MD KABIUL AKHTER ALIVBD Consultant,Public Health Wing,Malda
Goal of Anti Malaria MonthAnti –Malaria month is being observed all over India in the month of June.June, being the pre Monsoon month has been selected for creatingawareness among the masses against Malaria, a fever caused by a parasitetransmitted ensure appropriate public health focus to improved access toprimary health care, preby mosquito bite. The AMM campaign is also anattempt to enlarge and vention and control of communicable diseasesIncluding vector borne diseases, reduction of infant mortality rate andmaternal mortality ratio by 50% by year 2012 and promotion of healthylife styles as per the goals of the National Rural Health Mission launchedby the GoI in April 2005.
Objective of Anti malaria MonthThe specific objectives of the Anti Malaria Month campaign strategy through BCCare as under:1.Enhance awareness regarding source and transmission riskreduction, treatment, availability of services at different levels2.Promote attitudinal and value changes among target audiences leading toinformed decisions, modified behaviour, desirable practices at individual andsocietal level3.Stimulate increased and sustained demand for quality prevention and careservices and optimal utilization of available health care services4.Build support for the programme across inter-sectoral partnerorganizations, influential sectors of society (corporate houses, politicalrepresentatives, social activists, media, civil society organizations, etc.) and healthcare service providers and elicit commitment for action5.Ensure availability of services.
PHASING OF ANTI MALARIA MONTH CAMPAIGPhase I - Preparatory phase: 3 months (December - February)•Drawing up of Action Plans for the current AMM through BCC following inputs fromStates/UTs.•Finalization of BCC materials.•Distribution of BCC materials to different levels of implementation.•Compilation of AMM report of the previous year.Phase II – Advocacy: 3 months (March - May)•Organization of Advocacy workshops/conferences.•Organization of Task Force for observance of AMM at all levels of programmeimplementation•Finalization of BCC materials and printing for distribution to inter-sectoral partners.Phase III – Intensive campaign: 3 months (June – August)•Umbrella campaign•Localized campaign•On ground initiativesPhase IV –Evaluation and Report submission: 3 months (June - August)•Concurrent evaluation•Consecutive evaluationPhase V – Localized follow up campaign: 3 months (September – November)•Localized campaign•On ground initiatives
a. Early case diagnosis and prompt treatment: throughvillage based community volunteers designated as:i) Drug Distribution Centre (DDCs), who distribute chloroquine tabletsto patients with fever. andii) Fever Treatment Depots (FTDs), who collect blood smears from fevercases and provide appropriate treatment after slide examination at amicroscopy facility.
Chloroquine 25 mg/kg divided over 3 days(10 +10+ 5). Primaquine 0.25 mg/kg daily for 14 days. Primaquine contraindicated in Infants Pregnant women & Known G6PD deficient patients - do test ifavailable, Stop PQ if patient develops dark coloredurine, yellow conjunctiva, blue discoloration of lips,nausea, vomiting or abdominal pain & report todoctor
Age Chloroquine (150 mg) Primaquine(2.5 mg)(years) Day 1 Day 2 Day 3 No. of tablets< 1 ½ ½ ¼ Nil1 – 4 1 1 ½ 15 – 8 2 2 1 29 – 14 3 3 1½ 4> 15 4 4 2 6Primaquine given for 14 days in confirmed P vivaxContraindicated in infants, pregnant women & patients withG6PD deficiency
All cases confirmed by microscopy/ RDT should get Artemisinin Combination Therapy (ACT) –Artesunate (4 mg/ Kg BW)/ day for 3 days & SP(Sulphadoxine – 25 mg/Kg BW & Pyremethamine1.25 mg/Kg BW) single dose - day 0 & Primaquine single dose (0.75 mg/kg BW) on 2ndDay. Oral artemisinin monotherapy banned - can leadto drug resistance.
