Malaria advocacy

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Salient Features of Malaria

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Malaria advocacy

  1. 1. ADVOCACY ON MALARIA General Purpose and inclusive of all important subject areas BY DR. G. C. SAHU REGIONAL DIRECTOR (I/C) R O H & F W (G o I) AHMEDABAD Dr. G. C. Sahu/ ROH&FW/ 10/2/2010 A'bad/gcsahu61@gmail.com 1
  2. 2. IN THIS PRESENTATION……….. CAUSE OF MALARIA CAUSE OF MALARIA SIGNS AND SYMPTOMS SIGNS AND SYMPTOMS HUMAN MAL.PARASITES-TYPES HUMAN MAL.PARASITES-TYPES EPIDEMIOLOGICAL ASPECTS. EPIDEMIOLOGICAL ASPECTS. LIFE CYCLE IN MAN & THE VECTOR LIFE CYCLE IN MAN & THE VECTOR SOME HIGHLIGHTS OF ANTI MALARIAL DRUGS. SOME HIGHLIGHTS OF ANTI MALARIAL DRUGS. PARASITES AND VECTORS-DIFFICULT AREAS PARASITES AND VECTORS-DIFFICULT AREAS A PICTORIAL SOJOURN THROUGH MALARIA A PICTORIAL SOJOURN THROUGH MALARIA PARASITES,VECTOR MOSQUITOS, DRUG PARASITES,VECTOR MOSQUITOS, DRUG RESISTANCE ETC. RESISTANCE ETC. CONTROL ASPECTS. CONTROL ASPECTS. VACCINS, OTHER NEW DEVELOPMENTS ETC. VACCINS, OTHER NEW DEVELOPMENTS ETC. Dr. G. C. Sahu/ ROH&FW/ 10/2/2010 A'bad/gcsahu61@gmail.com 2
  3. 3. MALARIA!! AN ENVIRONMENTAL ISSUE ?? IN A WAY YES !! …. ALL DISEASES ARE CAUSED BY CONTINUOUS INTERACTION BETWEEN A PERSON AND THE ENVIRONMENT [Macro + Micro] THIS IS MORE RELAVENT IN MALARIA WHERE THREE LIVING SYSTEMS “MAN, MALARIA PARASITE AND MOSQUITO VECTOR” HAVING INTIMATE RELATIONSHIP WITH THE ENVIRONMENT INTIMATELY INTERACT WITH EACH OTHER. THEREFORE THE PREVALENCE, PERIODICITY AND INTENSITY OF MALARIA IN THE COMMUNITY DEPENDS ON HOW THE ENVIRONMENTAL FACTORS INFLUENCES THE PARASITE,THE MOSQUITO VECTOR AND THE MAN . Dr. G. C. Sahu/ ROH&FW/ 10/2/2010 A'bad/gcsahu61@gmail.com 3
  4. 4. Estimated global annual cost(in 1995) for malaria: US $ 2 billion which includes direct indirect and loss of labour. Estimated worldwide expenditure on malaria research is only US $ 58 which is one thousandth of the US $ 56 billion spent globally on health research annualy. annualy. Estimated annual cost on prevention and treatment US $ 84 million only. Malaria kills in one year what AIDS killed in 15 years. In 15 years, if 5 million have died of AIDS 50 million have died of malaria. That is to say, one HIV/AIDS death is equal to about 50 malaria deaths. Dr. G. C. Sahu/ ROH&FW/ 10/2/2010 A'bad/gcsahu61@gmail.com 4
  5. 5. Malaria accounts for 2.6 percent of the total disease burden of the world. And currently being reported from 100 countries around the world. It is responsible for the loss of more than 35 million Disability-Adjusted- Life-years(DALY) each year. Basing on the current trend, WHO forecasts a 16 % growth in malaria cases annually. ! ! ! Dr. G. C. Sahu/ ROH&FW/ 10/2/2010 A'bad/gcsahu61@gmail.com 5
  6. 6. Dr. G. C. Sahu/ ROH&FW/ 10/2/2010 A'bad/gcsahu61@gmail.com 6
  7. 7. ♥WHAT IS MALARIA? THE CAUSES: MALARIA IS CAUSED BY THE TINY PARASITE WHICH DWELLS INSIDE THE RBC OF A PERSON THERE EACH PARASITE DEVELOPS AND PRODUCES 12 TO 24 DAUGHTER PARASITES . ON EVERY ALTERNATE DAY, NEW BROODS OF PARASITES INVADE FRESH RBCs AFTER DESTROYING THE OLD ONES ……. Dr. G. C. Sahu/ ROH&FW/ 10/2/2010 A'bad/gcsahu61@gmail.com 7
  8. 8. Ψ SIGNS AND SYMPOTMS PATIENTS GET CHILL OR SHIVERING FOR ½ TO 2 HOURS FOLLOWED BY HIGH FEVER FOR 8 TO 12 HOURS . THE FEVER MAY BE ON ALTERNATE DAYS OR SOMETIMES DAILY . PATIENTS COMPLAINS OF HEAD ACHE, BODY ACHE, VOMITING FEVER GOES DOWN WITH PROFUSE SWEATING UNTREATED CASES MAY HAVE SPLEEN ENLARGEMENT, ANAEMIA, AND WEAKNESS . IF MALARIA PARASITE AFFECTS BRAIN, IT CAUSES CEREBRAL MALARIA WHICH MAY LEAD TO UNCONSCIOUSNESS FOLLOWED BY DEATH, ESPECIALLY IN CHILDREN AND PREGNANT WOMEN . IN CHILDREN AND PREGNANT WOMEN . Dr. G. C. Sahu/ ROH&FW/ 10/2/2010 A'bad/gcsahu61@gmail.com 8
  9. 9. Dr. G. C. Sahu/ ROH&FW/ 10/2/2010 A'bad/gcsahu61@gmail.com 9
  10. 10. MALARIA PARASITES IN INDIA, IN ORDER OF PREVALENCE THE FOLLOWING S ARE FOUND . PLASMODIUM VIVAX . PLASMODIUM FALCIPARUM . PLASMODIUM MALARIAE . AND…. ⌦ AROUND 60% OF TOTAL INFECTION REPORTED IN INDIA ARE CAUSED BY P. VIVAX AND AROUND 40 % ARE DUE TO P. FALCIPARUM. P. MALARIAE IS NOT A PUBLIC HEALTH PROBLEM IN INDIA. P. FALCIPARUM IS RESPONSIBLE FOR THE DREADED AND FATAL CEREBRAL MALARIA . Dr. G. C. Sahu/ ROH&FW/ 10/2/2010 A'bad/gcsahu61@gmail.com 10
  11. 11. Geographical Distributions P.vivax Widespread in tropical and subtropical areas Widespread in tropical and subtropical areas range extends into temperate areas range extends into temperate areas relatively uncommon in Africa relatively uncommon in Africa P.falciparum Widespread, but primarily in tropics and subtropics Widespread, but primarily in tropics and subtropics P.Malaria Broad, but spotty geographical distribution Broad, but spotty geographical distribution P.ovale Primarily tropical Africa, especially western Primarily tropical Africa, especially western coast coast Dr. G. C. Sahu/ ROH&FW/ 10/2/2010 A'bad/gcsahu61@gmail.com 11
  12. 12. F E V E M R A L P A A R T I T A E R N Dr. G. C. Sahu/ ROH&FW/ 10/2/2010 A'bad/gcsahu61@gmail.com 12
