National Vector Borne Disease Control Programme

National Vector Borne Disease Control Programme
(NVBDCP)
Dr. Priyansh Kothari
(Index Medical College Hospital and Research Centre, Batch 2017-18)

Guided by:
• Dr. (Col.) V. K. Arora Sir
• Dr. Aarti Sahasrabuddhe Ma’am
• Dr. Gajanan D. Bhide Sir
• Dr. Nisha Singh Ma’am
• Dr. Lubana Sheikh Ma’am
Head of Department & Professor Community Medicine
Professor Community Medicine
Professor Community Medicine
Assistant Professor Community Medicine
Senior Resident Community Medicine

Contents:
• Vectors & Vector Borne Diseases
• NVBDCP
• Diseases Under NVBDCP
• Malaria
• Filaria
• Kala-azar
• Japanese Encephalitis
• Dengue
• Chikungunya
• Conclusion
• Bibliography

Vectors
• In infectious disease epidemiology, vector is defined as an arthropod or
any living carrier that transports an infectious agent to a susceptible
individual.
• Transmission by a vector may be mechanical or biological.
• Arthropods are major group of pathogen vectors with mosquitoes, flies,
sand flies, lice, fleas, ticks, and mites.
• Rabies is transmitted through exposure to the saliva or brain tissue of an
infected animal.

NVBDCP
• National Vector Borne Diseases Control Programme (NVBDCP) started in
2002, implemented for prevention and control of 6 vector borne diseases:
Malaria, Japanese Encephalitis, Dengue, Chikungunya, Kala-azar and
Lymphatic Filariasis.
• Out of them 3 diseases namely, Malaria, Lymphatic Filariasis and Kala-azar
are targeted for elimination.
• Implemented by the State/UT whereas National Center for Vector Borne
Diseases Control (NCVBDC) provides technical and financial assistance to
the States/UTs under National Health Mission (NHM).
• Controlling spread is complex, as transmission depends on the interaction
of ecological, biological, social and economic factors including migration.

• Malaria, Filariasis, Japanese Encephalitis, Dengue and Chikungunya are
transmitted by mosquitoes, while Kala-azar is transmitted by sand flies.
• Under NVBDCP, the three-pronged strategy for prevention and control
of VBDs is as follows:
Disease management
including early case
detection and complete
treatment, strengthening
referral services and rapid
response
Integrated vector
management (IVM) for
transmission risk
reduction
Behaviour change
communication (BCC),
public private
partnership, human
resource development
NVBDCP

Malaria
• Life threatening parasitic disease caused by protozoa Plasmodium vivax
(P.vivax), Plasmodium falciparum (P.falciparum), Plasmodium malariae
(P.malariae) and Plasmodium ovale (P.ovale), Plasmodium knowlesi.
• Transmitted by the infective bite of female Anopheles mosquito
• Incubation Period: 10 to 14 days of being bitten by an infective mosquito
• There are two types of commonly reported parasites of human malaria in
India:
• Plasmodium vivax
• Plasmodium falciparum (most lethal form)
• Female Anopheles is the main vector of malaria.
• Anthropophilic and Zoophilic
• Rests during daytime in human dwellings and cattle sheds
• Breeds in rainwater pools and puddles, borrow pits, river bed pools, irrigation
channels, seepages, rice fields, wells, pond margins, sluggish streams with sandy
margins.
• Start biting soon after dusk. Therefore, biting starts much earlier in winter than in
summer but the peak time varies from species to species.

Life Cycle
Anopheles
stephensi (Urban)
culicifacies (Rural)

Signs and Symptoms
• Typically, presents with chills and fever – periodic intense bouts lasting
around 6 hours, followed by sweating
• Malaria in pregnancy poses a substantial risk to the mother, the fetus
and the newborn infant.

Paroxysm: a cyclical occurrence of sudden coldness followed by shivering
and then fever and sweating,
- Every 2 days (tertian fever) in P. vivax and P. ovale infections
- Every 3 days (quartan fever) for P. malariae.
- P. falciparum infection can cause recurrent fever every 36–48 hours, or a less
pronounced and almost continuous fever.

Magnitude of the Problem
Huge public health problem. About 95% population in the country resides in malaria
endemic areas and 80% of malaria reported in the country is confined to areas
consisting 20% of population residing in tribal, hilly, difficult and inaccessible areas.

• National Malaria Control
Programme started in 1953.
• Because of the spectacular
success achieved in the
control of malaria , the
control programme, was
converted in 1958 into an
eradication programme.
• Went through several
iterations, renaming and
modifications.
Programmes

• The main activities of the programme are :
1. Formulating policies and guidelines.
2. Technical guidance and Training.
3. Planning and Logistics.
4. Monitoring and evaluation.
5. Coordination of activities through the States/UT
6. Collaboration with WHO, World Bank, GFATM.
7. Facilitating research through NCDC, NIMR, Regional
Medical Research Centres etc.
8. Coordinating control activities

Organization
• 19 Regional Offices for Health and Family Welfare under Directorate General of
Health Services, Ministry of Health and Family Welfare, located in 19 states.
• Every state has a Vector Borne Disease Control Division headed by the State
Programme Officer (SPO) responsible for supervision, guidance and effective
implementation of the programme.
• States are responsible for the procurement of insecticides for indoor residual spray
(IRS) , spray equipment and certain anti-malarials, the central government supplies
DDT and larvicides.

