MALARIA CONTROL STRATEGIES IN INDIA-FROM INDEPENDENCE TO 2016 Moderators : Dr. Pragti Chhabra, Dr.Priya Presentors: Dr. Rashmi, Dr. Parinita MALARIA- BACKGROUND • Malaria is one of the major communicable diseases affecting humankind, caused by Plasmodium parasite, transmitted by the bite of infective female Anopheles mosquito. • Long before the British colonised India, malaria was a serious problem for the country, imposing enormous economic costs and a great deal of human misery. • In 1852, one malaria epidemic wiped out the entire village of Ula and then spread across the Bhagirathi River to Hooghly and continued to devastate populations for many years in Burdwan. • The development of the Indian railways under the British administration contributed to the spread of malaria. • In the early 1920s, Bengal suffered a severe malaria epidemic which resulted in over 7,30,000 deaths in 1921 alone. • During the Second World War malaria deaths in Bengal in 1943 were recorded over 6,80,000 and 7,63,220 deaths in 1944. • Although quinine was available at the time, its supply was inadequate and patients did not seek treatment on time. HISTORY OF MALARIA • 5th century BC - Hippocrates first described features of malaria. • 1880-Laveron, discovered malarial parasites in human RBCs • 1897-Ronald Ross discovered the role of Anopheles mosquitoes in the transmission of malaria. • 1939- Paul Muller discovered insecticidal property of DDT, which opened a new avenue in control of malaria Charles Alphonse Laveran discovered the the causative organism of malaria in autopsies he conducted on malaria victims, a protozoan he named Oscillaria malariae, later renamed Plasmodium. Sir Ronald Ross discovered malarial parasite in the gastrointestinal tract of a mosquito who had sucked blood from malaria victims and prove that malaria was transmitted by mosquitoes. HISTORY OF MALARIA CONTROL IN INDIA • 1900s- Malaria control operations centred on control of mosquito breeding • 1909- Central Malaria Bureau established at Kasauli • 1927- Renamed as Malaria Survey of India. • 1938- Renamed Malaria Institute of India, shifted to Delhi • 1910 to 1936 - control of mosquito breeding practised using larvicides like Paris green and oil. • 1945- DDT released for public health use & trials started in India. • For the first time, a cost-effective tool for mass application to interrupt malaria transmission. Milestones of Malaria Control Program YEAR PROGRAMME 1953 NATIONAL MALARIA CONTROL PROGRAMME (NMCP) 1958 NATIONAL MALARIA ERADICATION PROGRAMME (NMEP) 1971 URBAN MALARIA SCHEME (UMS) 1977 MODIFIED PLAN OF OPERATION (MPO) 1979 MULTIPURPOSE WORKER SCHEME 1995 MALARIA ACTION PLAN (MAP-95) 1997 ENHANCED MALARIA CONTROL PROJECT 2000 NATIONAL ANTI MALARIA PROGRAMME (NAMP) 2004 NATIONAL VECTOR BORNE DISEASE CONTROL PROGRAMME (NVBDCP) NATIONAL MALARIA CONTROL PROGRAMME, 1953 • 1947- 75 million malaria cases (21.8% population) with 800,000 deaths. • 1946- A comprehensive programme to control malaria recommended by the Bhore committee. • 1953-National Malaria Control Program (NMCP) launched in the country. Key activities : 1. Insecticidal residual spray (IRS) with DDT 2. Monitoring and surveillance of cases 3. Antimalarial treatment of patients Working of Program • 125 control units established, Each to protect a million people. • Each unit were to apply 100 mg of DDT per square foot of wall surface once every 6 months during the transmission season for 3 years (+2 years). • Surveillance mechanism started after child spleen rate fell below 5% parasite rate below 1% infant parasite rate to zero. Achievements • 5 years of NMCP operations (1953-57) achieved remarkable Success. • Malaria cases rapidly brought down from 75 million to 2 million . • Fall of Proportional Case Rate from 10.8 (1953) to 3.2 (1958) . • Paid rich dividends to the country in Agriculture, Land projects and Industry. Malariometric Indicators in Pre Eradication era NATIONAL MALARIA ERADICATION PROGRAMME, 1958 • The National Malaria Eradication Programme was launched in the year 1958. • This programme covered the entire territory (population of 547 million) except for 15 million