  13. 13. THE GENUS PLASMODIUM—THE MALARIA PARASITE φ THE GENUS OF PARASITE: PROTOZOA φ THE PHYLLUM: AN APICAL COMPLEX [AN INTRACELLULAR PRESENCE OF APICOMPLEXA: DISTINGUISHED BY THE APPARATUS, USED IN THE INVASION OF THE HOST CELL] SOME OF THE IMPORTANT CHARECTERSTICS ARE AS FOLLOWS: φ IN THE LIFE CYCLE, ONE SEXUAL PHASE IS FOLLOWED BY THREE PHASES OF ASEXUAL MULTIPLICATION. φ THE ONLY SEXUAL PHASE AND FIRST ASEXUAL PHASE OCCUR IN THE ANOPHELES MOSQUITO. φ THE SECOND AND THIRD ASEXUAL PHASE OCCUR IN A VERTEBRATE SPECIES. THE SECOND IN THE LIVER, THE THIRD IN THE BLOOD (RBC). Dr. G. C. Sahu/ ROH&FW/ 10/2/2010 A'bad/gcsahu61@gmail.com 13
  14. 14. ♣NATURALLYPHASE, IF ALLOWEDMANY THE THIRD MAY BE REPEATED TIMES. ♣ERYTHROCYTESARETHE VERTEBRATE GAMETOCYTES OF PRODUCED IN THE HOST AND MATURE INTO MALE AND FEMALE SEX CELLS (GAMETS) IN THE STOMACH OF A VECTOR MOSQUITO WHICH HAS FED ON THE HOST. ♣MALARIA THE PROCESS A SPECIFIC THE DURING PIGMENT IS PRODUCED IN SOME STAGES OF THE PARASITE. THIS PIGMENT (HAEMOZOINE) IS PRODUCED DURING THE DIGESTION OF HAEMOGLOBIN BY THE PARASITE Dr. G. C. Sahu/ ROH&FW/ 10/2/2010 A'bad/gcsahu61@gmail.com 14
  15. 15. LIFE CYCLE OF MALARIA PARASITE AS IT PROCEEDS IN HUMAN & VECTOR MOSQUITO Life Cycle Of Pf LIFE CYCLE OF MAL.PARASITE—PF. MAL.PARASITE— Dr.G.C.Sahu/ROH&FW/GoI/A'bad 28 LIFE CYCLE OF MAL.PARASITE—P.VIVAX MAL.PARASITE— Dr. G. C. Sahu/ ROH&FW/ 10/2/2010 A'bad/gcsahu61@gmail.com 15
  16. 16. ¥ LIFE CYCLE OF MALARIA PARASITE THE LIFE CYCLE REQUIRES TWO PHASES NAMELY ‘ASEXUAL AND SEXUAL' AND ……… TWO HOSTS FOR ITS COMPLETION NAMELY ‘FEMALE ANOPHELINE MOSQUITOS AND HUMAN BEINGS’ Dr. G. C. Sahu/ ROH&FW/ 10/2/2010 A'bad/gcsahu61@gmail.com 16
  17. 17. SEXUAL CYCLE OCCURES IN AN. MOSQUITO AND ASEXUAL CYCLE OCCURES IN HUMAN BEINGS ☯ IN NATURE MAN GETS MALARIA“AFTER RECEIVING THE WITH INFECTIVE STAGES OF PARASITE “SPOROZOITE” ALONG SPOROZOITE” THE SALIVA INJECTED BY AN INFECTIVE FEMALE ANOPHELINE MOSQUITO ☯ SPOROZOITE INVADE LIVER ,, GROWS UPTO SCHIZONTS GROWS UPTO SCHIZONTS RELEASUNG MEROZOITES WHICH ATTACKS RBC AT REPEATATEDLY REGULAR INTERVALS , CAUSING ALL THE SIGNS AND SYMPTOMS, AND EVENTUALLY GIVING RISE TO GAMETOCYTES STAGES WHICH ARE PICKED UP BY VECTOR MOSQUITOS FOR TRANSFER TO NEXT PERSON ☯ THUS GAMETOCYTES ARE RESPONSIBLE FOR SPREAD OF MALARIA . CONTD……. CONTD……. Dr. G. C. Sahu/ ROH&FW/ 10/2/2010 A'bad/gcsahu61@gmail.com 17
  18. 18. THE FEMALE ANOPHELINE MOSQUITO IS DRIVEN BY AN URGE TO OBTAIN A BLOOD MEAL FOR MATURATION OF HER EGGS, WHICH THE VECTOR MOSQUITO OBTAINS BY BITING A WARM BLOODED ANIMAL .IN CASE IT BITES AN INFECTED PERSON HAVING GAMETOCYTES, THEY ENTER THE STOMACH OF THE MOSQUITO AND DEVELOP FURTHER TO START THE SEXUAL CYCLE . IN MOSQUITO BODY BOTH MALE AND FEMALE GAMETOCYTES AFTER GOING THROUGH A SEXUAL AND AN ASEXUAL PHASE GIVE RISE TO “SPOROZOITES” THAT FIND THEIR WAY TO MOSQUITO SALIVARY GLANDS TO RENDER IT INFECTIVE.IN HER NEXT BITE VECTOR MOSQUITO TRANSFERS THE SPOROZOITES THE HEALTHY PERSON TO CONTINUE THE CYCLE . ☺ BUT THE MOSQUITOES NEVER SUFFER FROM MALARIA ! ! ! Dr. G. C. Sahu/ ROH&FW/ 10/2/2010 A'bad/gcsahu61@gmail.com 18
  19. 19. Human dynamics Age Pregnancy Immunity Haemoglobinopathies Asymptomatic malaria case load. Type of housing Cultural factors like clothing Sleeping habits Occupation Migration Dr. G. C. Sahu/ ROH&FW/ 10/2/2010 A'bad/gcsahu61@gmail.com 19
  20. 20. Disease transmission dynamics • Human • Parasites • Vector • Environment Dr. G. C. Sahu/ ROH&FW/ 10/2/2010 A'bad/gcsahu61@gmail.com 20
  21. 21. Parasite dynamics Predominant P. vivax: > 60% Rapidly increasing P. falciparum: < 40% Dr. G. C. Sahu/ ROH&FW/ 10/2/2010 A'bad/gcsahu61@gmail.com 21
  22. 22. Factors related to Gametocytes Density and viability in the circulation: Higher in primary attack Appear simultaneously with other stages in P. vivax [viable for 2- 4 days] 2- P. falciparum appear 7- 8 days later or 7- more [viable for a longer period] Higher density in P. falciparum as compared to P. vivax at the same level of asexual parasitemia. Dr. G. C. Sahu/ ROH&FW/ 10/2/2010 A'bad/gcsahu61@gmail.com 22
  23. 23. Vector dynamics Greater the frequency of man vector contact higher will be the transmission potential of the area. This contact is influenced by Vector density Flight range Feeding habit (Frequency of blood meal) Biting habit (Anthropophilic/ Zoophilic) (Anthropophilic/ Zoophilic) Resting habit (Indoor-outdoor) (Indoor-outdoor) Biting time Dr. G. C. Sahu/ ROH&FW/ 10/2/2010 A'bad/gcsahu61@gmail.com 23
  24. 24. TEMPERATURE TEMPERATURE AFFECTS THE TRANSMISSION OF MALARIA TEMPERATURE AFFECTS THE TRANSMISSION OF MALARIA PRINCIPALLY ON ITS IMPACT ON SPOROGONY CYCLE OF MP PRINCIPALLY ON ITS IMPACT ON SPOROGONY CYCLE OF MP IN VECTOR MOSQUITO. IN VECTOR MOSQUITO. THE IDEAL TEMPERATURE RANGE IS 20 DEGREE CENT TO THE IDEAL TEMPERATURE RANGE IS 20 DEGREE CENT TO 33 DEGREE CENT.BETWEEN THE LIMITS THE SPEED OF 33 DEGREE CENT.BETWEEN THE LIMITS THE SPEED OF SPOROGONY IS THE FUNCTION OF TEMPERATURE i.e THE SPOROGONY IS THE FUNCTION OF TEMPERATURE i.e THE HIGHERTHE TEMPERATURE FASTER THE DEVELOPMENT OF HIGHERTHE TEMPERATURE FASTER THE DEVELOPMENT OF SPOROZOITES. SPOROZOITES. TEMPERATURE BELOW 20 DEGREE C INDEFINITELY DELAY TEMPERATURE BELOW 20 DEGREE C INDEFINITELY DELAY THE COMLETION OF SPOROGONY CYCLE AND ABOVE 33 THE COMLETION OF SPOROGONY CYCLE AND ABOVE 33 DEGREE C IS LETHAL TO MOSQUITO. DEGREE C IS LETHAL TO MOSQUITO. TEMPERATURE HAS ALSO A BEARING ON THE LARVAL TEMPERATURE HAS ALSO A BEARING ON THE LARVAL DEVELOPMENT IN WATER.THE OPTIMAL DEVELOPMENTAL DEVELOPMENT IN WATER.THE OPTIMAL DEVELOPMENTAL WATER TEMPERATURE FOR AQUATIC STAGE IS ABOUT 31 WATER TEMPERATURE FOR AQUATIC STAGE IS ABOUT 31 DEGREE CENTIGRADE. DEGREE CENTIGRADE. Dr. G. C. Sahu/ ROH&FW/ 10/2/2010 A'bad/gcsahu61@gmail.com 24