• Divisional level: zonal officers have technical and administrative
responsibilities of the programme
• District level: the Chief Medical Officer (CMO)/District Health Officer (DHO)
has the overall responsibility of the programme.
• District malaria offices: Key unit for the planning and monitoring of the
programme. Spray operations are the direct responsibility of DMO/DVBDC
officer in the entire district under overall supervision of CMO and
collaborative supervision/monitoring by PHC's Medical Officer.
• There is one Assistant Malaria Officer (AMO) and Malaria Inspectors (Mis) to
assist him.
• The laboratories have been decentralized and positioned at the PHCs. The
medical officer - PHC has the overall responsibility.
• Case detection management and community outreach services are carried
out by MPWs as well as ASHAs and other community health volunteers.

Drug distribution centres and fever
treatment depots
• Drug Distribution Centres are only to dispense the anti-malarial tablets as per NMEP
schedules.
• Fever Treatment Depots collect the blood slides in addition to the distribution of
antimalarial tablets. These centres are manned by voluntary workers from the
community

Urban Malaria Scheme
• Launched in 1971 to reduce or interrupt malaria transmission in towns and cities.
• About 7.4% of the total cases of malaria and 10.9% of deaths due to malaria are
reported from urban areas.
• The vector of malaria in the urban areas breeds largely in man-made containers
including overhead tanks and underground water storage tanks, water coolers,
cisterns, roof gutters, flower vases, bottles and ornamental ponds, old tyres etc. ,
which can collect water.
• Large construction activities provide suitable breeding sites for the mosquitoes.
• Influx of migrant labour from malarious zones contribute to increase in incidence.

• At present, protecting 142.9 million people from malaria as well as from other
mosquito borne diseases in 131 towns in 19 States and Union territories.

Objectives of UMS
• The main aim is the reduction of the disease to a tolerable level in which the human
population can be protected from malaria transmission with the available means.
• The Urban Malaria Scheme aims at :
a) To prevent deaths due to malaria.
b) Reduction in transmission and morbidity.
NORMS:
• The towns should have a minimum population of 50,000.
• The API should be 2 or above.
• The towns should promulgate and strictly implement the civic by-laws to
prevent/eliminate domestic and peri-domestic breeding places

Control Strategies
• Under the scheme, Malaria Control strategy will comprise of:
(i) Parasite control
(ii) Vector control
1. Parasite Control:
Treatment is done through passive agencies viz. hospitals, dispensaries both in private &
public sectors institutions and private practitioners. In mega cities malaria clinics are
established by each health sector/ malaria control agencies.
2. Vector Control:
• Source reduction
• Use of larvicides
• Use of larvivorous fish
• Space spray
• Legislative measures

1. Source Reduction
Anti-larval operations causing the reduction or permanent elimination of mosquito
breeding places or sites are defined as source reduction methods.
• Elimination or reduction of breeding sites: This aspect of source reduction are
divided into
a) Filling for elimination of burrow pits, ditches, small unused irrigation canals
unused/abandoned wells
b) Drainage by eliminating breeding sites by draining away the water collections.
c) Drains constructed by as Surface ditches, Sub-surface drains and Vertical drains.
• Environmental manipulation: The measures included by which changes are done in
the natural conditions under which mosquitoes exist, rendering them unfavorable to
life, for example changing the salt content of water, silting, flooding, fluctuating
water levels, agitating of the water surface, mudding, etc.

Advice
• Never to throw any containers in open
capable of holding water for more than a
week.
• Lids of overhead tanks must be checked
and maintained on monthly basis. Any
leakage should be repaired immediately.
• Cover-up of underground and open tanks.
• Open tanks used for animals should be
dead dried once in week.

Advice
• Construction sites require special attention.
Building bye-laws, must be implemented to
prevent fault in designs, water flow on roof,
gully traps.
• Open tanks should be treated with larvicides
on weekly basis.
• Unused wells either be closed or treated with
larvicides.
• Ornamental tanks, fountains should be
checked periodically and larvivorous fish be
introduced.
• Wells in use may be cover with mosquito
proof nets.

2. Larvicides
• Recurrent anti-larval measures at weekly intervals with approved chemical larvicides
to control the vector mosquitoes are recommended.
• The following chemical larvicides are used in the Urban Malaria Scheme programme:
• Temephos (Abate)
• Bti (Wettable Powder & 12 Aqueous Suspension)

3. Larvivorous Fish
• These fishes are self-perpetuating after its establishment and continuous to reduce
mosquitoes larvae for a long time.
• The cost of introducing larvivorous fish is relatively lower than that of chemical
control.
1. Gambusia affinis
• Use in India since 1928, single
full grown fish eats about 100 to 300
larvae per day.
• Gambusia is a surface feeder, hence it is suitable for feeding on both anophelines
and culicines.
• It is small and inedible and can tolerate salinity.
• It can withstand transportation and survives in new places (water bodies) and
multiplies easily.
• After release when it becomes well established in a water body, the fish can survive
in good numbers for years and does not require constant care

2. Poecilia reticulata (GUPPY)
• A single fish eats about 80 to 100 mosquito
larvae in 24 hours
• Tolerates handling and transportation very well.
• It is highly carnivorous and parents or older brood may eat up their own young ones.
Therefore, a fair amount of weeds is required in the water so that young ones can
hide and survive.
Criteria for selection of Natural water body:
• It should be a permanent water body of depth of water at least 1.5 m or more.
• Water should be confined and without big natural outlet.
• The minimum size of water body should be at least 5 m X 4 m. The water body
of 10 m X 5 m can support 50000 fish.
• It should be free from other carnivorous fish.
• Water should not be contaminated by chemical or other harmful substances.
• Easily accessible for daily or periodic inspection and for collection of fish.

4. Space Spray
Space spraying refers to the process of dispersing liquid droplets of an insecticide into
an area as a fog, with the aim of knocking down and killing adult insects.
1. Pyrethrum spray (2%) sprayed with pump or
hand operated fogging machine fitted with
micro-discharge nozzle.
2. Malathion fogging or Ultra Low Volume (ULV) spray
producing a cloud of insecticide droplets that remain
suspended in air for an appreciable time and
driven under the influence of wind.