Age(years)Number of tabletsFor AS & SPPrimaquine(7.5 mg)Day 1 Day 2 Day 3 Day 2<1 ASSP½¼½Nil½NilNil1 – 4 ASSP111Nil1Nil15 – 8 ASSP21½2Nil2Nil29 – 14 ASSP323Nil3Nil415 & above ASSP434Nil4Nil6
Treatment of mixed infections Mixed infections with Pf should be treated asfalciparum malaria. Anti-relapse treatment with Primaquine to be givenfor 14 days.Treatment of malaria in pregnancy Pf cases: ACT in 2nd & 3rd trimesters & quinine in 1sttrimester (if quinine NA, use ACT). P. vivax treated with Chloroquine in all trimesters. No anti relapse treatment (Primaquine)
Avoid treatment on an empty stomach. First dose under observation & repeat if vomiting occurswithin 30 minutes. Ask to report back, if no improvement after 48 hrs orsituation deteriorates (Not responding to treatment). Also examine for concomitant illnesses.(an illness thatoccurs during the same time as another illness.)
b. Integrated vector management :1. Indoor residual spray in selected pockets at high risk ofmalaria2. Promotion of use of insecticide treated bed nets(ITBNs) through free or subsidized supply to belowpoverty line (BPL) population living in remote,inaccessible areas with high risk of malaria as well asinsecticide treatment of community owned bed nets3. Use of biological vector control measure as larvivorousfish4. Environmental and minor engineering methods.
c. Capacity building:Of the medical and non-medical personnel as well asinter-sectoral partner organizations, communityvolunteers for imparting knowledge and strengtheningskills in respect of prevention and control initiativesincluding innovative technology.d.Information, Education and Communication(IEC1 IEC 2)To enhance awareness among members of the targetcommunities and health care service providers about causes,prevention and treatment of malaria, availability offacilities.
InternalStimulusChangeAgentInnovation Policies Technology MassMediaCommunity DialogueRecognition ofa ProblemIdentification &Involvement ofLeaders &StakeholdersClarification ofPerceptionsExpression ofIndividual &SharedInterestsVision ofthe FutureConflict-DissatisfactionAction Plan Consensus ofActionOptions forActionSettingObjectivesAssessment ofCurrent StatusCollective ActionAssignment ofResponsibilitiesMobilisation ofOrganisationsImplementation Outcomes ParticipatoryEvaluationIndividual ChangeSkills, Knowledge, Attitudes, PerceivedRisks, Self-Image, Emotion, Self-Efficacy, Social Influence, PersonalAdvocacy, Intention, BehaviourSocial ChangeLeadership, Degree and equity ofparticipation, information equity,collective self-efficacy, sense ofownership, social cohesion, socialnormsSocietal ImpactExTERNalCOnstRaINts&SUPPortCatalystThe Integrated Model of Communication for Social Change
e. Epidemic preparedness and response:Under NVBDCP, it is visualized that everydistrict in the country should have rapidresponse teams for undertaking promptremedial measures in the event of an outbreakof malaria.
f. Monitoring and Evaluation of theProgramMonthly Computerized Management InformationSystem(CMIS)Field visits by Program Officers / personnelField visits by Malaria Research Centers andother ICMR InstitutesFeedback to states on field observations forcorrection actions.
Logistic and Anti Malarial DrugManagementThe norms for calculation of Anti-malarial drugs to avoid stock-outs even inthe circumstances like unforeseen outbreaks and procurement delays are asfollows:•The data of positive malaria cases of the last completed year is taken asbasis for calculation.•25% additional quantity is to be taken as buffer on the technicalrequirement.•In declining trend of malaria cases, the chance of outbreak is always there.Therefore the maximum possible deviation may be up to maximum number ofcases reported in any of the years during the decade may be considered.This figure should also be considered for calculation of requirements ofanti-malarias. This factor is also considered especially when underreporting is known.
Objectives- to prevent deaths due to malaria- to reduce malaria morbidity- to maintain agriculture and Industrial- production through intensive anti malariameasures in such areas-to consolidate the gains achieved so far Areas were reclassified based on the Annual Parasitic Incidence(API) as those having API > 2 and those having < than 2 foroperational purposes
Regular 2 rounds of insecticidal spray withDDT/ Malathion / Synthetic Pyrethroids at thedose of 1, 2, 0.5 mg/sq meter respectively. Entomological assessment for vector behaviorand development of insecticidal resistance Active and passive surveillance is carried outonregular basis every fortnight Presumptive Treatment to all fever cases andradical treatment to all slide positive cases isgiven
Regular spray is not carried out but ‘focal’spray is carried out around falciparum casesdetected during surveillance Regular passive surveillance once in a fortnight Treatment –All positive cases to receive radicaltreatment Follow up- All positive cases to be followed upfor 1 year at monthly intervals aftercompletion of radical treatment Epidemiological investigation of all malariapositive cases .This may also include mass bloodsurvey.
