Malaria program

MALARIA
PROGRAM
Dr. Mihir Rupani
Assistant Professor
Dept. of Community Medicine
Government Medical College, Bhavanagar

Burden
 Globally, 207 million estimated
cases reported in 2012 with 6.2
lakh deaths (Source: World Malaria Report
2013)
 SEAR estimated 27 million cases
with 42000 deaths in 2012 (Source:
World Malaria Report 2013)

Burden
 India population wise distribution
(Source: World Malaria Report 2013, total population
of India 1237 million)Transmission
area
Cases Percentage
High
transmission
> 1 case per
1000
population
22%
Low
transmission
0-1 case per
1000
population
67%
Malaria free 0 cases 11%

Year
Population (in
‘000)
Total Malaria
Cases
(million)
P.falciparum
cases
(million)
Pf % API
Deaths due
to malaria
1995 888143 2.93 1.14 38.84 3.29 1151
1996 872906 3.04 1.18 38.86 3.48 1010
1997 884719 2.66 1.01 37.87 3.01 879
1998 910884 2.22 1.03 46.35 2.44 664
1999 948656 2.28 1.14 49.96 2.41 1048
2000 970275 2.03 1.05 51.54 2.09 932
2001 984579 2.09 1.01 48.2 2.12 1005
2002 1013942 1.84 0.9 48.74 1.82 973
2003 1027157 1.87 0.86 45.85 1.82 1006
2004 1040939 1.92 0.89 46.47 1.84 949
2005 1082882 1.82 0.81 44.32 1.68 963
2006 1072713 1.79 0.84 47.08 1.66 1707
2007 1087582 1.51 0.74 49.11 1.39 1311
2008 1119624 1.53 0.77 50.81 1.36 1055
2009 1150113 1.56 0.84 53.72 1.36 1144
2010 1167360 1.6 0.83 52.12 1.37 1018
2011 1194901 1.31 0.67 50.74 1.1 754
2012(Prov.) 1211509 1.06 0.53 50.01 0.88 519
Burden in India (Source: NVBDCP)

Year
Population
in
thousand
Blood Smear
Examined
Positive
cases
Pf Cases ABER API SPR SFR Deaths
2001 984579 9,03,89,019 20,85,484 10,05,236 9.18 2.12 2.31 1.11 1005
2002 1013942 9,16,17,725 18,41,229 8,97,446 9.04 1.82 2.01 0.98 973
2003 1027157 9,91,36,143 18,69,403 8,57,101 9.65 1.82 1.89 0.86 1006
2004 1040939 9,71,11,526 19,15,363 8,90,152 9.33 1.84 1.97 0.92 949
2005 1082882 10,41,43,806 18,16,569 8,05,077 9.62 1.68 1.74 0.77 963
2006 1072713 10,67,25,851 17,85,129 8,40,360 9.95 1.66 1.67 0.79 1707
2007 1087582 9,49,28,090 15,08,927 7,41,076 8.73 1.39 1.59 0.78 1311
2008 1119624 9,73,16,158 15,26,210 7,75,523 8.69 1.36 1.57 0.8 1055
2009 1150113 103396076 15,63,574 8,39,877 8.99 1.36 1.51 0.81 1144
2010 1167360 106040223 1495817 779549 9.21 1.37 1.41 0.74 1018
2011 1194901 109313294 1310656 665004 9.12 1.1 1.2 0.61 754
2012(P) 1211509 108989326 1066981 533535 9 0.88 0.98 0.49 519
Burden in India (Source: NVBDCP)

Trend of malaria cases and deaths 2001-12

 Lancet study claims: malaria toll 40 times
the govt. count
 Malaria killed an estimated 46,800
Indians in 2010
• Source: Murray Christopher, et al. Global malaria mortality
between 1980 and 2010: a systematic analysis. The Lancet, Vol.
Magnitude of problem

Vectors of Malaria
 Anopheles culicifacies is the main
vector of malaria
 1. Feeding habits
 It is a zoophilic species
 When high densities build up
relatively large numbers feed on men
 2. Resting habits
 Rests during daytime in human
dwellings and cattle sheds

Vectors of Malaria (contd.)
 Breeding places
 Breeds in rainwater pools and
puddles, borrow pits, river bed pools,
irrigation channels, seepages, rice
fields, wells, pond margins
 Extensive breeding is generally
encountered following monsoon
rains.