  25. 25. RELATIVE HUMIDITY. IT IS THE DRYING POWER OF THE ATMOSPHERE WHICH IS IMPORTANT WHICH IS EXPRESSED AS THE NUMBER OF GRAMMES OF WATER ADDED TO CUBIC METERS OF AIR,TEMPERATUREREMAINING NORMAL. THE RELATIVE HUMIDITY REQURED FOR TRANSMISSION IS AROUND 60 to 65. RELATIVE HUMIDITY INFLUENCES THE BITING HABIT OF THE MOSQUITO AND AT RELATIVE HUMIDITY LESS THAN 50 BITING DOES NOT OCCUR. Dr. G. C. Sahu/ ROH&FW/ 10/2/2010 A'bad/gcsahu61@gmail.com 25
  26. 26. RAINFALL. RAINFALL AFFECTS LARVAE AND THEIR BREEDING PLACES. TORRENTIAL RAINS MAY FLUSH OUT EXISTING BREEDING SITES RENDERING A POSITIVE IMPACTAND SLOW RAIN MAY ADD TO THE BREEDING SITES. IT ALSO INFLUENCES THE RELATIVE HUMIDITY. DEGREE OF WETNESS i.e THE NUMBER OF RAINY DAYS IS MORE IMPORTANT THAN THE AMOUNT OF RAINS. Dr. G. C. Sahu/ ROH&FW/ 10/2/2010 A'bad/gcsahu61@gmail.com 26
  27. 27. Classical Epidemiological Triad of Malaria Environment Agent Host Dr. G. C. Sahu/ ROH&FW/ 10/2/2010 A'bad/gcsahu61@gmail.com 27
  28. 28. Classical Epidemiological Triad of Malaria-Variables Environment* (biophysical, psycho-social, etc.) Agent Host (diverse exposures, (animal, plant, including non- ultimately human) contagious ) *CLIMATE is an Environmental Influence Dr. G. C. Sahu/ ROH&FW/ 10/2/2010 A'bad/gcsahu61@gmail.com 28
  29. 29. Classical Epidemiological Triad of Malaria-Interplay of factors Environment Agent Host Dr. G. C. Sahu/ ROH&FW/ 10/2/2010 A'bad/gcsahu61@gmail.com 29
  30. 30. Complex interplay of factors…… Examples of other Infectious Diseases (malaria included) Environment longevity & infectivity nutrition outside host hygiene host distribution, treatment abundance, infection housing e.g. cholera e.g. TB, HIV/AIDS, hantaviral disease diarrheal diseases, hookworm acute respiratory schistosomiasis infections Agent Host tissue tropisms, e.g. rabies, pathogenicity, Lyme disease, malaria, immune response, cryptosporidiosi. host specificity Dr. G. C. Sahu/ ROH&FW/ 10/2/2010 A'bad/gcsahu61@gmail.com 30
  31. 31. Complex interactions of each factor with rest occur all the time... Environment Altered hygiene Improved irrigation Redesigned housing Better nutrition Agent Host Dr. G. C. Sahu/ ROH&FW/ 10/2/2010 A'bad/gcsahu61@gmail.com 31
  32. 32. Complex interactions of each factor with rest occur all the time... Environment Agent transport to new areas New antibiotics, pesticides Labor actions affecting toxin exposure Agent Host Dr. G. C. Sahu/ ROH&FW/ 10/2/2010 A'bad/gcsahu61@gmail.com 32
  33. 33. Complex interactions of each factor with rest occur all the time... Environment Agent Host Exposure probability, host immunity, support networks, availability of supportive care Dr. G. C. Sahu/ ROH&FW/ 10/2/2010 A'bad/gcsahu61@gmail.com 33
  34. 34. Environmental Determinants of Malaria Social and Economic Policies Institutions (including medical care) Living Conditions Social Relationships Individual Risk Factors Genetic/Constitutional Factors ent Pathophysiologic pathways m on nvir Individual/Population c a lE ysi Health Ph Dr. G. C. Sahu/ ROH&FW/ Modified from Kaplan, 2002 10/2/2010 A'bad/gcsahu61@gmail.com 34
  35. 35. Research Challenge – Analyze and understand interactions! Social and Economic Policies Institutions (including medical care) Living Conditions Social Relationships Individual Risk Factors Genetic/Constitutional Factors Pathophysiologic pathways Individual/Population a te? Health C lim Dr. G. C. Sahu/ ROH&FW/ 10/2/2010 A'bad/gcsahu61@gmail.com 35
  36. 36. Malaria Paradigms Irrigation malaria Tribal-forest malaria Urban malaria Industrial/ Project malaria Epidemic prone areas Border malaria Desert Malaria Dr. G. C. Sahu/ ROH&FW/ 10/2/2010 A'bad/gcsahu61@gmail.com 36
  37. 37. Dr. G. C. Sahu/ ROH&FW/ 10/2/2010 A'bad/gcsahu61@gmail.com 37
  38. 38. Aims Of Treatment of a malaria case. Aims Causation Therapy Drugs To Symptoms are caused by Blood schizonticidal Chloroquine, quinine, alleviate blood forms of the parasite drugs pyrimethamine/sulphadoxin symptoms , artemisinin To Relapses are due to Tissue schizonticidal Primaquine prevent hypnozoites of P. vivax/ P. drugs relapses ovale To Spread is through the Gametocytocidal drugs Primaquine prevent gametocytes spread Thus, in effect, a blood schizonticidal drug and primaquine should be Thus, in effect, a blood schizonticidal drug and primaquine should be administered to ALL types of malaria. administered to ALL types of malaria. Dr. G. C. Sahu/ ROH&FW/ 10/2/2010 A'bad/gcsahu61@gmail.com 38