Investigation of all Malaria Deaths-All cases suspected to have died due to malaria are tobe investigated Monitoring and control of allepidemics and focal out breaks ofmalaria –Any increase in the number of fever cases suggestiveof malaria should be promptly investigated andmeasures to contain the outbreak should beinstituted.
Definition:Anti-larval operations causing the reduction orpermanent elimination of mosquito breeding places orsites are defined as source reduction methods. Sourcereduction primarily aims to prevent development ofaquatic stages of mosquito larvae reducing breedingsource. These methods are environment friendly,economical in the long run with minimum maintenance andsurveillance.Guidelines on Source Reduction
Source reduction methods are furtherclassified into1. Elimination or reduction of breeding sites primarilyinvolving engineering methods.2. Environmental manipulation.
Advisory for Control -Vectors ofmalaria, dengue and chikungunya1. Source Reduction.Elimination of breeding sites by removing potential breeding places like waterbottles, solid waste, coconut shells, tyres, etc.Weekly cleaning/Drying of watercontainers, Room coolers. Extensive IEC activities for social mobilization of thecommunity on preventive measures and destroying breeding habitats.Minor Engineering measures like proper placing of lids of overheadtanks, underground tanks, repairing of leakage from pipeline and preventions ofover flowing tanks, channelizing of water collections in roof and cleaning ofgutters/water outle ts.Overall general sanitation in and around domestic environment.2. Anti larval Measures:Application of weekly anti- larval (Temephos, Bti. etc.) in water collections in andaround domestic environments.Release of larvivorous fish in permanent water bodies, ornamental tanks etc.3. Adult Control Measures:Indoor Space spray with DDT.Outdoor fogging with malathion
GUIDELINES FOR ITBNS AND LLINSPreface:Malaria transmitted by the bite of mosquitoes and the protozoacompletes life cycle. Pregnant women, babies and young childrenare at the greatest risk of dying of malaria. Sleeping under a bednet reduces the risk of man-vector contact as mosquitoes bite atnight and is thus an effective preventive measure. But ordinarymosquito nets provide limited physical barrier between mosquitoand man and protection as they may still bite through the net orget inside the net following improper use. The Insecticide TreatedBed nets (ITBNs) or Long Lasting Impregnated Bed nets (LLINs)provide better and effective protection by keeping awaymosquitoes as well as killing them. ITNs and LLINs also kills orkeeps away other nuisance insects . cockroaches, bedbugs,houseflies, fleas, etc.
INSECTICIDE TREATED BED NETS(ITBNS)Insecticide treatment is recommended for synthetic nets(nylon, polyester), as treatment of cotton nets is not cost-effective and effect of insecticide is not long lasting.Insecticides used for mosquito nets are not harmful topeople, if used correctly. Direct skin contact with theinsecticide on a still wet net may cause a tingling sensationon the skin. This is not harmful, even for small children.After treatment, the net may smell of insecticide. This willgo away in a few days and is not harmful to people who sleepunder the net.
LONG LASTING INSECTICIDAL NETS(LLINS)LLINs are mosquito nets which have the insecticide incorporated intheir fibre, so that it is not removed by as many as 20 washes.Because these nets have an even and quality controlled insecticideapplication, they are generally more effective than conventionalITNs. Furthermore the LLIN is more cost-effective (as it can be usedfor 3-5 years) than distribution of conventional bed nets andtreating them with insecticide once or twice a year. ConventionalITNs are therefore only a rational option in areas, where thepopulation already has so many nets that at least 50% of peoplesleep under one.
For a given village the number of LLINs to be provided isusually equal to the number of households multiplied by 2 orthe total population divided by 2.5. However, some villagesmay have many large households, which will need additionalnets. It is therefore prudent to add 20%, i.e. plan:►Number of LLINs = Number of households x 2.4.This will normally ensure a sufficient quantity for thefollowing schedule:1-2 persons: 1 LLIN3-5 persons: 2 LLINs6-7 persons: 3 LLINs8-10 persons: 4 LLINsDISTRIBUTION OF LLINS
Generally, for a targeted village, the required number of LLINs should bedistributed in one single operation.However, if LLINs are not in sufficient supply, it can be considered todistribute one per household per year over a period of two years, i.e. withtwo rounds of distribution separated by 12 months.Timing of LLIN distribution is less critical than the timing of IRS or re-treatment of nets. However, for educational as well as logistical reasons,distribution shortly before the start of the rainy season may be optimal.In addition to distribution to targeted high-risk villages aiming at completepopulation coverage, LLINs should be given to pregnant women in high riskareas and to special groups such as children in tribal schools and hostels.These children should take the nets home with them during vacations.