Vectors of Malaria (contd.)
 Biting time
 Most of the vectors, including
Anopheles culicifacies, start biting
soon after dusk.
 Therefore, biting starts much earlier
in winter than in summer

History of Malaria control
 Bhore Committee (1946)
 National Malaria Control Program
(1953)
 National Malaria Eradication Program
(1958)

 Urban Malaria Scheme (1971)
 Modified Plan of Operation (1977)
 Malaria Action Program (1995)
 Enhanced Malaria Control Program
(1997)
(contd.)

 National Anti Malaria Program (1999)
 National Health Policy (2002)
 National Vector Borne Disease Control
Program (2004)
(contd.)

 Intensified Malaria Control Project
(2005)
 National Rural Health Mission (2005)
(contd.)

Bhore Committee (1946)
 Country wide comprehensive program
to control malaria recommended
 Endorsed by Planning Commission in
1951

National Malaria Control
Programme (1953)
 Objectives:
1. To bring down malaria transmission to
a level at which it would cease to be a
major public health problem
2. Thereafter an achievement was to be
maintained by each state to hold down
the malaria transmission at low level
indefinitely

 Strategies:
1. Residual insecticide spray of human
dwelling and cattle sheds
2. Malaria control teams to carry out
surveys and to monitor the malaria
incidence in the control areas
3. Anti-malarial drugs were made
available for patients reporting to an
Institution
Programme (1953)

 Impact:
 Number of malaria cases and deaths
had decreased significantly
Programme (1953)

 Change in concept from control to
eradication
 Objective: eradicate malaria in 7-9
years
 Impact: spectacular reduction in cases
and nil death reported in 1965
National Malaria Eradication
Programme (1958)

 Setback: financial, logistic,
administrative and technical constraints
 Result: resurgence of malaria during
1970’s
 Way forward: urban areas had not
received special attention
National Malaria Eradication
Programme (1958)

Urban Malaria Scheme (1971)
 Cause of concern:
 urban malaria
 proliferation of malaria from urban
to rural

 Presently covering 131 towns
 NORMS for selection of town:
 The towns should have a minimum
population of 50,000
Urban Malaria Scheme (under
NVBDCP)

 NORMS for selection of town:
 The API should be 2 or above
 Towns should promulgate and strictly
implement the civic by-laws to prevent/
eliminate domestic and peri-domestic
breeding places
NVBDCP)

 The Municipal areas are divided into
wards of 25.6 sq. km;
 each ward divided into 10 sectors of
2.56 sq. km
NVBDCP)

 Staffing pattern for each ward:
 1 malaria officer and 1 insect collector
 Staffing pattern for each sector:
 1 superior field worker, 2 field workers
 1 additional field worker for de-silting,
de-weeding and minor levelling
NVBDCP)

 From the year 2009, procurement and
supply of larvicides has been
decentralized,
which means that the states will
procure themselves as per approved
norms from the cash provided by GoI
NVBDCP)

Malaria – problematic states
(under UMS)

 The strategies include:
 Early case Detection and Prompt
Treatment (EDPT) through passive
surveillance institutions such as
hospitals, dispensaries and malaria
clinics.
NVBDCP)

 Recurrent anti-larval measures through
larvicides in towns reporting malaria.
 Minor engineering methods like source
reduction, canalization, de-weeding etc.
 Biological control using larvivorous fish
at appropriate breeding sites.
NVBDCP)

 IEC campaigns for community
awareness and their involvement.
 Space spray as emergency response to
control vector mosquitoes and their
rapid reduction in domestic and peri
domestic situations.
 Legislative measures.
NVBDCP)

