This presentation is prepared as part of the Course assignment of “Epidemiology of Diseases and Health Problems” for the Master's Degree of Public Health (MPH), Pokhara University and can be used as reference materials. The content and facts included in the presentation are as of information available till December 2022 and no conflict of interest is associated with the presentation. The presentation is prepared by Sagar Parajuli.

1. Epidemiological Perspective of Malaria & Review
of National programs and activities
Sagar Parajuli
MPH Second Semester 2022
School of Health & Allied Sciences
Pokhara University

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Presentation Outlines
• Introduction (Malaria & Dengue)
• Epidemiological Determinants (Agent, Host and Environment)
• Distribution (Global, Regional, National)
• Prevention, Control and Treatment Activities
• Response towards Malaria and Dengue (WHO & Government of Nepal);
National policies and programs review
Presentation followed by discussion

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Introduction to Malaria (ICD 11, 1F40-1F4Z)
• Etymologically, the term malaria derived as Italian word as mala-bad, aria- air
is a protozoan infection, dominantly in tropics and sub-tropics
• Acute febrile illness, caused by Plasmodium parasites spread by bite of an
infected female Anopheles mosquito
• Plasmodium 5 species- P. falciparum, P. ovale, P. vivax, P. malariae, P.
knowlesi-zoonotic malaria
• P. falciparum known as deadliest malaria parasite (malignant tertian) and P.
vivax as dominant malaria parasite poses the greatest threat of malaria
(benign tertian)

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Epidemiological Determinants
• Agent: Plasmodium parasites, 5 species
• Vector: Female Anopheles Mosquito ‘invertebrate definite host’
• Host Factors: Human as ‘intermediate host’ and ‘reservoir’ as well
1. Genetic Factors: Biological advantage for people having sickle cell trait,
thalassemia, G6PD deficiency to P. falciparum, people with duffy blood
type to P. vivax
2. Immunological Factors: Newborn of mother infected with malaria
developing acquired immunity for first few months of birth
3. Behavioral factors
Risk population: living in endemic and slum areas, pregnant women, traveler,
children

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Epidemiological Determinants
• Environmental Factors: vital for vector and parasite growth and
development, as well as for creating contact environment between agent, host
and vector
1. Climate-based factors: rainfall
2. Temperature- 16-34 Degree Celsius with optimal transmission at 25
3. Precipitation; frequency, duration and intensity
4. Waste water management, breeding places like damp and waterlogged
Peak season and months: May-July, September-December following end of dry and
wet season, dominant during rainy season due to waterlogged and damp places
suitable for mosquito breeding

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Transmission Dynamics
• Mode of transmission: ‘Bite, Blood, Birth’
Through bite of an infected female Anopheles mosquito (during dusk, early
night hours, early morning hours), Blood Transfusion & share of needles,
vertical transmission to lesser extent ‘congenital malaria’
• Incubation Period: 7-14 days for P. falciparum, 8-14 days for P. vivax and P.
ovale, 7-30 days for P. malariae
• Period of Communicability: as long as infective gametocytes present in
blood; not more than a year for P. falciparum, 1-2 years for P. vivax and P.
ovale, 7 months-3 years for P. malariae (EWARS Guideline)

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Natural History of Malaria

8. • Mosquito stage
(Sporogonic cycle)
• Human Liver stage
(Exo-erythrocytic
cycle)
• Human Blood stage
(Erythrocytic cycle)
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Plasmodium Life Cycle

9. • Intermittent Periodic fever; a
characteristic paroxysmal malarial
fever with ‘cold, hot, and wet’
phases, usually after 10-15 days
of mosquito bite
• Headache, Vomiting, Chills
• Anemia, Splenomegaly
• Dry (Nonproductive cough)
Symptoms repeat 48-72 hrs in a cyclic manner.
Based on symptoms and complications, malaria
categorized as uncomplicated and complicated
(severe) malaria.
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Clinical presentations

10. Diagnosis
• Microscopy ‘Gold Standard’;
Thick and Thin smear
• RDT
• Serological Test
Complications
• Anemia
• Cerebral Malaria
• Others; liver failure, jaundice,
ARDS, kidney failure, shock,
pulmonary oedema
• Complications during pregnancy
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Diagnosis & Complications

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Global Status- Malaria
• Globally, estimated 247 million cases in 2021 from 84 malaria endemic
countries, increased from 245 million cases in 2020
• Malaria case incidence globally- 59 cases per 1000 population at risk
• 29 countries accounted for 95% malaria cases globally; Nigeria (27%),
Democratic Republic of Congo (12%)
• South East Asia accounted for 2% burden of malaria globally, with 76%
case reduction and 82% reduction in case incidence, case incidence reported in
2021- 3 cases per 1000 population at risk
Source: Global Malaria Report, WHO 2020

12. Malaria Microstratification
2021, Annual Report-
DoHS 078/79
• 22 High Risk Wards
• 69 Moderate Risk
Wards
• Malaria risk shift to
upper hilly river valley
• 82% high risk burden
and 94% of moderate
risk burden
concentrated in Karnali
and Sudurpaschim
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National Status- Malaria
Source: DoHS Annual Report 077/78

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National Status- Malaria
Source: Malaria Surveillance Guideline 2019