  39. 39. SITE OF ACTION SITE OF ACTION OF ANTI-MALARIALS OF ANTI- ANTI-MALARIALS UNDER USE. UNDER USE. Dr. G. C. Sahu/ ROH&FW/ 10/2/2010 A'bad/gcsahu61@gmail.com 39
  40. 40. DRUG RESISTANCE-HYPOTHESIS OF POSSIBLE WESTWARD SPREAD. Dr. G. C. Sahu/ ROH&FW/ 10/2/2010 A'bad/gcsahu61@gmail.com 40
  41. 41. DRUG RESISTANCE—R I , R I I AND R I I I. Dr. G. C. Sahu/ ROH&FW/ 10/2/2010 A'bad/gcsahu61@gmail.com 41
  42. 42. Treatment of P. vivax malaria: A flow chart Chloroquine + Primaquine After 48 hours Clinical Recovery Status quo / worse Continue the treatment Suspect P. falciparum, repeat M.P. test at 48 Repeat the M.P. test on hrs. (A thin smear examination is better for species the 6th day identification and for assessing parasite count) NEGATIVE POSITIVE POSITIVE NEGATIVE Cured Consider other causes P. Falciparum P. Vivax of fever, may Treat as possibly If the patient has be in typical malarial association chloroquine resistant complications, treat as with malaria P. falciparum; otherwise, wait. Dr. G. C. Sahu/ ROH&FW/ 10/2/2010 A'bad/gcsahu61@gmail.com 42
  43. 43. Treatment of P. falciparum malaria - A flow chart Complicated and Uncomplicated and chloroquine chloroquine sensitive sensitive Tab. Chloroquine + Primaquine Inj. Chloroquine + Inj. single dose Primaquine single dose Status quo/ worse; Better; parasite count reduced by parasite count reduced > 75% by < 75% Continue Consider resistance Dr. G. C. Sahu/ ROH&FW/ 10/2/2010 A'bad/gcsahu61@gmail.com 43
  44. 44. Drugs for chloroquine resistant malaria Complicated and Uncomplicated and Chloroquine Chloroquine resistant resistant 1. Inj.Quinine + Use any one of the following combinations: Pyrimethamine/Sulphadoxine Pyrimethamine/Sulphadoxine 1. Tab.Quinine + Tab. Pyrimethamine/ + Tab. Pyrimethamine/ 2. Inj. Quinine + Tetracycline Inj. Sulfa. // Doxycycline Doxycycline 2. Tab. Quinine + Tetracycline //doxycycline doxycycline 3. Inj. Artemether / Arteether Inj. 3. Tab. Artesunate + Tab. Mefloquine // Artesunate + Mefloquine. Artesunate + Mefloquine. 4.Tab.Mefloquine + Pyrimethamine/Sulpha. Pyrimethamine/Sulpha. Dr. G. C. Sahu/ ROH&FW/ 10/2/2010 A'bad/gcsahu61@gmail.com 44
  45. 45. Established antimalarial drugs Drug Role Best features(s) Best features(s) Limitation Chloroquine TX of and CP against non-Pf TX of and CP against non-Pf Very safe; low cost; Very safe; low cost; Widespread R Widespread R and sensitive Pf parasites and sensitive Pf parasites long half-life long half-life Quinine/quinidine Quinine/quinidine Best TX for Pf malaria; low Best TX for Pf malaria; low Limited R; rapidly Limited R; rapidly Fairly toxic ((cinchonism, Fairly toxic cinchonism, cost cost acting acting cardiac) cardiac) Amodiaquine TX of R Pf malaria TX of R Pf malaria Low cost Low cost Toxicity (bone marrow, Toxicity (bone marrow, liver); R Common liver); R Common Mefloquine CP against R malaria; not CP against R malaria; not Relatively little R, Relatively little R, Moderately toxic (mostly Moderately toxic (mostly approved for TX in United approved for TX in United though increasing; though increasing; CNS); high cost; R in SE CNS); high cost; R in SE State State long half-life long half-life Asia Asia Fansidar TX of Pf malaria; no longer TX of Pf malaria; no longer Relatively low cost; Relatively low cost; Skin toxicity (can be fatal); Skin toxicity (can be fatal); recommended for CP recommended for CP long half-life long half-life increasing R increasing R Primaquine Eradication of chronic liver Eradication of chronic liver Only drug for this Only drug for this Hemolysis with G6Pd Hemolysis with G6Pd stage Pv,Po malaria stage Pv,Po malaria indication indication deficiency; increasing R deficiency; increasing R Progunil CP only (often with CP only (often with Low cost; nontoxic Low cost; nontoxic R common R common Chloroquine) Chloroquine) S-P Combinations S-P Combinations CP only (often with CP only (often with Low cost Low cost R Common; skin rashes R Common; skin rashes Chloroquine) Chloroquine) Tetracycline Cp; TX of Pf malaria in Cp; TX of Pf malaria in Low cost Low cost Skin and gastrointestinal Skin and gastrointestinal Combination with quinine Combination with quinine Dr. G. C. Sahu/ ROH&FW/ 10/2/2010 A'bad/gcsahu61@gmail.com 45
  46. 46. New antimalarial drugs Drug Role Best Feature(s) Limitations Halofantriine TX of Pf malaria; not TX of Pf malaria; not Usually effective against R Usually effective against R Variable bioavailability, Variable bioavailability, approved for CP approved for CP Pf malaria Pf malaria cardiac toxicity cardiac toxicity Artemisinin and Artemisinin and TX of Pf malaria TX of Pf malaria Rapidly acting; effective Rapidly acting; effective Recurrence after TX fairly Recurrence after TX fairly related compounds related compounds against multidrug-R against multidrug-R common common Atovaquone ? TX of Pf malaria? ? TX of Pf malaria? Limited toxicity Limited toxicity Limited studies so far Limited studies so far CP (Probably in CP (Probably in show frequent recurrence show frequent recurrence combination with combination with after TX after TX proguanil proguanil Pyronaridine ? TX of malaria ? TX of malaria Effective against R strains Effective against R strains Studies limited to date Studies limited to date Desferrioxamine ? TX of severe Pf ? TX of severe Pf Well tolerated when used Well tolerated when used Studies limited to date Studies limited to date malaria malaria for iron overload for iron overload Azithromycin ? CP ? CP Limited toxicity Limited toxicity Studies limited to date Studies limited to date Dr. G. C. Sahu/ ROH&FW/ 10/2/2010 A'bad/gcsahu61@gmail.com 46