 Intensive anti larval measures and drug
treatment were the mainstay of UMS in
1971
 Setback: high number of cases
recorded in 1976
Urban Malaria Scheme (1971)

Modified Plan of Operation
(1977)
 Attempts at malaria eradication were
given up
 MPO adopted

 Objectives
 Elimination of malarial deaths
 Reduction of malaria morbidity
 Maintenance of gains achieved to stop
further transmission
(1977)

 Strategies: to divide area in 2 groups
 API 2 and above
 API less than 2
(1977)

 API less than 2
• Focal Spray of DDT (BHC or
malathion)
• Surveillance and treatment: active and
passive surveillance should be carried
out and presumptive treatment is given
to all the fever suspected cases
(1977)

 API less than 2
• Epidemiological investigation of a
malaria case to determine the causative
factors
• Ensuring radical treatment of those
patients who are found positive in their
blood smear
(1977)

 API 2 and above
• Insecticidal spray
• Entomological studies
• Malaria surveillance
• Treatment of cases
• Decentralization of laboratory services
to PHC level
• Establishment of DDC and FTD
(1977)

 API 2 and above
• Attempts were made to intensity the
efforts in rural areas with assistance of
the Swedish International Development
Agency (SIDA) by providing input under
P falciparum Containment Program
(1977)

 API 2 and above
• Regular 2 rounds of insecticidal spray
with DDT/ Malathion / Synthetic
Pyrethroids at the dose of 1, 2, 0.5
mg/sq meter respectively.
• Entomological assessment for vector
behavior and development of
insecticidal resistance
(1977)

 API 2 and above
• Active and passive surveillance is
carried out on regular basis every
fortnight
• Presumptive Treatment to all fever
cases and radical treatment to all slide
positive cases is given
(1977)

Technical Advisory Committee on
Malaria further prioritized the criteria for
undertaking IRS in 2002
(2002 recommendations)

 Criteria:
1. All areas with > 5 API where ABER is >
10%
2. All areas reporting > 5% SPR, if ABER
< 10%
3. P falciparum > 50%

 Criteria:
4. API < 5 or SPR < 5%
• in case of drug resistant foci;
• project areas with population
migration;
• and aggregation or other vulnerable
factors including peri-contonment
areas

 Criteria:
5. Provision of insecticidal spraying in
epidemic situation
6. Other parameters including
entomological, ecological, etc. also
considered while prioritizing areas

 High risk areas and populations will be
re-defined at least annually
 High risk areas protected by IRS and
ITNs and coverage will be more than
80%

 API > 5:
• Areas are planned to be covered by
LLINs
 API > 2:
• Conventional net treated with
insecticides and IRS
 API 2-5:
• Conventional net treated with

 Impact: MPO was able to control
malaria deaths, but during 1994,
resurgence of malaria was observed in
some states
 Outbreaks were reported from
Rajasthan, Manipur and Nagaland
 During 1995 from Assam, Maharashtra
and West Bengal
 1996: Rajasthan and Haryana
(1977)

Malaria Action Programme
(1995)
 Malaria control was made 100%
centrally sponsored scheme since
December 1994 for seven North-
eastern states and states like Andhra
Pradesh, Bihar, Gujarat, Maharashtra,
Orissa and Rajasthan

 Problem areas:
A. Hardcore areas (Tribal Areas)
B. Epidemic Prone Areas
C. Project Areas
D. Triple Insecticide resistant Areas
E. Urban Areas
(1995)

 Hardcore (tribal areas)
• Difficult terrain areas
• Predominantly tribal
• Predominantly P falciparum
• Stable malaria with transmission period
extending up to 9 months or more
• Predominantly have more deaths due to
malaria
(1995)

 Disease management
• IEC and intensified IEC
• Case detection and presumptive
treatment of fever
• Radical treatment with priority to Pf
cases within 48 hours
(1995)

• MPW should be able to identify severe
cases of malaria requiring referral
• PHC well-equipped to tackle severe
malaria
• Alternative drug in chloroquin resistant
Pf areas
(1995)