National Framework for Malaria
Elimination in India (2016- 2030)
Launched in February 2016, in line with the WHO Global Technical Strategy (GTS) for
Malaria 2016-2030 with the goal to:
- Eliminate malaria (zero indigenous cases) throughout the entire country by 2030.
- Maintain malaria-free status in areas where malaria transmission has been
interrupted and prevent reintroduction of malaria.
Objectives:-
- By 2022, transmission of malaria interrupted and zero indigenous cases to be attained
in all 26 States/UTs that were under Categories 1 and 2 in 2014;
- By 2024, incidence of malaria to be reduced to less than 1 case per 1000 population in
all States and UTs, and their districts;
- By 2027, indigenous transmission of malaria to be interrupted in all States and UTs of
India; and
- By 2030, malaria to be eliminated throughout the entire country, and re-establishment
of transmission prevented.

Parameters
1. Annual Parasite Incidence (API): It is a sophisticated measure of malaria incidence in
a community based on intensive active and passive surveillance, with cases confirmed
by blood examination.
2. Annual blood examination rate (ABER): ABER is an index of operational efficiency. A
sufficient number of blood slides must be systematically obtained and examined
for malaria parasite.
3. Slide positivity rate: slide positivity rate is the percentage of slides found positive for
malarial parasite, irrespective of the type of species.
4. Slide falciparum rate: It is the percentage of slides positive for P. falciparum parasite.
Confirmed cases during one year
Population under surveillance
X 1000
API =
Number of Slides Examined
Population
ABER = X 100

Phasing
• Carried out in a phased manner because the various States/ UTs have different levels
of malaria burden.
• Based on their Annual Parasite Incidence as primary criterion with due consideration
given to Annual Blood Examination Rate and Slide Positivity Rate as secondary
criteria.

Milestones
By the end of the year 2016
All states and UTs to have included malaria elimination in their broader health policies
and planning framework.
By the year 2020
1. All 15 states/UTs that were under category 1 (elimination phase) in 2014 to
completely interrupted malaria transmission and achieved zero indigenous cases and
deaths due to malaria
2. All 11 states/UTs under category 2 (pre-elimination phase) in 2014 to enter into
category 1 (elimination phase);
3. 5 states/UTs under category 3 (intensified control phases) in 2014 to enter into
category 2 (pre-elimination phase)
4. 5 states/UTs under category 3 (intensified control phase) in 2014 to reduce disease
burden but continue to remain in category 3; and
5. Estimated malaria burden at national level to reduce by 15- 20% as compared to
2014.

By the year 2022
1. All 26 states/UTs that were under categories 1 and 2 in 2014 to interrupt malaria
transmission and achieved zero indigenous cases and deaths due to malaria;
2. 5 states/ UTs which were under category 3 (intensified control phases) in 2014 to
enter into category 1 (elimination phase);
3. 5 states/UTs which were under category 3 (intensified control phases) in 2014 to
enter into category 2 (pre-elimination phase) ; and
4. Estimated malaria burden at national level reduced by 30- 35% as compared to 2014.
By the year 2024
1. All states and UTs and their districts to reduce API to less than 1 case per 1000
population at risk, sustain zero deaths due to malaria and establish fully functional
malaria surveillance to track, investigate and respond to each case;
2. 31 states/ UTs to interrupt transmission of malaria and zero indigenous cases and
deaths attained; and
3. 5 states/ UTs which were under category 3 (intensified control phases) in 2014 to
enter into elimination phase.

By the year 2027
Indigenous transmission of malaria interrupted and the entire country to have no
indigenous cases and no deaths due to malaria.
By the year 2030
The entire country to sustain status of zero indigenous cases and deaths due to malaria
for 3 consecutive years; and India to initiate the processes for certification of malaria
elimination status.
Focus on High-Endemic Areas and Tribal Population:
• Most of the malaria cases in India are reported from Andhra Pradesh, Chhattisgarh,
Jharkhand, Madhya Pradesh, Maharashtra, Meghalaya, Mizoram, Odisha, Telangana
and Tripura.
• The high incidence in these states is particularly noted n tribal populations living in
foothills forested or conflict - affected areas. The malaria programme plans to scale
up interventions in these areas.

Special strategy for P vivax elimination
India accounts for more than 50% of the estimated P. vivax cases in the world.
Why do we need a special strategy?
(1) Plasmodium vivax hypnozoites prolong the parasite's lifespan and are difficult
to detect;
(2) RDTs currently available to detect P vivax are less sensitive than RDTs for P
falciparum detection;
(3) Radical treatment for P. vivax requires 14 days of primaquine therapy to kill the
hypnozoites whereas treatment for P. falciparum can be completed in only 3 days;
(4) P. vivax strains have a longer incubation period.
Special Measures:
• Expanding bivalent RDTs and quality microscopy services to detect all P vivax
infections;
• Ensuring compliance of the 14-days radical treatment by affected individuals;
• Tackling urban malaria by targeting An. stephensi by antilarval measures.