  47. 47. Compatibility of Anti-Malaria Drugs Pregnan Breast Scuba Epilepsy Psoriasis Altitude cy Feeding Diving OK OK NO NO OK OK Chloroquine OK OK OK OK OK OK Paludrine OK* OK OK OK OK OK Maloprim OK* NO NO OK NO NO Mefloquine NO NO OK OK OK OK Doxycycline NO NO OK OK OK OK Malarone * These drugs are not suitable during the first trimester of pregnancy. Dr. G. C. Sahu/ ROH&FW/ 10/2/2010 A'bad/gcsahu61@gmail.com 47
  48. 48. Sign or Symptom Percent with Finding · Fever & Chills 96 · Headache 79 · Muscle Pain 60 · Palpable Liver 33 · Palpable Spleen 28 · Nausea & Vomiting 23 · Abdominal Cramps/Diarrhea 6 Dr. G. C. Sahu/ ROH&FW/ 10/2/2010 A'bad/gcsahu61@gmail.com 48
  49. 49. Some Laboratory Findings……….. Percent with Finding Normal Range Abnormal Findings · Reticulocytosis 3 - 18% 42 · Thrombocytopenia 12K-150K 36 · Bilirubin Increased 1 - 1.8 33 · VDRL Positive (-) 28 (+) · Anemia 5.8 - 12 (Hgb) 28 · Leukopenia 3,000 - 4,700 26 · Alk. Phos. Increased 11-27 17 · SGOT Increased 40 - 108 10 Dr. G. C. Sahu/ ROH&FW/ 10/2/2010 A'bad/gcsahu61@gmail.com 49
  50. 50. G-6 P D Deficiency-Four most common variants out of 300+ known All World GdB Normal Activity Populations Normal Activity; Acetic acid substituted for Africa (most GdA asparagine at position 126, Guanine for common adenine at DNA position 376 variant) 8 - 20% Normal Activity; Methionine for Valine at position 67 and Aspartic Acid for Asparagine at GdA- position 126, Adenine for Guanine at position 202 Africa and Guanine for Adenine at position 376 < 5% Normal Activity; Phenylalanine for Iran, Iraq, India, GdMed Serine at position 188; Thymine for Cytosine Pakistan, at position 563 Greece, Sardinia Dr. G. C. Sahu/ ROH&FW/ 10/2/2010 A'bad/gcsahu61@gmail.com 50
  51. 51. Primaquine Treatment Regimens Adult-1 tablet* per day x 14 days G-6-PD NORMAL * The Indian programme recommends 14 days RT regime to all P.vivax cases. 3 tablets per week for 8 G-6-PD deficiency weeks (Mild African form) 2 tablets per week for 30 G-6-PD deficiency weeks (More severe Mediterranean variety) * Primaquine – Not an absolute contraindication in G-6-PD deficient persons * 1 tablet consists of 26.3 mg pimaquine phosphate, 15 mg primaquine base. Dr. G. C. Sahu/ ROH&FW/ 10/2/2010 A'bad/gcsahu61@gmail.com 51
  52. 52. Malaria in Pregnancy : Double Trouble Malaria is more common in pregnancy compared to the general More common population. Immuno suppression and loss of acquired immunity to malaria could be the causes. In pregnancy, malaria tends to be more atypical in presentation. This More atypical could be due to the hormonal, immunological and hematological changes of pregnancy. Due to the hormonal and immunological changes, the parasitemia tends to be 10 times higher and as a result, all the complications of falciparum More severe malaria are more common in pregnancy compared to the non-pregnant population. P. falciparum malaria in pregnancy being more severe, the mortality is More fatal also double (13 % ) compared to the non-pregnant population (6.5%). Some anti malarials are contra indicated in pregnancy and some may Selective treatment cause severe adverse effects. Therefore the treatment may become difficult, particularly in cases of severe P. falciparum malaria. Management of complications of malaria may be difficult due to the various physiological changes of pregnancy. Careful attention has to be Other problems paid towards fluid management, temperature control, etc. Also decisions regarding induction of labour may be difficult and complex. Foetal loss, IUGR, and premature labour are common. Dr. G. C. Sahu/ ROH&FW/ 10/2/2010 A'bad/gcsahu61@gmail.com 52
  53. 53. Potential Vaccines in Malaria. Target Protection sporozoite anti-infection merozoite anti-parasite infected RBC anti-parasite exoantigens anti-disease sexual stages anti-transmission Malaria is a preventable infection that can be fatal if left untreated. Malaria is a preventable infection that can be fatal if left untreated. Currently, you cannot be vaccinate against malaria, but you can protect yourself Currently, you cannot be vaccinate against malaria, but you can protect yourself Dr. G. C. Sahu/ ROH&FW/ 10/2/2010 A'bad/gcsahu61@gmail.com 53
  54. 54. MALARIA---BEYOND CLINICAL CURE SOME POINTS TO PONDER FOR PHYSICIANS Ø CLINICAL CURE WITH APPROPRIATE BLOOD SCHIZONTICIDALS Ø GAMETOCYTES,WHEN LATER SUCKED BY THE VECTOR MOSQUITOS,DEVELOP IN THEIR BODY INTO DISEASE CAUSING SPOROZOITES WHICH ARE TRANSMITTED AGAIN TO THE NEXT HEALTHY PERSON BY THE MOSQUITO BITE –THUS ANOTHER HUMAN BEING FALLS VICTIM TO THE DEADLY MALARIA . Ø THIS TRANSMISSION OF MALARIA CAN BE PREVENTED BY ADMINISTERING GAMETOCIDAL DRUGS LIKE PRIMAQUINE AFTER CONTROLLING THE ACUTE STAGES OF THE DISEASE . Ø THE PRACTICE OF USING GAMETOCIDAL DRUGS SHOULD BE CONSIDERED AS IMPORTANT AND SHOULD BECOME A PART OF STANDARD TREATEMENT STRATEGY WHENEVER A CASE OF P.FALCIPARUM IS ENCOUNTERED. ……contd Dr. G. C. Sahu/ ROH&FW/ 10/2/2010 A'bad/gcsahu61@gmail.com 54