 Action required
• Link worker: one for 2000 population
• Also work as FTD and carry all blood
slides of his area to PHC or malaria
clinic twice a week
• Also bring drugs and microslides for
FTDs in his area
(1995)

 Epidemic prone areas
• Climatic zones with annual rainfall up to
100 mm
(1995)

 Epidemic prone areas
• Case detection and presumptive
treatment
• Blood slide collection and examination
cases within 48 hours
(1995)

 Project areas
• Non-immune population of laborer to
endemic areas
• Prolific increase in vector breeding
places
• Increased man-mosquito contact
(1995)

 Project areas
• Mass screening of labor/incoming
population should be continuously done
if transmigration is frequent
• All incoming persons from high risk
tribals should be given presumptive
treatment along with a single dose of
45mg Primaquine
(1995)

 Project areas
• Alternative drug in chloroquine resistant
of Pf areas
(1995)

 Urban areas
 15 cities are accountable for nearly
80% of Pf malaria cases
(1995)

 Urban areas
• Active surveillance in slum areas
weekly
• Passive surveillance in hospitals
• Presumptive treatment
cases
(1995)

 Urban areas
 Action required
• Provide adequate staff for active
surveillance in slum areas and one
worker for 20000 population
• Establish one malaria clinic for 50000
population
(1995)

 Urban areas
 Action required
• Location of malaria clinic should be
preferably adjoining slum area if
possible and wherever feasible its
location should be in existing
dispensary
(1995)

Enhanced Malaria Control
Project (1997)
 Center sought external support from
World Bank
 Selection of PHCs is based on:
i) API > 2 for last 3 years;
ii) Pf cases are more than 30% of the
malaria cases;

Project (1997)
 Center sought external support from
World Bank
 Selection of PHCs is based on:
iii) 25% population of the PHC is tribal;
iv) The area has been reporting deaths
due to malaria and also has the
flexibility to direct resources to any
needy areas in case of outbreak of

 Objectives:
1. Effective control of malaria to bring
reduction in malaria morbidity
2. Prevention of death due to malaria
3. Consolidation of the gain achieved so
far
Project (1997)

 Strategies
1. Early case detection and prompt
treatment;
2. Vector control by indoor residual
insecticide spray in rural areas with API
of 2 and above in the preceding three
years with appropriate insecticide and
by recurrent anti-malaria in urban
Project (1997)

 Strategies
3. Health Education and community
participation
Project (1997)

 Components of EMCP
treatment
2. Selective Vector Control
3. Legislative Measures
4. Personal Protective Measures
Project (1997)

5. Epidemic Planning and Rapid
Response and Intersectoral
Coordination
6. Institutional and Management
capacities strengthening
Project (1997)

Project (1997)
8. Community Participation

treatment:
Link worker in high Pf areas for a
population of 2000 is appointed by
Panchayat and paid rs. 500 per month
He collects blood smears, provides
presumptive treatment and forwards
slides to PHC
Project (1997)

treatment:
One microscope for every 30000
population at PHC in rural areas and for
50000 for urban areas
Dipstick test in selected areas
1 FTD in every village
Project (1997)

treatment:
Drugs in sufficient quantity made
available
Artemisinine derivatives also introduced
Involvement of private sectors in case
detection and treatment
Project (1997)

Bioenvironmental Methods
Introduction of Larvivorous fishes
Use of biocides: bacillus thuringiensis H-
14 in selected urban areas
Environmental management methods
Project (1997)

BIOLOGICAL CONTROL - BtiBIOLOGICAL CONTROL - Bti
The bacillus Bti (Bacillus Thuringiensis Israelensis !!!) can be incubated in
coconuts, where it multiplies. The coconuts are then broken open and
thrown into pools, where the bacilli are eaten by the mosquito larvae.
They kill the larvae by destroying its gut.
The bacillus Bti (Bacillus Thuringiensis Israelensis !!!) can be incubated in
coconuts, where it multiplies. The coconuts are then broken open and
thrown into pools, where the bacilli are eaten by the mosquito larvae.
They kill the larvae by destroying its gut.
Spraying Bti
from a boat
Spraying Bti
from a boat
The
incubation
stage
The
incubation
stage
Adding
to pools
Adding
to pools