District as the unit of planning and implementation:
Each district should stratify its PHCs and sub-centres the following five strata, as those
with:
1. Zero cases
2. API > 0 to < 1
3. API 1 to < 2
4. API 2 to < 5
5. API ≥ 5

Strategies
• Early diagnosis and radical treatment
• Case-based surveillance and rapid response
• Integrated vector management (IVM)
- Indoor residual spray (IRS)
- Long-lasting insecticidal nets (LLINs) / Insecticide treated bed nets (ITNs)
- Larval source management (LSM)
• Epidemic preparedness and early response
• Monitoring and evaluation
• Advocacy, coordination and partnerships
• Behavior change communication and community mobilization
• Programme planning and management

Category 3 (Intensified control phase: States/UTs with API ≥ 1)
1. Massive scaling up of existing disease management and preventive services.
2. Screening of all fever cases suspected of malaria.
3. Classification of areas as per local malaria.
4. Strengthening of intersectoral collaboration.
5. Special interventions for high-risk groups such as tribal populations and populations
residing in conflict affected or hard-to-reach areas.
6. One- stop centers or mobile clinics
7. Timely referral and treatment of severe malaria
8. Strengthening all district and sub-district hospitals in malaria endemic areas as per
Indian Public Health.
9. Establishment of a robust supply chain management system. Maintenance of an
optimum level of surveillance using appropriate diagnostic measures

Category 2 (Pre-elimination phase: States/UTs with API < 1, but some of their districts
reporting API ≥ 1)
1. Setting up an elimination surveillance system and initiating elimination phase
activities in those districts where the API has been reduced to less than 1 case per
1000 population at risk per year.
2. The planning of elimination measures will be based on epidemiological investigation
and classification of each malaria case and focus.
Category 1 (Elimination phase: States/UTs with API <1, and all their districts reporting
API < 1)
1. Interrupting local transmission in all active foci of malaria.
2. Mandatory notification of each case of malaria from the private sector, or any other
health facility.
3. Adequate case-based surveillance and complete case management.
4. Investigation and classification of all foci of malaria.
5. Effective vector control measures.

6. Early detection and treatment of all cases of malaria.
7. State and national level malaria elimination database.
8. Implementation of interventions for effective screening, management and prevention
of malaria among mobile and migrant populations.
9 . Establishment of an effective epidemic forecasting and response system.
10. Ensuring rigorous quality assurance of all medicines and diagnostics.
11. Setting up a national-level reference laboratory to serve following two functions:
(a) All positive and a fixed percentage of negative slides will be referred to this
laboratory for confirmation of diagnosis and cross-checking. 100% of cases will
be notified to this laboratory for confirmation of diagnosis.
(b) Training of master trainers and accreditation/certification of microscopists as
per Indian Public Health Standards shall also be undertaken at this laboratory.
12. Screening and Surveillance

Category 0 (prevention of re-establishment phase)
1. Detect any re-introduced case of malaria.
2. Notify immediately all detected cases of malaria.
3. Determine the underlying causes of resumed local transmission.
4. Apply rapid curative and preventive measures.
5. Prevent re-introduction and possible re-establishment of malaria transmission
6. Maintain malaria-free status in these areas.

Surveillance
• Initially set up in the early 1960s.
• Active case detection (ACD) is carried out in rural areas with blood smears collected
by MPWs/ANM during fortnightly house visits.
• Passive case detection (PCD) is done in fever cases reporting to peripheral health
volunteers/ASHAs and at sub-centres, malaria clinic, CHC, and other secondary and
tertiary level health institutions.
• ASHA and other volunteer workers provide diagnostic services by RDTs, and at PHCs
by examination of blood smears.
• In villages where there is no ASHA or other volunteer, ACD and case management is
done by the MPWs.
• Screening of 100 million fever cases with an aim to screen 10% of the population,
even though the disease transmission is expected to reduce.
• Use of bivalent RDT for early diagnosis of malaria in the year 2012 to detect P. vivax
and P. falciparum and distributed RDTs to community level workers/volunteers.

Sentinel Surveillance
• One of the weakness of the existing malaria surveillance system is the lack of
articulation with hospitals.
• Severe malaria cases are not reported separately and that only a small fraction of
malaria deaths are recorded.
• Therefore, sentinel surveillance is being established in high endemic districts, by
selecting in each district, depending on its size, 1-3 sentinel sites in large hospitals for
recording of all out-patient and in-patient cases of malaria, and malaria related
deaths.

Case Management
Pregnancy: Quinine 10mg/kg TDS for 7 days (1st Trimester), ASN-SP/AMT-L (2-3 Trimester)

Cases have consistently declined from 2.09 million to 0.19 million during 2001 to 2020.
Similarly, Pf cases have declined from 1.0 to 0.12 million cases during the same period.
Less than 2000 deaths were reported during all the years within this period with a peak
in 2006 when an epidemic was reported in NE States. This indicates declining overall
endemicity of malaria in the country.

Integrated Vector Management (IVM)
• Done by using identical vector control methods to control malaria and leishmaniasis
in rural areas, and malaria and dengue in urban areas, to achieve cost-effectiveness
and synergy.
• The IVM includes safe use of insecticides and monitoring of insecticide resistance.
• The measures of vector control and protection include :
• Measures to control adult mosquitoes :
- Indoor Residual Spray (IRS)
- Antilarval measures
- Personal protection : use of bed-nets, insecticide treated nets.
• The national malaria control program is currently using IRS as the primary method of
vector control in rural settings and anti-larval measures in the urban areas
• High risk areas and populations shall be protected by indoor residual spray and
insecticide treated nets and the coverage will be more than 80%.

• Insecticide treated bed-nets
Minimum hole size : 2x2mm
Wash resistance up to 20 washes
• Indoor Residual Spray

• The population living in areas with API ≥5 is planned to be covered by LLINs and
population living in endemic areas registering API ≥2 is covered with conventional
net treated with insecticides and IRS.
• Conventional nets treated with insecticides will continue to be used in areas
registering API 2 to 5.
• IRS is still the preferred method of vector control in areas with very hot summers and
where ITNs are not acceptable to population.
• DDT is the insecticide of choice.
• DDT, the alternatives are malathion and synthetic pyrethroids.
• Two rounds of spraying are done for DDT and synthetic pyrethroids to provide
protection during the entire transmission season, and in the case of malathion, three
rounds of spraying are required.
• The real coverage by IRS is, however, limited by the low community acceptance due
to the white marks left on plastered surface, acrid smell associated with malathion,
replastering of walls after completion of IRS etc.