  55. 55. Manifestations of the Malaria Burden Anemia Anemia Long-term Long- Long-term Hypoglycemia sequelae sequelae Hypoglycemia Acute Acute Severe illness Severe illness Respiratory Respiratory febrile febrile distress distress Death Death illness illness Hypovolemia Hypovolemia Infected Infected Cerebral malaria Cerebral malaria Mosquito Mosquito Anemia Anemia Chronic Chronic Impaired Impaired Infected Neurologic Neurologic Malnutrition Malnutrition Infected effects growth and growth and Human Human effects Cognitive Cognitive development development Developmental Developmental Low birth weight Low birth weight Fetus Infant and fetal Infant and fetal Fetus Abortion, stillbirth Abortion, stillbirth mortality mortality Pregnancy Pregnancy Acute illness Acute illness Maternal Maternal Long-term Long- Long-term Anemia Anemia sequelae sequelae Dr. G. C. Sahu/ ROH&FW/ 10/2/2010 A'bad/gcsahu61@gmail.com 55
  56. 56. Prognosis: Uncomplicated malaria due to P vivax, P malariae, and P ovale has an excellent prognosis. Most patients have a full recovery with no sequelae. Malaria due to P falciparum is dangerous. If not treated quickly and completely, complicated and severe malaria can result, which carries a grave prognosis. Malaria in children younger than 5 years carries the worst prognosis in endemic areas. In a nonimmune population, malaria is equally deadly at all ages. Cerebral malaria has a mortality rate of 25%, even with the best treatment. Survivors may have sequelae (e.g., hemi paresis, cerebellar ataxia, aphasia, spasticity). Repeated attacks of malaria can lead to chronic anemia, malnutrition, and stunted growth. Pregnancy: Malaria can be severe in pregnancy(Special Concerns). This is a major problem because many anti-malarial drugs are considered unsafe during pregnancy. Dr. G. C. Sahu/ ROH&FW/ 10/2/2010 A'bad/gcsahu61@gmail.com 56
  57. 57. Malaria the disease --I --I 9-14 day incubation period Fever, chills, headache, back and joint pain Gastrointestinal symptoms (nausea, vomiting, etc.) Dr. G. C. Sahu/ ROH&FW/ 10/2/2010 A'bad/gcsahu61@gmail.com 57
  58. 58. Malaria the disease -- II Symptoms intensify Irregular high fever Anxiety, delirium and other mental problems Sweating, increased pulse rate, severe exhaustion Worsening GI symptoms Enlarged spleen and liver Dr. G. C. Sahu/ ROH&FW/ 10/2/2010 A'bad/gcsahu61@gmail.com 58
  59. 59. Malaria the disease -- III Dr. G. C. Sahu/ ROH&FW/ 10/2/2010 A'bad/gcsahu61@gmail.com 59
  60. 60. Dr. G. C. Sahu/ ROH&FW/ 10/2/2010 A'bad/gcsahu61@gmail.com 60
  61. 61. MOSQUITO OF ANOPHELINE SPECIES Dr. G. C. Sahu/ ROH&FW/ 10/2/2010 A'bad/gcsahu61@gmail.com 61
  62. 62. ANOPHELINE MOSQUITO SUCKING BLOOD. Dr. G. C. Sahu/ ROH&FW/ 10/2/2010 A'bad/gcsahu61@gmail.com 62
  63. 63. ANOPHELINE-DORSAL VIEW. Dr. G. C. Sahu/ ROH&FW/ 10/2/2010 A'bad/gcsahu61@gmail.com 63
  64. 64. MOSQUITOS OF PUBLIC HEALTH IMPORTANCE AEDES-- DENGUE ANOPHELES-MALARIA ANOPHELES- CULEX--FILERIA …….AND THE TYPE OF EGGS THEY LAY. ANO. AED. CUL. Dr. G. C. Sahu/ ROH&FW/ 10/2/2010 A'bad/gcsahu61@gmail.com 64
  65. 65. The mosquito goes through four distinct stages during its life cycle: egg - hatches when exposed to water; larva - (plural. - larvae) lives in the water; molts several times; most species surface to breathe air; pupa - (plural - pupae) does not feed; stage just prior to emerging as adult; adult - flies short time after emerging and after its body parts have hardened. Dr. G. C. Sahu/ ROH&FW/ 10/2/2010 A'bad/gcsahu61@gmail.com 65
  66. 66. Examination of blood smear Demonstration of the parasite in a smear of the blood definitely establishes the presence Demonstration of the parasite in a smear of the blood definitely establishes the presence of malaria. of malaria. A negative finding on examination does not rule out malaria.. Only 50% of A negative finding on examination does not rule out malaria Only 50% of children with malaria are smear positive, even on repeated examination. children with malaria are smear positive, even on repeated examination. examination. A positive finding on examination does not confirm clinical malaria, especially A positive finding on examination does not confirm clinical malaria, especially in patients from an endemic area, in whom a symptomatic parasitemia often exists. in patients from an endemic area, in whom a symptomatic parasitemia often exists. parasitemia Both thick and thin films are essential.. If the parasitemia is light, a thin film Both thick and thin films are essential If the parasitemia is light, a thin film examination may miss the diagnosis. Thick films save time in diagnosis of scanty infections examination may miss the diagnosis. Thick films save time in diagnosis of scanty infections diagnosis but make species identification of the parasite difficult. but make