE OF 0.1 MILLION IN 1965NO REPORTED DEATHS DUE TO MALARIA

RESURGENCE OF MALARIA 1967 TO 1976

IN 1965-SUDDEN WITHDRAWAL OF ASSISTANCE AND INSECTICIDES REGISTANCE ,STEEP RISE IN MALARIA INCIDENCE

URBAN MALARIA SCHEME 1971

IN 139 TOWNS IN 19 STATES AND UNION TERRITORIESOBJECTIVES

a) To prevent deaths due to malaria.b) Reduction in transmission and morbidity.

NORMS The towns should have a minimum population of 50,000.The API should be 2 or above.The towns should strictly implement the civic by-laws to prevent/eliminate domestic and peri-domestic breeding places

Control Strategies under Urban Malaria Scheme:

-Parasite control -Vector controlParasite control: Treatment is done through passive agencies viz. hospitals, dispensaries both in private & public sectors and private practitioners. In mega cities malaria clinics are established by each health sector/ malaria control agencies viz. Municipal Corporations, Railways, Defence services

Vector control comprises of the following componentsSource reductionUse of larvicidesUse of larvivorous fishSpace sprayMinor engineeringLegislative measure

Aerosol Space Spray

Space spraying of pyrethrum extract (2%) in 50 houses in and around every malaria and dengue positive cases to kill the infective mosquitoes is recommended.Town –biologistState-additional director (malaria/filaria)Central level-director NVBDCP

RE-CLASSIFICATION OF ENDEMIC AREASBASED ON ANNUAL PARASITE INCIDENCE

API LESS THAN 2 API GREATER THAN 2

MODIFIED PLAN OF OPERATION 1977

OBJECTIVES

PREVENTION OF DEATH DUE TO MALARIAREDUCTION OF MORBIDITY DUE TO MALARIARETENTION OF ACHIEVEMENTS GAINED SO FAR

AREAS WITH API > 2

SPRAYINGENTOMOLOGICAL ASSESSMENTSURVEILLANCETREATMENT OF CASESDECTRALISATION OF LABORATORY SERVICES AT-PHCESTABLISHMENT OF DDCS AND FTDS

AREAS WITH API < 2

FOCAL SPRAYING SURVEILLANCE AND TREATMENTFOLLOW UPEPIDEMIOLOGICAL INVESTIGATION

DRUG DISTRIBUTION CENTRE

DISPENSE ANTI MALARIAL DRUGS

FEVER TREATMENT DEPOT

COLLECT BLOOD SLIDES

DISTRIBUTE ANTI MALARIAL DRUGS

RESEARCH

MONITORING TEAMS TO IDENTIFY FALCIPARUM SENSITIVITY TO CHLOROQUINE

TEAM TO TEST ALTERNATE DRUGS FOR CHLOROQUINE RESISTANCE

HEALTH EDUCATION

P.FALCIPARUM CONTAINMENT 1977

COMPONENT OF MPO

INTRODUCED WITH THE ASSISTANCE OF SWEDISH INTERNATIONAL DEVELOPMENT AGENCY

TO PREVENT OR CONTROL THE SPREAD OF FALCIPARUM MALARIA

AREAS

SURVEILLANCEAIM•CASE DETECTION THROUGH LAB SERVICES•FACILITIES FOR PROPER TREATMENT

ACTIVE

TYPES

PASSIVE

ACTIVE SURVEILLANCE☻CARRIED OUT BY SURVEILLANCE WORKERS

PASSIVE SURVEILLANCE

SEARCH FOR CASES BY LOCAL HEALTH AGENCIES

CASES THOSE ESCAPED ACTIVE SURVEILLANCE ARE SCREENED

MALARIA ACTION PROGRAMME 1995

RESURGENCE OF MALARIA (RAJSTAN/MANIPUR/NAGALAND/ASSAM/WB/MAHARASHTRA)

EXPERT COMMITTEE 1994

HIGH RISK AREAS IDENTIFIED

FTD MICROSCOPY FACILITY

1000 POPULATION 30,000 POPULATION

ELEMENTSEARLY DIAGNOSIS AND PROMPT TREATMENTSUSTAINABLE PREVENTIVE MEASURES INCLUDING VECTOR CONTROLPREVENTION OF EPIDEMICSREGULAR ASSESSMENT

