Malaria: Bringing Down The Burden
In Odisha
Dr. MM Pradhan
Dy. Director,
NVBDCP, Odisha
MMV Stakeholders’ Meeting, Delhi (India), 8th Nov, 2012
Odisha at a glance
Area: 156,000 sq kms (4% of
India’s land area)
Popln: 42 million (3% of India)
Rural : 82% , Urban : 18%
Tribal - 22% + sch. caste -16%
( St & SC = 36%)
Out of 75 Primitive Tribal Groups in
India ,13 are in Odisha.
There are 30 district with 314 blocks
and >51,000 villages
Favourable geo-ecotypes: Perennial streams in forest areas
-Forest area are also rich in minerals with mining activities and high
migratory population
Average temperature : 15 0 to 35 0С (extreme: 50С to 48 0С)
Rain fall : 1452 mm with high humidity (>60%)}
Transmission seasonality
2009 - Death
2011 - Death
40000
22
19
23
16
14
21
15
15
10
4
20
16
19
15
28
19
15
8
11
2
11
14
9
15
12
4
7
12
15
2
15
13
10000
14
20000
25
25
23
30000
35
30
31
50000
40
2010 - Death
2009 - Cases
38
60000
8
10
5
0
0
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Transmission is perennial with one peak in
forested districts (mostly tribal dominated)
Forest covers 34.2%
Kandhamal ( Pf > 90%)
5000
4500
4000
No of cases
3500
3000
2500
2000
1500
1000
500
0
Jan Feb Mar Apr May June July Aug Sep Oct Nov Dec
Malaria cases 1765 1864 2193 2691 2542 3760 4154 4826 4363 3190 2865 2338
Pf cases
Death
1678 1771 2077 2549 2410 3583 3935 4543 4143 2975 2644 2203
1
2
7
3
5
7
3
2
3
3
3
0
Malaria Epidemiological Situation, 2002-12
Year
Total
Tested
+ve
PF
Death
ABER
SPR
Pf%
API
83.16
12.64
2002
4570466 473223
393523
465
2007
4945551 371879
323150
221
12.22
7.52
86.90
9.19
2008
5029677 375430
329631
239
12.23
7.46
87.80
9.13
2009
5015489 380904
336047
198
12.00
7.59
88.22
9.12
2010
5240458 395651
350428
247
12.30
7.55
88.57
9.29
2011
4657978 298423
272971
100
11.13
6.41
91.47
7.13
2010 –
upto Sept.
3743258
277915
244744
162
7.42
88.06
2011 –
upto Sept.
3452288
232911
213029
66
6.75
91.46
2012 –
upto Sept.
3457988
187176
173137
46
5.41
92.50
12.21
10.35
Malaria cases decreased by 20% & deaths by 30% (2011 vs 2012 by September)
2007
Status of Malaria API of Odisha from 2007-2011
2009
2010
Year wise distribution of Districts with API
Year
0-2
2-5
5-10
>10
2007
7
3
6
14
2008
7
5
5
13
2009
10
3
4
14
2010
10
4
4
12
2011
12
5
3
10
2011
There is a decrease in API
2008
Malaria control strategy:
As per the National program with
state specific appropriation
A. Primary:
1. Early diagnosis (Microscopy & RDT) and completer
treatment with effective & appropriate
Antimalaria drugs
2. Integrated vector control : LLIN , IRS, source
reduction
B. Supportive: Monitoring & evaluation, capacity building IEC
& BCC – PPP & Social mobilisation advocacy, Operational
research
Structure of health services in Odisha
30 Districts with 32 Dist
Hospital
314 Blocks
(125K pop per block)
Malaria
surveillance,
Diagnosis &
treatment available
free of cost at each
Health facility
Primary Health Center (20-30K pop)
4-5 PHCs per block
Sub-center (5K pop)
(4-5 SCs per PHC)
51,000 villages (0.5-1K pop per village)
(8-10 villages per SC)
Inputs & interventions for malaria control from 2009 onwards.