Tribal Malaria Action Plan (TMAP)
• A large section of tribal population lives in inaccessible terrains, forest, hilly and
riverbed conditions, and characterized by high degree of mobility, poverty,
inadequate clothing, outdoor sleeping habits, forest-based economy etc.
• Presence of efficient vectors, triple insecticide resistance and innumerous breeding
sites add to the problem.
• Health infrastructure is generally found to be inadequate in these areas.
• The key interventions as follows :
1. Strengthening surveillance.
2. Provision of hamlet-wise ASHAs instead of village-wise.
3. Wherever engagement of ASHAs is not possible, anganwadi workers of ICDS,
faith healers, local medical/ health care providers, village headmen, PRIs or school
teachers may be trained and provided relevant logistics to diagnose and treat
malaria cases.
4. Mobile health services.

5. Involvement of locally available, credible NGOs.
6. Strengthening of PHCs with quality microscopy facilities.
7. Provision of diagnosis and treatment facilities by contractors/owners of development
projects to the labours on site, should be made mandatory.
8. On the spot, species-specific radical treatment of all positive cases of malaria.
9. Identification of serious cases and early referral to specialized health facilities ,
ensuring free transport services.
10. Follow up and epidemiological tracking of all positive cases.
11. Mass screening of migrants wherever necessary.
12. Integrated Vector Management (IVM) for appropriate vector control.
13. Social marketing to increase usage of bed nets.
14. Regular and efficient supply chain management.
16. Intensive training and Community.

Behaviour change communication
(BCC)
• BCC is a systematic process that motivates individuals, families and communities to
change their inappropriate or unhealthy behaviour, or to continue a healthy
behaviour.
• BCC is a key supportive strategy for malaria prevention and treatment under
NVBDCP.
• BCC is directed at :
(a) early recognition of signs and symptoms of malaria
(b) early treatment seeking from appropriate provider
(c) adherence to treatment regimens
(d) ensuring protection of children and pregnant women
(e) use of ITNs/LLINs
(f) acceptance of IRS
Anti-malaria month is observed every year in the month of June throughout the
country, prior to the onset of monsoon and transmission season.

Lymphatic Filariasis
• Elephantiasis, occurs when filarial parasites
are transmitted to humans through mosquitoes.
• Covers infection with three closely related
nematode worms - Wuchereria bancrofti,
Brugia malayi and Brugia timori.
• The disease manifestations range from none to
both acute and chronic manifestations such as
lymphangitis, lymphadenitis, elephantiasis
of genitals, legs and arms or as a hypersensitivity
state such as tropical pulmonary eosinophilia.
• Adult worms nest in the lymphatic vessels and disrupt the normal
function of the lymphatic system.

• They can live for approximately 6–8 years and produce millions of
microfilariae that circulate in the blood and are taken up by mosquitos.
• Microfilaria show nocturnal periodicity.
• Culex quinquefasciatus (major) is the vector of Wuchereria bancrofti in
India and Mansonia for Brugian filariasis.
• Breeds in association with human habitations and prefers polluted
waters.
• Has a flight range of average 3 km but has been known to go up to
10km.
• In India, 99.4% of the cases are caused by the species - Wuchereria
bancrofti whereas Brugia malayi is responsible for 0.6% of the problem

• Incubation Period: 8 to 16 months or maybe longer
• Clinical Types
1. lymphatic filariasis
2. occult filariasis
1. Lymphatic filariasis
(i) Asymptomatic amicrofilaraemia : In all endemic areas a proportion of
population does not show Mf or clinical manifestations of the disease although
they have the same degree of exposure to infective larvae as those who become
infected.
(ii) Asymptomatic microfilaraemia : A considerable proportion of people are
asymptomatic, although their blood is positive for Mf. They may remain without
any symptoms for months - in some instances for years. They are an important
source of infection in the community.
(iii) Stage of acute manifestations: Recurrent episodes of acute inflammation in
lymph glands and vessels. The clinical manifestations comprise filarial fever,
lymphangitis, lymphadenitis, lymphoedema of the various parts of the body and
of epididymo-orchitis in the male.
Signs and Symptoms

(iv) Stage of chronic obstructive lesions : The chronic stage usually develops 10-
15 years from the onset of the first acute attack. This phase is due to fibrosis and
obstruction of lymphatic vessels causing permanent structural changes.
• In chronic Bancroftian filariasis, the main clinical features are hydrocele,
elephantiasis and chyluria.
2. Occult filariasis
The term occult or cryptic filariasis refers to filarial infections in which the
classical clinical manifestations are not present and Mf are not found in the
blood. Occult filariasis is believed to result from a hypersensitivity reaction to
filarial antigens derived from Mf

• Diagnosis:
1. The thick film test: 20 cu. mm of blood is collected by a deep finger prick
around 12 AM.
2. Membrane filter concentration (MFC): detecting low density microfilaraemia
3. DEC provocation test: Mf can be induced to appearing blood in the daytime
by administering diethylcarbamazine (DEC) 100 mg orally. Mf begin to reach
their peak within 15 minutes and begin to decrease 2 hours later. The blood
may be examined one hour after administration of DEC.
• Treatment for acute dermato-lymphangioadenitis:
1. Uncomplicated: paracetamol for pain, Amoxicillin 1.5g TDS for 8 days,
antiseptic cleaning,
2. Complicated: Intravenous benzylpenicillin (Penicillin G) 5 million units TDS
until fever subsides, phenoxymethylpenicillin 750mg TDS upto 8 days.
• Hydrocele surgery
Diagnosis and Treatment

• Diethylcarbamazine (DEC) is both safe and effective. The dose of DEC that is
most generally accepted for the treatment of Bancroftian filariasis is 6 mg/kg
body weight per day orally for 12 days, given preferably in divided doses after
meals.
• For Brugian filariasis, recommended doses range from 3 to 6 mg of DEC/kg
body weight per day, up to a total dose of 36-72 mg DEC/kg body weight as a
full treatment.
Specific Treatment

Indigenous cases have been reported from about 257 districts in 21 States/Union Territories.