HIGH RISK AREAS

HIGH APIHIGH PROPORTION OF PF CASESREPORTED DEATH DUE TO MALARIASPR DOUBLEDSPR >5%

ENHANCED MALARIA CONTROL PROJECT 1997

•WITH WORLD BANK ASSISTANCE•1997-2003, EXTN TO 2005

OBJECTIVES

EFFECTIVE CONTROL OF MALARIABRING DOWN MALARIA MORBIDITYPREVENTION OF DEATH DUE TO MALARIACONSOLIDATION OF GAIN ACHIVED SO FAR

SELECTION OF PHC-CRITERIA

API>2 FOR LAST 3 YRSP.FALCIPARUM>30% OF CASES25% TRBAL POPULATONDEATH DUE TO MALARIA

MAIN COMPONENTS

EARLY CASE DETECTION AND TREATMENTSELECTIVE VECTOR CONTROL AND PERSONAL PROTECTIONHEALTH EDUCATION AND COMMUNITY PARTICIPATION

PLAN OF ACTION

SYNTHETIC PYRETHROIDSBED NETSRAPID DIAGNOSTIC KITSARTEETHER INJECTIONSBLISTER PACKSFUNS FOR TRAINING

NATIONAL ANTI-MALARIA PROGRAMME 1999

NATIONAL VECTOR BORNE DISEASE CONTROL PROGRAMME 2004

OBJECTIVES

REDUCE MALARIA MORBIDITY AND MORTALITY BY 50%

TARGETS AND INDICATORS

ABER>10%MBER OF 0.8% 1.2 – 1.8%API 1.3 OR LESS25% REDUCTION IN MORBIDITY AND MORTALITY BY 201050% REDUCTION IN MORBIDITY AND MORTALITY BY 2012

NATIONAL VECTOR BORNE DISEASE CONTROL PROGRAMME

Launched in year 2003-04Major vector borne diseases-• Malaria• Filaria• Kala-azar• Japanese Encephalitis• Dengue / Dengue Hemorrhagic fevers• Chikungunya

Mission statement

• Integrated accelerated action towards – reducing mortality on account of Malaria, Dengue

and JE by half– Elimination of Kala-azar by 2010– elimination of lymphatic filariasis by year 2015.

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INTENSIFIED MALARIA CONTROL PROJECT

Launched in july 2005 with assistance of global fund for AIDS,TB and malaria in NE states,Odisha,jharkhand and WB

OBJECTIVES:1-Increase access rapid diagnosis and treatment through

community participation2-reduce transmission by used of insecticide treated bednets

and larvivorous fish3-Enhance awareness about malaria control4-To promote community,NGO,private sector participation

Blood collected with sterile technique

Making the smears

Making of Thick smear

Thin and Thick smear

Appearance of Thick and Thin Smears

Specific antimalarial treatment of severe malaria

Severe malaria is an emergency and treatment should be givenpromptly. Parenteral artemisinin derivatives or quinine shouldbe used irrespective of chloroquine sensitivity.• Artesunate: 2.4 mg/kg body weight i.v. or i.m. given onadmission (time=0), then at 12 hours and 24 hours, then

once a day (Care should be taken to dilute artesunate powder in 5% Sodium bi-

carbonate provided in the pack).• Intravenous preparations should be preferred over intramuscular preparations.

Parenteral treatment should be given for minimum of 24 hours once started. In first trimester of pregnancy, parenteral quinine is the drug of choice.

• Other drugs used are arteether , artemether, quinine ( along with doxycycline/clindamycin)

chemoprophylaxisChemoprophylaxis is recommended travellers, migrantlabourers and military personnel exposed to malaria in highly endemicareas. Use of personal protection measures like insecticide-treatedbednets should be encouraged for pregnant women and othervulnerable populations.

PROGRAM EVALUATION

Internal assessments are conducted by central teams as well as by LQAS, periodically. External assessments are done through large sample surveys every 2-3 years and are conducted by NVBDCP / NIMR.

• The study in 10 randomly sampled high burden blocks with API > 2 can be spread out over 80

• villages to include 1600 households / fever cases. Such samples are adequate to detect differences of more than 10% across two surveys. The survey data will be examined along with other sources of information, including MIS and LQAS and planning data.

THANK YOU