Selective spray
Village in which there is one case of Pf
or more qualify for residual spray in
project area.
Synthetic pyrethroids (safer)
Project (1997)

3. Legislative Measures
Byelaws for control of mosquitoes (as in
Delhi and Mumbai) would be extended to
cover whole country
Project (1997)

4. Personal Protective Measures
Bednet program
Project (1997)

5. Epidemic Planning and Rapid
Response and Intersectoral Coordination
Sector like agriculture, environment,
education and so on are sensitized to
malaria problem
Project (1997)

6. Institutional and Management
Capacities Strengthening
Management Information System (MIS)
IEC
Project (1997)

7. Operation Research
Health seeking behaviour especially of
malaria patients
Economic analysis of various
interventions
Alternative drug regimens and
introduction of artesunate
Project (1997)

7. Operation Research
Evaluation of bednets and curtains
Trial with biolarvicidal agents
Entomological monitoring
Migratory patterns leading to malaria
outbreaks
Project (1997)

“Bottom up” planning, in which village
Panchayat would be responsible for all
matters related to health and
development
Project (1997)

 PROGRESS:
 Since 1997, EMCP implemented in
1045 PHCs in 100 districts
predominantly Pf malaria endemic and
tribal dominated districts in AP,
Jharkhand, Gujarat, MP, Chhattisgarh,
Mh, Odisha and Rajasthan covering
62.2 million population.
Project (1997)

 PROGRESS:
 In addition 19 cities/town in these states
and in TN, Karnataka, and WB
Project (1997)

 IMPACT:
 Out of 100 EMC districts, 79% have
recorded decline in Malaria incidence
during 2003
 Number of Pf cases has declined from
0.72 million in 1997 to 0.41 million in
2004
Project (1997)

National Anti-Malaria Program
(1999)
 NMEP dropped
 Soon became part of NVBDCP

National Health Policy (2002)
 Goal:
 Reduction in mortality on account of
malaria and other VBDs by 50% by
2010 and efficient morbidity control

NVBDCP (2004)
1. Early case Detection and Prompt
Treatment:
main strategy of malaria control – radical
treatment is necessary to prevent
transmission of malaria
Chloroquine is the main anti-malaria
drug for uncomplicated malaria

1. Early case Detection and Prompt
Treatment:
DDCs and FTDs have been established
in the rural areas
Alternative drugs for chloroquine
resistant malaria are recommended as
per the drug policy of malaria
NVBDCP (2004)

2. Vector Control
(i) Chemical Control
 Use of IRS with insecticides
recommended under the programme
 Use of chemical larvicides like Abate
in potable water
 Aerosol space spray during day time
 Malathion fogging during outbreaks
NVBDCP (2004)

NVBDCP (2004)
2. Vector Control
(ii) Biological Control
 Use of larvivorous fish in ornamental
tanks, fountains etc.
 Use of biocides.

2. Vector Control
(iii) Personal Prophylactic Measures
Use of mosquito repellent creams,
liquids, coils, mats etc.
Screening of the houses with wire mesh
Use of bed nets treated with insecticide
Wearing clothes that cover maximum
surface area of the body
NVBDCP (2004)

 Sensitizing and involving the
community for detection of Anopheles
breeding places and their elimination
 NGO schemes involving them in
programme strategies
 Collaboration with private sector.
NVBDCP (2004)

4. Environmental Management & Source
Reduction Methods
 Source reduction i.e. filling of the
breeding places
 Proper covering of stored water
 Channelization of breeding source
NVBDCP (2004)

5. Monitoring and Evaluation of the
Program
 Monthly Computerized Management
Information System(CMIS)
 Field visits by state by State National
Program Officers
 Field visits by Malaria Research
Centers and other ICMR Institutes
 Feedback to states on field
observations for correction actions
NVBDCP (2004)

Insecticide Policy
 DDT should be the insecticide of choice
for residual spray.
 If resistance found to DDT then
Malathion is the alternative choice.
 In case of resistance to both DDT and
malathion then synthetic Pyrethroids is
the choice.