people which lived at an altitude higher than 5000 ft where there was no malaria transmission. • The programme was implemented through 393 N.M.E.P. Units. Objectives • Total ending of transmission of malaria. • Elimination of the reservoir of infection. • Prevention of reestablishment of malaria by 1968-1969. Strategy The programme was divided into 4 phases Preparatory phase This phase was not taken up because of experience gained during the control programme Attack phase • complete insecticidal coverage was the main theme with DDT application twice a year during the malaria transmission season for a period of 34 years to interrupt malaria transmission. • In later part of the attack phase ; when the API was reduced to 0.5 cases per 1000 population surveillance was instituted. Consolidation phase: Spraying was withdrawn, but surveillance continued. The main activity in this phase was active and passive surveillance, presumptive and radical treatment of malaria cases, epidemiological investigation of cases, and institution of remedial measures to eliminate the foci of malaria. Maintenance phase: When no more indigenous cases of malaria appeared despite careful searching during the period of 3 years of which 2 years were in the consolidation phase, antimalaria units went into maintenance phase and were handed over to the state governments for continuation of malaria vigilance activities. • Achievements of National Malaria Eradication of India • Phenomenal Achievement. • In 1958-61, cases were reduced to 50,000. This was the Period of Highest Achievement. • As against one hundred million cases and a million deaths due to malaria in 1947, there were hardly 1.5 million cases and practically no deaths in 1963-64. • In terms of money gains it had been a substantial achievement. Reversal • During 1965, there were some focal outbreaks in consolidation phase areas. • Most outbreaks in Rajasthan, Gujarat, Madhya Pradesh, Uttar Pradesh and Maharashtra. • In 1976, Cases increased to 6.4 million cases and 59 deaths. • 0.1 API in 1964 increased to 11 in 1976. • P. falciparum 11% of all malaria cases. Causes of Setbacks 1. ADMINISTRATIVE FAILURES 2. TECHNICAL FAILURES • Shortages of insecticides and anti malarial drugs. • Shortage of experienced malaria field workers. • Rising cost of anti malarial operations. • Difficulty in recruitment of labourers for spray work. • Inability to procure BHC, Malathion in required quantities. • Entrusting the work to multipurpose and basic health facilities. • Insecticide resistance in vectors. • Parasite resistance to chloroquine. 3. OPERATIONAL FAILURES • Inadequate surveillance and case detection. • Principle of “Total Coverage” not observed during attack phase. • Premature take-off into consolidation and maintenance phases. • Undue reliance on basic health services who were ill prepared for the task. Modified plan of operation, 1977 • Modified Plan of Operation (MPO) was launched in 1977 with following objectives: 1) Elimination of deaths from malaria 2) Reduction in the malaria morbidity 3) Maintenance of the gains achieved earlier by reducing transmission wherever possible • Strategy under MPO- 3 pronged 1. Early diagnosis and prompt treatment 2. vector control 3. IEC/BCC with community participation. Reclassification of endemic area: Area divided into two group on the basic of API (Annual Parasite Incidence) 1. Areas with API more than 2 2. Areas with API less than 2 1. Areas with API more than 2 • Indoor Residual Spraying – 2 rounds of DDT every year, if refractory to DDT, 3 rounds of HCH, if refractory to both DDT and HCH, 3 rounds of malathion at intervals of 6 weeks. Doses of DDT, HCH and malathion were 1.0, 0.2 and 2.0 grams per square meter surface respectively • Entomological assessment: carry susceptibility test and suggest appropriate insecticide • Malaria surveillance: Active and Passive • Treatment of cases : Presumptive and radical treatment 2. Areas with API less than 2 • Focal spray if case of Pf in the area. • Surveillance and Treatment • Follow-up: blood smear to be collected from all positive cases at the end of radical treatment and thereafter at monthly