Parameters
1. Microfilaria rate: It is the percentage of persons showing Mf in their peripheral blood
(20 cu. mm) in the sample population (prevalence of infection)
2. Filarial endemicity rate: It is the percentage of persons examined showing
microfilariae in their blood, or disease manifestation or both.(prevalence of disease)
3. Microfilarial density: It is the number of Mf per unit volume (20 cu. mm) of blood in
samples from individual persons. It indicates the intensity of infection.

• Launched in 1955.
• In June 1978, NFCP was merged with the urban malaria scheme for
maximum utilization of available resources.
• Filaria control strategy includes
• Vector control through anti larval operations
• Source reduction
• Detection and treatment of microfilaria carriers with DEC
• Morbidity management
• IEC (Information education and communication)
• National Filaria Control Programme is being implemented through 206
filaria control units, 199 filaria clinics and 27 survey units, primarily in
endemic urban towns. In rural areas anti filaria medicines and morbidity
management services are provided through primary health care system.
National Filaria Control Programme

• Mass Drug Administration (MDA) started in 2004.
• Initially with single dose of DEC only.
• In 2007: DEC + Albendazole (400mg) co-administration
• From 2018: Triple Drug Therapy (IDA) i.e. DEC + Albendazole + Ivermectin
(200 μg/kg) launched
• DEC dose 50mg (1-2 years), 100mg (3-4 years), 150mg (5-8 years),
200mg (9-11 years), 250mg (12-14 years) and 300mg >14 years
Twin Pillar
Strategy
Annual Mass Drug Administration
(MDA) of single dose of DEC
(Diethylcarbamazine citrate) and
Albendazole for 5 years or more to
the eligible population.
•Home based management of
lymphoedema cases and up-scaling of
hydrocele operations in identified CHCs/
District hospitals /medical colleges.

• The mass drug administration starts in the month of November and the
coverage has improved from 72.42% in the year 2004 to 87.25% in 2019.
• Initiation has also been taken to demonstrate the simple washing of
foot to maintain hygiene for prevention of secondary bacterial and
fungal infection in chronic lymphoedema cases, so that the patients get
relief from frequent acute attacks.

• Antilarval measures: Elimination of breeding places.
(a) Mosquito Larvicidal oil: Active against all preadult stages. It has been
the main chemical used to control C. quinquefasciatus for some time.
Replaced by pyrethrum oil, temephos and fenthion .
(b) Pyrosene oil- E: This is a pyrethrum-based emulsifiable larvicide. The
emulsion concentrate contains 0.1 to 0.2 per cent pyrethrins by weight
and is required to be diluted with water before use.
(c) Organophosphorus larvicides: The frequency of application is once
weekly on all breeding places.
• Removal of pistia plant : In the case of Mansonia mosquitoes, breeding
is best controlled by removing the supporting aquatic vegetation such as
the pistia plant from all water collections and converting the ponds to
fish or lotus culture.
• Minor environmental measures
• Space Spray: Pyrethrum (Shown resistance to DDT)
• Personal Protection (Bed Nets)

Kala Azar
• Slow progressing disease caused by a protozoan intracellular parasite
Leishmania donovani.
• The parasite primarily infects reticuloendothelial system and may be found
in abundance in bone marrow, spleen and liver.
• Post Kala-azar Dermal Leishmaniasis (PKDL) is a condition when Leishmania
donovani invades skin cells, resides and develops there and manifests as
dermal lesions.
• Some of the kala-azar cases manifests PKDL after a few years of treatment.
Recently it is believed that PKDL may appear without passing through
visceral stage.

• Recurrent fever and weakness
• Loss of appetite, pallor and weight loss with progressive emaciation.
• Splenomegaly - spleen enlarges rapidly to massive enlargement, usually soft
and nontender
• Liver - enlargement not to the extent of spleen, soft, smooth surface, sharp
edge Lymphadenopathy - not very common in India
• Skin - dry, thin and scaly and hair may be lost. Light colored persons show
grayish discoloration of the skin of hands, feet, abdomen and face which gives
the Indian name Kala-azar meaning "Black fever“
• Anemia - develops rapidly
Signs and Symptoms

1. Visceral leishmaniasis (VL), also known as Kala-azar is fatal if left untreated in
over 95% of cases . It is characterized by irregular bouts of fever, weight loss,
enlargement of the spleen and liver, and anaemia. Most
2. Cutaneous leishmaniasis (CL), is the most common form of leishmaniasis and
causes painful skin lesions, mainly ulcers, on exposed parts of the body where
sandflies bit, leaving life-long scars and serious disability.
3. Muco-cutaneous lesihmaniasis leads to partial or total destruction of mucous
membranes of the nose, mouth and throat.
Clinical Types

• Condition in which Leishmania donovani parasites are found in skin and
develops in some of the Indian kala-azar patients usually 1-2 years or more
following recovery of Kala-azar.
• Early hypopigmented macules similar to macular lesions less than 1 cm. Usually
occur on face but can affect any part of the body.
• Later diffuse nodular lesions on those macules
• Erythematous butterfly rash which may be aggravated by exposure to Sunlight;
an early sign of PKDL
• Erythematous papules and nodules which usually occur on face, especially the
chin.
• Lesions progressive over many years , seldom heal spontaneously
Post Kala-azar Dermal Leishmaniasis