 ITMN: as a measure for protection
against mosquitoes was started in
general and in NE states particularly
 Synthetic Pyrethroids namely
Deltamarin (2.5%) at dosage of
25mg/sq m and Cyflutharin (5%) at
50mg/sq m is used to impregnate the
nets
Insecticide Policy

World Bank assisted NVBDCP
project
 On Malaria control and Kala azar
elimination effective from 6th
March,
2009; though started from August 2008
for a period of 5 years
 Being implemented in 2 phases in 93
districts of 10 states

 Strategies :
 improve case management, improving
surveillance, effective vector control, m
& e, program management & capacity
building
World Bank assisted NVBDCP
project

Global Fund supported project
“Intensified Malaria Control
Project”:
Implemented in 106 districts of 10 states
for a period of 5 years from July 2005 to
June 2010
Intensified Malaria Control
Project (2005)

Project”:
For areas under GFATM project,
additional support is given for the
following 5 activities:
Provision of rapid diagnostic kits
Provision of artemisinin combination
therapy (ACT) for Pf cases
Project (2005)

Project”:
Additional manpower for strengthening
supervision and monitoring
Provision of ITMN to high endemic areas
Treatment of community owned bed nets
with insecticides
Project (2005)

Roll back Malaria (RBM)
 Is a global partnership founded in 1998
by WHO ,UNDP, UNICEF and the
World bank
 To halve malaria-associated mortality
by 2010 and again by 2015

Malaria vaccine
 RTS,S malarial candidate vaccine is
only vaccine which is found to be
effective in adults ,children and infants
in neutral field trials ,for which Phase 3
clinical trial is planned.
 It leads to formation of antibodies
against AMA 1(Apical Membrane
Antigen) which is present on merozoite
of P.falciparum

Remote Sensing in Vector
Borne Disease Control
 Remote Sensing (RS) technology is a
tool for the surveillance of habitat,
densities of vector species and even
prediction of the incidence of disease
that must be considered as new
invention in the epidemiology of malaria
and vector-borne diseases.

 Remote sensing is to sense any object
from a distance
 The principle of RS rests on the fact
that every object absorbs some part of
radiation received from sunlight.

 Depending upon its physical and
chemical properties, the object absorbs
some part of radiation while the
remaining part is reflected in specific
wavelength of the electromagnetic
spectrum (EMS). This reflected energy
is channelised through a telescope to
detectors/sensors present on board of
the satellites.

 The sensors are sensitive to different
bands of EMS. The sensors convert the
light energy into electrical voltages
produces two-dimensional discrete
pictures.

 These are different for different objects
and the satellite pass over a particular
part of earth at the fixed time intervals
repeatedly making it possible to monitor
changes in the lad use categories viz.
Water bodies, vegetation, forests, soil
mapping, geology, crop estimation,
detection of fire in forest, mines, oil
sleek in sea, etc.

 Such data is generated in National
Remote Sensing Agency, Hyderabad,
in India. A feasibility study using
Satellite data in collaboration with the
Indian Space Research Organisation in
and around Delhi was carried out and
correlation of changes in the areas of
land use features viz. Water bodies and
vegetations with mosquito density was
found significant in some sites

NIMR
 National Institute of Malaria Research
(NIMR) was established in 1977 as
'Malaria Research Centre', which was
renamed as 'National Institute of
Malaria Research' in November 2005.
 NIMR is one of the institutes of the
ICMR

 The primary task of the Institute is to
find short term as well as long term
solutions to the problems of malaria
through basic, applied and operational
field research.
 The Institute also plays a key role in
man power resource development
through trainings/workshops and
transfer of technology.
NIMR

NIMR
 15 studies are conducted in a year
through Pf monitoring teams through
ROH&FWs and National Institute of
Malaria Research (NIMR) at different
places
 Based on their report, resistance areas
are identified and their drug policy
changed

Malaria program

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