3000000
2774000
300
2500000
9.29
LLIN
ITN
250
247
MO-Mashari
9.12
2000000
200
RDT
150
RDT(Bi-valent)
procure by
State
1750725
1500000
50
6220
API
0
2009-10
2010-11
2011-12
ACT
ASHA Capacity
building
683400
500000
650000
622875
100
0
121700
674324
100
15000
0
0
700000
254356
101350
83911
0
0
0
0
15000
500000
0
RDT(Monovalent) procure
by Sate
7.13
1199000
1000000
1902668
198
Death
Surveillance and Early Diagnosis & Complete Treatment
(RDT + ACT) at village level
Out of 41264 ASHAs, >38000 have
been trained (92% )
646 AYUSH doctors & around
2000 tribal school teachers have
been trained on EDCT
Around 500 Forest (VSS)
Animators have been trained as
FTD to provide EDCT service in
Forest villages in four tribal
districts (Rayagada, Gajapati,
Kandhamal and Koraput)
Sentinel Site Malaria laboratories-2011
Characteristics of IPD patients at SSL, 2011
2501000
450000
400000
Characteristics of OPD cases at SSL, 2011
380987
2001000
350000
1957077
No of in patients
300000
1501000
250000
200000
1001000
150000
100000
50000
25139
(6.59%)
7203
(1.89%)
501000
158871
(8.1%)
0
Total In Patient In patient suspected Confirmed Malaria
as malaria
cases
11175
(.57%)
1000
Total New OPD
Cases
Suspected malaria Confirmed Malaria
Cases
cases
Seasonality of IPD cases in 2011
Total IPD
1569
94156
4220
5773
10575
40000
20000
1500
1000
4571
60000
74368
80000
2000
85844
1405
100000
2500
2280
Total Positive
126619
120000
Total In patients suspected as malaria
1949
140000
Oct - Dec
Jul - Sep
Apr - Jun
0
Jan - March
0
500
Integrated Vector Control: IRS
IRS – 2 rounds protect high risk
population ( API > 5) - around 8.7
million in 22 districts
Hand Compression Sprayer Pumps
(HCSP) have been introduced
Integrated Vector Control : LLIN
Total 18.99 Lakhs LLIN distributed in 2009-10
and another 19 Lakh in 2011-12 (total
around 38 lakh LLIN) - protect around 90
lakh population,
State specific LLIN guidelines
adopted for LLIN distribution
LLIN distribution was done
through GKS (village health
sanitation
committee),followed by
intensified IEC & BCC
Sundargarh
Sonepur
Sambalpur
Rayagada
Nuapada
30000
40000
30000
80000
95000
API-10
150000
150000
140000
Nawarangapur
40000
102600
100000
100000
90000
94000
LLIN Distribution 2009-10
Mayurbhanj
Malkangiri
50000
40000
Koraput
Keonjhar
Kandhamal
Kalahandi
40000
30000
20000
Jharsuguda
Ganjam
Gajapati
68500
80000
Dhenkanal
Bolangir
65000
60000
Bargarh
111000
100000
Angul
API trend after 1st phase LLIN distribution ( around 19 lakh)
160000
120.00
API-11
0
100.00
120000
80.00
60.00
40.00
20.00
0.00
Encouraging results after the new
interventions:
positive
2037
pf
pv
•LLIN in 2009 along with
ACT
1707
•Special awareness
campaign- NIDHI RATH
925
690
336
•Nil reported death
235
No. of Positive casese
pf
650
5000
550
4000
450
3000
350
2000
250
1000
150
50
0
2008
2009
2010
2011
K. Nagar Sub. Divisonal Hospital catering
the population of a High Endemic Tribal
block of Dhenkanal district
State initiative Mo Mashari (my mosquito net)
In 2 phases 2.24 Lakh LLINs have been provided to Pregnant mothers in
7 high burden tribal districts to protect pregnant mothers
Besides, pregnant mothers, Tribal school boarders and inmates are
protected by ITN/LLIN - 2.04 Lakh Single size ITN/ LIIN provided to these
vulnerable group.