It is essential that residual insecticidal spray should be planned andimplemented with sound technical skill under expert guidance.It should not be entrusted to non-technical personnel like contractors,voluntary bodies etc.In the revised approach to malaria control, it has been decided to sprayhumandwellings and mixed dwellings.Cattle sheds are not to be sprayed with a view to conserve insecticide,improve coverage of human dwellings and the present diversion ofmosquitoes from sprayed cattle sheds to human dwellings.Insecticide spray operations:
Planning for spray operations:Spray operations are to be carried out in all area withAPI 2 or above. However, the priority of spray will begiven to High Risk areas all over the country.S.No. Name of highrisk PHCPopulationof PHCNo. of highrisk sub-centres inPHCHigh riskpopulationfor sprayRemarksPHC and sub-centres of “High risk” areas for spray operations
S.No. Nameof thePHCPopulationof PHCNumber ofsub-centreshaving API2 & abovePopulation ofsub-centreshaving API 2& abovequalified forsprayRemarksIn sub-centres with API 2 above (excluding the high risksub-centres) population of qualifying sub-centres only to beconsidered for spray in a PHC is segregated in the followingformat :While planning for spray, the epidemiological data ofpreceding three years are considered for selecting thepopulation to be protected.
The spray lance should be kept 45 cms (18 inches) away fromthe wall surface.The swath should be parallel.Spray is applied in vertical swath of 53 cm (21 inches) wide.Successive swaths should overlap by 7.5 cm (3 inches).Spray is done from roof to floor, using downward motion, tocomplete one swath; then stepping sideways and sprayingupwards from floor to roof.Do not let the spray drip to the floor.Spraying is done on inner surfaces including eaves and roofs.Important points to be remembered duringIRS
The discharge rate should be 740 to 850 ml per minute.To obtain the above discharge rate, the pump man shouldgive 20 to 26 strokes per minute with 10-15 cms plungermovement at a pressure of 10 PSI (0.7 kg/sq.cm) at thenozzle tip.Spraying into a bucket for one minute and measuring thequantity of the suspension in a graduated mug should checkthe correct discharge rate (740 to 850ml/minute).The nozzle tip should be discarded if the discharge rateexceeds 850 ml per minute.Important points to be remembered duringIRS
If the spray stops due to a blockage in the nozzle, the nozzlecap be unscrewed to remove the blockage and replaced with anew one.The blocked nozzle should be put in a container with waterfor a few hours before the blockage is removedA good quality spray should lead to uniform deposit on wallsand other sprayable surfaces. This is easy to verify for DDTon sprays as the insecticide deposits are clearly visible.The supervisor through physical verification should verify thequality and coverage of spray randomly.It takes about 5 minutes to spray a house with an averagesurface area of 150 sq. metres.Important points to be remembered duringIRS
Concurrent supervisionThe following should be checked during such inspections:•Date of advance notification and the maintenance of time table for sprayoperations•Turn out of spray crew•Nozzle tip discharge rate•Conditions of spray pumps•Preparation of insecticide suspension•Actual spraying operation including the technique, speed and coverage etc.•Extent of refusal to accept spray and the numbers and percentage oflocked houses•Maintenance of spray records•Consumption of insecticide as determined by the quantity issued and stockin hand•Date and time of checking of the squad by Inspectors/ Supervisors andother supervisory personnel and their remarks, if any•Arrangements for mopping up•Future programme and time schedule
Consecutive supervisionThe following is to be checked in consecutive supervision•Evidence of insecticide deposit on sprayable surfaceparticularly on the ceiling and wooden material like windowsetc.•Dispersal of the insecticide deposits on the walls to verifyuniformity of deposits•Number of rooms in each house sprayed satisfactorily,partially and not at all•Percentage of refusals and locked houses•Factors responsible for not spraying any area as elicitedthrough enquiries from the residents•Attempts made for mopping up operation in the event ofhigh refusal•Extent of mud plastering on the walls, if any and otherrelevant matters.