1. RDT: rk39 - rapid diagnostic test
2. Parasitological diagnosis: demonstration of the parasite LD bodies in the
aspirates of the spleen, liver, bone marrow, lymph nodes or in the skin
3. ELISA:
4. Leishmanin (Montenegro) test: An intradermal injection of 0.1 ml
Leishmanin on the flexor surface of the forearm is given and examined after
48 to 72 hours. lnduration is measured and recorded. An induration of 5 mm
or more is considered positive.
Treatment:
1. Single dose Liposomal Amphotericin B (LAMB) injection IV in dose of 10
mg/kg
2. Miltefosine capsules of 10 mg (paediatric) and 50 mg (adults) in the age
group between 2-65 years.

• Sand fly vector of Kala-azar in India Phlebotomus aregentipes.
• Sandflies are small insects, about one fourth of a mosquito. The length of
body ranges from 1.5 to 3.5 mm, night feeder.
Life Cycle

Endemic in eastern States of India namely Bihar, Jharkhand, Uttar Pradesh and West Bengal
54 districts endemic; sporadic cases reported from a few other districts. Estimated 165.4
million population at risk in 4 states
Mostly poor socio-economic groups of population primarily living in rural areas are affected

• All programmatic activities are being implemented through NVBDCP.
• Goal: To improve the health status of vulnerable groups and at-risk
population living in Kala-azar endemic areas by the elimination of Kala-azar
so that it no longer remains a public health problem.
• Strategy:
National Kala-azar Elimination
Programme
I.Early
diagnosis &
complete case
management
I.Integrated
Vector
Management
I.Supervision,
monitoring,
surveillance
and
evaluation
I.Strengthening
capacity of
human
resource in
health
I.Advocacy,
communication
and social
I.Programme
management

• Integrated Vector Management: IRS twice a year in all houses and
complete coverage of cattle sheds in villages which had a Kala-azar case
reported in the last 3 years
• DDT is effective and 1st choice, sprayed upto a height of 6 feet at 1-
2g/sqm
• Two rounds: 1st round during February - March when sand fly are fairly
active and 2nd round during May – June to limit sand fly population
supplemented with focused IRS in the villages reporting KA cases.
• Active Surveillance: The frequency of case searches has been increased
from a single annual case search to Quarterly case searches.
• The active case searches are carried out during a fortnight designated as
the "Kala-azar Fortnight" , during which the peripheral health workers
and volunteers are engaged to make door-to-door search and refer the
cases conforming to the case definition of kala-azar and PKDL to the
treatment centres for definitive diagnosis and treatment.

• An incentive amount of Rs. 300 is provided to ASHA for identifying each
case of kala-azar and Rs. 100 for ensuring one round and Rs. 200 for
two rounds of insecticide spraying.
• Even the patient being treated in the hospital will be given Rs. 500 as
compensation of daily wage for the time he spends in the hospital
during the treatment for kala-azar and Rs. 2,000 for PKDL.
• The new strategy also includes introduction of Rapid Diagnostic Kit
developed by ICMR into the programme and single dose treatment with
Liposomal Amphotericin B given intravenously in 10 mg/kgbw dose. It is
to reduce the human reservoir of infection.
• Social mobilization: Intensive awareness campaigns with the
involvement of communities and community health volunteers.

Japanese Encephalitis
• Japanese Encephalitis is a viral disease transmitted by infective bites of
mosquitoes mainly belonging to Culex tritaeniorhynchus, Culex vishnui and
Culex pseudovishnui group.
• JE virus (flaviviridae) is primarily zoonotic in its natural cycle and man is an
accidental host.
• JE virus is neurotropic and arbovirus and primarily affects CNS

• Incubation: 2 to 26 days, many are asymptomatic
• Febrile illness of variable severity associated with neurological symptoms
ranging from headache to meningitis or encephalitis.
• Symptoms can include headache, fever, meningeal signs, stupor, disorientation,
coma, tremors, paralysis (generalized), hypertonia, loss of coordination, etc.
• Prodromal stage may be abrupt (1-6 hours), acute (6-24 hours) or more
commonly subacute (2-5 days)
• In acute encephalitic stage, symptoms noted are convulsions, alteration of
sensorium, behavioral changes, motor paralysis and involuntary movement
supervene, and focal neurological deficit is common.
Signs and Symptoms

• Culicine mosquitoes mainly Culex group (Culex tritaeniorhynchus, Culex
vishnui and Culex pseudovishnui) are the chief vectors of JE in different
parts of India.
Life Cycle

• JE viral activity has been widespread in India. First case was reported in 1955.
• During recent past (1998-2004), 15 states and Union Territories have reported JE
incidence.
• Annual incidence ranged between 1714 and 6594 and deaths between 367 and 1665

• Clinically suspect for encephalitis and then:
• Lab Tests: Compliment Fixation Test (CF), Enzyme Linked Immuno-Sorbant
Assay (ELISA) for IgG (paired) and IgM (MAC) antibodies, RTPCR etc.
• IgM ELISA is the method of choice provided samples are collected 3-5 days
after the infection.
• The cases are managed symptomatologically.
• Clinical management of JE is supportive and in the acute phase is directed
at maintaining fluid and electrolyte balance and control of convulsions, if
present.
• Maintenance of airway is crucial.