Study findings:
•91% of pregnant women slept
under LLIN last night (n=809).
•88% of pregnant women slept
under LLIN last night with their child
under 2 years (n=809).
•But in general / cluster distributed
areas (n=2925), 70% of family
members slept under LLIN last night
Innovative IEC &BCC
• Use of traditional folk theatre, Jatra
etc.
• Partnership with GKS & CBOs
• Advocacy & Inter-sectoral
coordination
• Involvement of School teacher &
student, Traditional / Faith healers
Nidhi
Mausa
Adalat
NGO/PPP and Inter Sectoral Co-ordination
NGOs engaged under NRHM
are involved in screening of
malaria cases, impregnation of
bed nets, laboratory diagnosis
and community mobilization
and monitoring.
Other departments: Women & Child Development., Forest and Environment, Schedule Caste &
Schedule Tribe, School and Mass Education, Panchayati Raj Institutions, ICMR institutes
Lot Quality Assurance
Sampling: LQAS
LQAS : ME tool in malaria program.
Conducted twice a year –at present
conducted in 21 districts.
The LQAS findings from 2009 to 2011 on % of people protected either by ITN/LLIN.
Sundargarh
Mayurbhanj
Nabarangpur
Kandhamal
Mon Target
70%
60%
50%
40%
Sundargarh
30%
Mayurbhanj
20%
Nabarangpur
Kandhamal
10%
Mon Target
0%
Nov (2009)
Aug (2010)
Nov(2010)
Aug(2011)
Nov (2011)
Research & Documentation
Operational research
(Dfid support):
• Vector study by VCRC in 10
southern districtspublication awaited
• Mo-Mashari (my mosquito
nets) by T & MST (of Dfid)
– report released
• LLIN impact study by ICMR
institutes – reports
awaited
Guidelines and reports:
– LLIN state Guidelines
– Operational manuals
– Annual Activity report –
used for advocacy
– Training manuals for
doctors, Health workers,
ASHA
– FAQs for school students
and others
Comprehensive case management(Pilot): MMV-NIMR - Odisha
3Ts: test, treat & tract
Rationale:
• Case management of malaria, beyond ‘treating the
sick’, could reduce the infectious reservoir.
• The size of the infectious reservoir is an important
determinant of malaria transmission in low &
medium endemic areas
Universal vector control is difficult and expensive
where large populations are at variable risk
Objectives of the Study
Primary
• To assess the impact of CCM for uncomplicated malaria on its incidence/
transmission in different transmission settings in the state of Odisha, India
Secondary
• Determine the mix of interventions and related costs needed for scale-up
of comprehensive case management
• Develop a community based surveillance model for reporting and timely
action
• Better define the burden and epidemiological profile of malaria in the area
• Identify challenges in the radical cure of malaria, particularly P. vivax
• Strengthen the pharmaco-vigilance system to generate community level
data on adverse events
Project design
High case load
(ca. 2000
patients p.a)
Medium
transmission
(API: 8)
Mixed vivax
(30%)
Medium case
load
(ca. 1000
patients p.a.)
Intervention / Control
High
transmission
(API: 18)
Low vivax (10%)
Intervention / control
Intervention / Control
• Operational research project with NVBDCP
• Total study population 800,000
• 3 year study period (October 2012 – 2015)
Low
transmission
(API: 3)
High vivax (50%)
Low case load
(ca. 300 patients
p.a)
I want to play at school
- help me for no malaria
Challenges:
•Tribal areas - cultural
and language barrier
•Forest villages
•Inaccessibility and poor
health services
•Inadequate health staff
•Increased mining and
developmental activities
•Urban set ups with
migratory population &
poor health structure for
public health activities
Thanks
Challenges:
More research for newer
interventions
Health system research
-functioning of ASHA
& other health volunteers
-Community based
organizations (GKS)
-Community mechanism
- Role of Traditional
healers in tribal areas
-Role of general
practitioners, chemists,
private and other sectors