species identification of the parasite difficult. At least 100-200 fields of a thick film should be scrutinized before a slide is At least 100-200 fields of a thick film should be scrutinized before a slide is reported as negative for malaria. In doubtful cases, the examination can be repeated reported as negative for malaria. In doubtful cases, the examination can be repeated after 4 hours. after 4 hours. Various techniques to enhance the diagnostic utility of the peripheral blood smear Various techniques to enhance the diagnostic utility of the peripheral blood smear peripheral examination are in use. Fluorescent staining and microscopy, centrifugation, selective centrifugation, selective examination are in use. Fluorescent staining and microscopy, centrifugation, magnetic separation techniques, and other techniques have been used but have only a magnetic separation techniques, and other techniques have been used but have only a used moderate effect. moderate effect. Dr. G. C. Sahu/ ROH&FW/ 10/2/2010 A'bad/gcsahu61@gmail.com 66
  67. 67. ….. AND P.VIVAX AS SEEN UNDER MICROSCOPE. Dr. G. C. Sahu/ ROH&FW/ 10/2/2010 A'bad/gcsahu61@gmail.com 67
  68. 68. P.FALCIPARUM UNDER MICROSCOPE. Dr. G. C. Sahu/ ROH&FW/ 10/2/2010 A'bad/gcsahu61@gmail.com 68
  69. 69. P.FALCIPARUM UNDER FLOUROCENT MICROSCOPY Dr. G. C. Sahu/ ROH&FW/ 10/2/2010 A'bad/gcsahu61@gmail.com 69
  70. 70. P.FALCIPARUM-GAMETOCYTES P.FALCIPARUM-GAMETOCYTES UNDER MICROSCOPE. Dr. G. C. Sahu/ ROH&FW/ 10/2/2010 A'bad/gcsahu61@gmail.com 70
  71. 71. TROPHOZOITE STAGE OF P.VIVAX. Dr. G. C. Sahu/ ROH&FW/ 10/2/2010 A'bad/gcsahu61@gmail.com 71
  72. 72. P.VIVAX- TROPHOZOITES,GAMETOCYTES. Dr. G. C. Sahu/ ROH&FW/ 10/2/2010 A'bad/gcsahu61@gmail.com 72
  73. 73. P.VIVAX-TROPHOZOITES P.VIVAX-TROPHOZOITES in Thin Smear Dr. G. C. Sahu/ ROH&FW/ 10/2/2010 A'bad/gcsahu61@gmail.com 73
  74. 74. P.VIVAX-GAMETOCYTE Dr. G. C. Sahu/ ROH&FW/ 10/2/2010 A'bad/gcsahu61@gmail.com 74
  75. 75. P.VIVAX-MATURE SCHIZONT P.VIVAX-MATURE in Thin Smear. Dr. G. C. Sahu/ ROH&FW/ 10/2/2010 A'bad/gcsahu61@gmail.com 75
  76. 76. P.VIVAX UNDER FLOURECENT MICROSCOPY.. Dr. G. C. Sahu/ ROH&FW/ 10/2/2010 A'bad/gcsahu61@gmail.com 76
  77. 77. PF GAMETOCYTES-UNDER FLOUROCENT GAMETOCYTES-UNDER MICROSCOPY Dr. G. C. Sahu/ ROH&FW/ 10/2/2010 A'bad/gcsahu61@gmail.com 77
  78. 78. PLASMODIUM SPOROZOITES OBTAINED FROM AN ANOPHELINE MOSQUITO. Dr. G. C. Sahu/ ROH&FW/ 10/2/2010 A'bad/gcsahu61@gmail.com 78
  79. 79. Clinical approach to cases of recurrent malaria Recurrence Within 8- After 2 After 2 10 days weeks months 1st ?P. ?Re-infection ?Re-infection possibility falciparum 2nd ?Compliance ?P. ?Relapse possibility falciparum Dr. G. C. Sahu/ ROH&FW/ 10/2/2010 A'bad/gcsahu61@gmail.com 79
  80. 80. OUTER WALL OF A FEM. AN.MOSQUITO GUT,- GUT,- INFESTED WITH OOCYSTS CONTAINING SPOROZOITES. Dr. G. C. Sahu/ ROH&FW/ 10/2/2010 A'bad/gcsahu61@gmail.com 80
  81. 81. THE INVASION--MEROZOITE STAGE OF THE INVASION--MEROZOITE MALARIA PARASITE ATTACKING AN RBC. Dr. G. C. Sahu/ ROH&FW/ 10/2/2010 A'bad/gcsahu61@gmail.com 81
  82. 82. Control of malaria is a complex chain of measures that often complement one another. The complement above diagram depicts this control chain: For example, by taking personal protective taking measures, three things can be achieved - prevention of malaria in the given individual, thus reduced parasite load and reduction in spread, and by denying blood meal to the mosquito blood the egg laying is also hampered! In the recent years, more emphasis is being laid on early hampered! diagnosis and treatment, on personal protection especially with insecticide treated bednets and on biological vector control. By these means, it is intended to minimise use of potentially harmful chemical insecticides. Dr. G. C. Sahu/ ROH&FW/ 10/2/2010 A'bad/gcsahu61@gmail.com 82
  83. 83. VECTOR CONTROL MEASURES AT A GLANCE Dr. G. C. Sahu/ ROH&FW/ 10/2/2010 A'bad/gcsahu61@gmail.com 83
  84. 84. Control of the Malaria Burden Current Interventions Drugs (treatment, prevention) Protection Insecticides (insecticide- (house impregnated spraying, materials) larvicides) Environmental and Behavioral Modification Vaccines Genetic (preerythrocytic, blood stage, modification transmission- Future Interventions of vectors blocking) Dr. G. C. Sahu/ ROH&FW/ 10/2/2010 A'bad/gcsahu61@gmail.com 84
  85. 85. The Acts of Commissions And Omissions IN MALARIA. 1. Mis-diagnosis 1. Mis-diagnosis In an endemic area, there may be a tendency to diagnose all cases of In an endemic area, there may be a tendency to diagnose all cases of fever as malaria, forgetting to even consider other causes. Whereas fever as malaria, forgetting to even consider other causes. Whereas Over-diagnosis presumptive treatment with chloroquine in cases of fever is well presumptive treatment with chloroquine in cases of fever is well Over-diagnosis accepted, sometimes, doctors may go beyond that and indulge in accepted, sometimes, doctors may go beyond that and indulge in Obsession with Obsession with presumptive treatment with newer drugs, (reserved for multi drug presumptive treatment with newer drugs, (reserved for multi drug malaria and malaria and resistance falciparum malaria), even if the MP test is repeatedly resistance falciparum malaria), even if the MP test is repeatedly forgetting the forgetting the negative. Most often such cases turn out to be non-malarial fevers. negative. Most often such cases turn out to be non-malarial fevers. OTHER causes of OTHER causes of Therefore consider other causes of fever. Therefore consider other causes of fever. fever fever 1. Malaria may not be considered as a possibility in places where iit 1. Malaria may not be considered as a possibility in places where t is not common-history of travel to malarious area should be is not common-history of travel to malarious area should be elicited. elicited. 