Program
• Japanese encephalitis is a disease with high mortality rate and those who
survive do so with various degrees of neurological complications.
• The strategies for prevention and control include strengthening of the
surveillance activities through sentinel sites in tertiary health care
institutions, early diagnosis and proper case management, integrated vector
control, capacity building and behavior change communication.
• As the JE vectors are outdoor resters, Indoor residual spray is not effective.
• The government of India provides need- based assistance to the states,
including support for training programmes and social mobilization.
• As there is no specific cure for this disease, early case management is very
important to minimize the risk of complications and death

• JE vaccination is recommended for children (1st dose at 9-12 months and 2nd
dose at 16-24 months SC LA) and catch-up dose can be given up to 15 years
of age (Single Dose 0.5ml < 3 yrs and 1ml > 3yrs).
• Emphasis should be given on keeping pigs away from human dwellings, or in
pigsties, particularly during dusk to dawn.
• Use of clothes which cover the body.
• Use of bed-nets is also very important precaution.
• The states are advised to use malathion for outdoor fogging as outbreak
control measure in the affected areas.
• Epidemiological monitoring of the disease for effective implementation of
preventive and control measure and technical support is provided on
request by the state health authorities.

Dengue Fever
• Dengue is a viral disease transmitted by the infective bite of Aedes Aegypti.
• Man develops disease after 5-6 days of being bitten by an infective
mosquito
• It occurs in two forms:
• Dengue Fever is a severe, flu-like illness
• Dengue Haemorrhagic Fever (DHF) is severe form of disease, may cause death

• Aedes aegypti is the vector: Small, black
mosquito with white stripes and is
approximately 5 mm in size.
• Takes about 7 to 8 days to develop the
virus in its body and transmit the disease
• It is a Day biter, mainly feeds on human
beings in domestic and peri-domestic
situations
• Bites repeatedly.
• Rests in the dark corners of the houses,
on hanging objects like clothes,
umbrella, etc. or under the furniture
• Breeds in any type of man made
containers or storage containers having
even a small quantity of water
• Eggs of Aedes aegypti can live without
water for more then one year.
Life Cycle

Program
• During 1996, an outbreak of dengue was reported in Delhi.
• In view of this a "Guideline of Preparation of Contingency Plan in case of
outbreak/epidemic of Dengue/Dengue haemorrhagic fever" was prepared
and sent to all the states.
• It includes all the important aspects of control measures like identification
of outbreak, demarcation of affected area, containment of outbreak, case
management, vector control, IEC activities about Do's and Don'ts for
prevention of dengue, monitoring and reporting etc.
• Government of India has identified 521 sentinel surveillance hospitals with
laboratory support for augmentation of diagnostic facilities in the endemic
states.
• For advanced diagnosis and back-up support 14 Apex Referral Laboratories
have been identified and linked with sentinel surveillance hospitals.
• To make these functional lgM capture ELISA test kits are provided through
National Institute of Virology, Pune free of cost.
• Contingency grant is also provided to meet the operational costs.

For early diagnosis ELISA based NS1 kits have been introduced under the
programme which can detect the cases from 1st day of infection.
lgM capture ELISA tests can detect the cases after 5th day of infection.
Steps for prevention and control of dengue:
(a) Surveillance: Disease and entomological surveillance.
(b) Case management: Laboratory diagnosis and clinical management.
(c) Vector management : Environmental management for source reduction.
chemical control, personal protection and legislation.
(d) Outbreak response : Epidemic preparedness and media management.
(e) Capacity building : Training, strengthening human resource and operational
research .
(f) Behavioral change communication Social mobilization, and information,
education and communication (IEC) .
(g) Inter-sectoral coordination : with ministries of urban development, rural
development, Panchayati raj, surface transport and education sector.
(h) Monitoring and supervision : Analysis of reports, review, field visit and feed-
back.

Chikungunya Fever
• Chikungunya (chik'-en-GUN-yah), also called chikungunya virus disease or
chikungunya fever, is a viral illness that is spread by the bite of infected
mosquitoes primarily Aedes aegypti.
• Resembles dengue fever, and is characterized by severe, sometimes
persistent, joint pain (arthritis), as well as fever and rash.
• It is primarily found in urban /peri-urban areas.
• There is no specific treatment for chikungunya.
• Prevention centers on avoiding mosquito bites in areas where chikungunya
virus may be present, and by eliminating mosquito breeding sites.
• Diagnosed by ELISA.

Signs and Symptoms
• Starts suddenly with fever, chills, headache, nausea, vomiting, joint pain,
and rash.
• In Swahili, "chikungunya" means "that which contorts or bends up". This
refers to the contorted (or stooped) posture of patients who are afflicted
with the severe joint pain (arthritis) which is the most common feature of
the disease.
• Frequently, the infection causes no symptoms, especially in children.

The states affected by chikungunya are Andhra Pradesh, Karnataka, Maharashtra, Madhya
Pradesh, Tamil Nadu, Gujarat & Kerala.

Program
• Guidelines for prevention and control of the disease have been prepared
Since same vector is involved in the transmission of dengue and
chikungunya, strategies for transmission risk reduction by vector control are
also the same.
• Support in the form of logistics and funds are provided to the states.
• Carrying out proactive surveillance and enhancing diagnostic facilities for
chikungunya, the 521 sentinel surveillance hospitals involved in dengue in
the affected states also carry out chikungunya tests.
• The diagnostic kits are provided through National Institute of Virology,
Pune, by the central government.
I.Integrated
Vector
Management
I.Supervision,
monitoring,
surveillance
and
evaluation
I.Logistics
Support

Bibliography
• K. Park’s Textbook of PSM (Primary Resource)
• nvbdcp.gov.in (For Latest Statistical Data and Current Guidelines)
• who.int (For Life Cycles Illustrations and Treatment Protocols)
• Google Images (For Stock Images)

National Vector Borne Disease Control Programme

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