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National Status- Malaria
Source: Malaria Surveillance Guideline 2019

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National Status- Malaria
0
200
400
600
800
1000
1200
2075/76 2076/77 2077/78
1069
619
377
440
102 66
625
517
311
Indigenous and Imported Malaria Cases
Total Positive cases Indigenous cases Imported cases
• 90 % reduction in
Indigenous Malaria Cases in
FY 077/78 compared to FY
71/72
• Annual Blood Examination
Rate (ABER) decreased to
1.32 %
• Annual parasite incidence
rate-0.03 per 1000 population,
slide positivity rate- 0.24%
• 86.47 % P. vivax cases
• 13.52 % P. falciparum cases
• High malaria cases reported in
Kailali, Kanchanpur, Banke,
Achham, Surket and Baitadi
Source: DoHS Annual Report 077/78

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Global Malaria Control Activities
•Era
• Period
• Major achievement
Era Period Major achievement
Eradication 1955-1969 Malaria control by Insecticide Spray
Resurgence 1969-mid 1980 Establishment of microscopic center
amnd treated by sign and symptoms
Control 1980 onwards Research activities, IRS, Medical
Recording
Roll back 1998 onwards Epidemic control, surveillance
strengthening, Elimination strategy

17. 1950
• 2 Million cases (40% of total population) and 10-15 % Deaths
1954
• IBDCP; started malaria control activities, with support of USAID (USOM)
1958
• Malaria Eradication Program; first national public health program
1978
• Redefined and revised as ‘Malaria Control Program’
1993
• Adopted WHO supported Global Malaria Eradication Strategy (GMCS)
1998
• Roll back malaria (RBM) launched, initially in 12 endemic districts
17
Chronological Activities: Malaria Eradication to Control, Nepal

18. • National Malaria Laboratory
Technical Steering Committee &
TWG- EDCD, NPHL, VBDRTC
• Health Office as focal point at
district level
• Malaria Microscopy Center Testing
service at HP, PHCCs, Primary
Hospital
• PACD, RACD & Community-based
testing as per necessity
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Institutional Framework
Source: National Malaria Laboratory Plan

19. • Case Notification, Surveillance and Information System: Reporting
through DHIS 2, MDIS, EWARS (Immediate reporting of single case of
severe and complicated malaria), within 24 hrs and 74 hrs action
1. Case-based surveillance
2. Integrated Entomological Surveillance
3. Vector survey
• Case Identification and Detection: Case investigation, Foci investigation,
PACD, RACD & Community-based testing as per necessity
• Risk mapping: Micro-stratification
• Prevention & Promotion activities: Distribution of LLIN, ITN,
Development of IEC and SBCC materials, celebration of Malaria Day
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National programs and activities

20. • Capacity building of HSPs and stakeholders: Palika level, district
level, women group focused, FCHVs focused
• Research: Operational research on malaria, vectors and parasites
• Interventions: Vector control interventions
• System strengthening: Supportive supervision
• Specific activity for imported malaria: Testing at PoEs/GC (Point of
Entry and Ground Crossing)
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National programs and activities

21. • Malaria Disease Information System (MDIS); developed by Ekbana for
EDCD for Malaria Control Program
• In operation, for case notification and analysis through two systems;
mobile application and CMS system
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MDIS- A short brief

22. 1. Case
Investigation Form;
Mobile application
2. Case
Notification
3. Data Analysis
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MDIS- A short brief

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Surveillance Framework

24. Vision: Malaria Elimination in Nepal by 2025
Mission: Ensure universal access to quality
assured malaria services for prevention,
diagnosis, treatment and prompt response in
outbreak.
Goal: Reduce the indigenous malaria cases to
zero by 2022 and sustain thereafter.
Objectives: To ensure proportional and
equitable access to quality assured diagnosis and
treatment in health facilities as per federal
structure and implement effective preventive
measures to achieve malaria elimination
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National Malaria Strategic Plan (2014-2025)
Surveillance &
Information System
Vector Control
Intervention
Early Diagnosis
and treatment
Leadership &
Community
engagement
Strengthening
technical and
managerial
capacities

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WHO Response towards Malaria
• WHO Committee: MPAG, VCAG, TAG-MEC
• Development of ‘Global Technical Strategy for Malaria (2016-2030)’-
technical framework for all malaria endemic districts
Target: Reduce case incidence and malaria mortality by 90% in 2030
Eliminate malaria in at least 35 endemic countries by 2030
• Global Malaria Programme; providing technical support and assistance to
country programs
• SDG Target 3.3: “By 2030, end the epidemics of AIDS, tuberculosis, malaria
and neglected tropical diseases and combat hepatitis, water-borne diseases and
other communicable diseases.”

26. • ABCD strategy; Awareness, Bite prevention,
Chemoprophylaxis, Diagnosis
• Surveillance; Identification, detection and
treatment
• Preventive chemotherapies: PMC, SMC,
IPTp, IPTsc, PDMC, MDA
• Interventions: Vector-control, IVM, IRS
• Health Promotion; Use of LLIN, ITNs
• Health Education
• Specific Protection: Vaccine (recommended
from October 2021) RTS,S/AS01 malaria
vaccine
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Prevention, Control and Management

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Thank you!