2. It may not be considered in patients on chemoprophylaxis for 2. It may not be considered in patients on chemoprophylaxis for malaria. Chemoprophylaxis does not offer 100% protection and malaria. Chemoprophylaxis does not offer 100% protection and Under-diagnosis Under-diagnosis malaria should be therefore looked for in these patients. malaria should be therefore looked for in these patients. Forgetting malaria Forgetting malaria 3. Malaria can always co-exist with other infections in an endemic 3. Malaria can always co-exist with other infections in an endemic area. Therefore, it should be considered even in patients with other area. Therefore, it should be considered even in patients with other obvious infections causing fever. obvious infections causing fever. Dr. G. C. Sahu/ ROH&FW/ 10/2/2010 A'bad/gcsahu61@gmail.com 85
  86. 86. 2. Mis-report Mis-report Artifacts may be read as malarial parasites on peripheral smear as well as QBC test. Dirty False positive slides, contaminated stains, inexperienced microscopist, recycled QBC tubes may be the microscopist, causes. Malarial parasites may be missed and the test reported as negative. Inadequate smear, dirty stains, contaminated/deteriorated stains, wrong buffer pH, inexperienced technician, False negative incomplete examination of the slide, storage of blood in anticoagulant before preparing the smear etc. may contribute to this problem. Dr. G. C. Sahu/ ROH&FW/ 10/2/2010 A'bad/gcsahu61@gmail.com 86
  87. 87. 3. Mis-judgement of severity Mis-judgement Panic reaction to P. falciparum malaria is common among Panic reaction to P. falciparum malaria is common among patients and not uncommon among doctors, resulting in patients and not uncommon among doctors, resulting in over-reaction to the situation and over-treatment. Mild over-reaction to the situation and over-treatment. Mild anemia, mild icterus, headache etc. are common in anemia, mild icterus, headache etc. are common in falciparum malaria and need not necessarily imply severe falciparum malaria and need not necessarily imply severe Over-estimation Over-estimation malaria. Such patients need not be treated with parenteral malaria. Such patients need not be treated with parenteral or second line antimalarial drugs. Also it should not be or second line antimalarial drugs. Also it should not be forgotten that some of the manifestations could be due to forgotten that some of the manifestations could be due to fever, drugs etc., and not necessarily due to severe malaria. fever, drugs etc., and not necessarily due to severe malaria. P. falciparum malaria can cause dramatic complications P. falciparum malaria can cause dramatic complications and therefore one should be always looking for them. and therefore one should be always looking for them. Patients who are at for development of complications Patients who are at for development of complications Under-estimation Under-estimation should be ideally admitted for observation. Any indication should be ideally admitted for observation. Any indication of complication should be properly managed. Neglecting of complication should be properly managed. Neglecting the signs like high fever, prostration, significant pallor and the signs like high fever, prostration, significant pallor and jaundice, dehydration etc. may prove costly. Hypoglycemia jaundice, dehydration etc. may prove costly. Hypoglycemia may be easily missed. may be easily missed. Dr. G. C. Sahu/ ROH&FW/ 10/2/2010 A'bad/gcsahu61@gmail.com 87
  88. 88. MOSQUITO(MALARIA),YET TO BE CAGED---ALL CAGED---ALL THE GLOBAL EFFORTS GOING IN VAIN ??? !! Dr. G. C. Sahu/ ROH&FW/ 10/2/2010 A'bad/gcsahu61@gmail.com 88
  89. 89. MALARIA BURDEN—ERADICATION IMPOSSIBLE,CONTROL BURDEN—ERADICATION PROSPECTS NOT PROMISING IN NEAR FUTURE--A SIGN OF FUTURE--A INCREASING GLOBAL HELPLESSNESS. postal stamp of Cameroon. Dr. G. C. Sahu/ ROH&FW/ 10/2/2010 A'bad/gcsahu61@gmail.com 89
  90. 90. MALARIA CONTROL-SUCCESS STRATEGY CONTROL-SUCCESS DEPENDS ON COORDINATED,MULTI PRONGED,FOCUSSED AND RESULT ORIENTED GLOBAL EFFORTS. Dr. G. C. Sahu/ ROH&FW/ 10/2/2010 A'bad/gcsahu61@gmail.com 90
  91. 91. …..And Dr. G. C. Sahu/ ROH&FW/ 10/2/2010 A'bad/gcsahu61@gmail.com 91
  92. 92. Have a nice…..and nice…..and a…. malaria free a…. time folks !!! Dr. G. C. Sahu/ ROH&FW/ 10/2/2010 A'bad/gcsahu61@gmail.com 92

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