intervals for 12 months. • Epidemiological investigation P.Falciparum Containment Program (PfCP) • During implementation of MPO, emergence of P.falciparum in epidemic form in some areas posed a serious challenge. • Government in collaboration with WHO and financial support from SIDA launched PfCP within MPO in 1977 to arrest the frequent epidemics of P.falciparum. • The specific purpose of this component was to prevent or contain or control the spread of falciparum malaria. • It was started in North east, Orissa, Bihar, WB,AP, MP, Rajasthan, By 1983, 84 districts covering 98 million population under it. Urban Malaria Scheme • By 1970s rural malaria incidence came down to 0.1 million cases but urban malaria showed rising trend to the extent of 9 to 10% of total cases • Urban Malaria Scheme (UMS) was sanctioned in 1971 after the recommendations of Madhok Committee in 1969. • Initially, 23 towns were selected for programme implementation. Subsequently, the Scheme was extended to 131 towns in 19 states/Union Territories covering a population of 116 million. • Objectives 1.To control malaria by reducing the vector population in the urban areas 2. To Reduce morbidity and mortality NORMS a. The towns should have a minimum population of 50,000. b. The API should be 2 or above. c. The towns should promulgate and strictly implement the civic by-laws to prevent/eliminate domestic and peri-domestic breeding places Strategies under Urban Malaria Scheme: i. Parasite control: Treatment through passive agencies viz. hospitals, dispensaries both in private & public sectors and private practitioners. ii. Vector control comprises of the following components • Source reduction • Biological control-Use of larvivorous fish • Chemical control- Use of larvicides • Space spray- in and around malaria positive cases • Legislative measure High risk areas for malaria in Urban areas Active surveillance of malaria • Health worker(male) does house to house survey every fortnightly in his area of subcenter villages • He enquires a) if there is a case of fever ? b) was there a case of fever in the house between his previous and present visit? • If the answer to any question is YES, • He makes thick and thin blood films and sends them to PHC • Gives presumptive treatment ( 600mg of chloroquine; adult dose ) • If slide is positive for malaria, health worker goes back to that house and gives radical treatment depending on the species of malarial parasite. • For Pv: chloroquine 600 mg & primaquine 15mgX 5days • For Pf: chloroquine 600mg & primaquine 45mg stat Parameters of malaria surveillance Annual Blood Examination Rate (ABER)% of population examined for peripheral blood smear during a given year. ABER = Number of smears examined in a year x 100 Total population under surveillance Annual Parasite Incidence No. of new confirmed cases of malaria occurring in an area during a given year. (by blood smear examination) API= Number of positive smears in a year x 1000 Total population under surveillance Annual falciparum incidence: Confirmed new cases of falciparum malaria per 1000 population, during a given year AFI= Number of positive smears in a year x 1000 Total population under surveillance Plasmodium falciparum percentage: % of P. falciparum positive blood smears out of total positive blood smears Slide Positivity Rate Percentage of slides positive for malarial parasite irrespective of species. SPR ● = Total number of positive smears for MP Total blood smears examined Gives info about parasite load in community Slide falciparum Rate Percentage of slides positive for P. falciparum parasites SFR = Total number of positive smears for P f Total blood smears examined • The implementation of urban malaria scheme (UMS) and the modified plan of operation (MPO) improved the malaria situation for 5-6 years. • Malaria cases were reduced to about 2 million. • The impact was mainly on vivax malaria. • Easy availability of drugs under the MPO prevented deaths due to malaria and reduced morbidity. • The P. falciparum containment programme (PfCP) helped reduce falciparum malaria in the areas where the containment programme was operated but its general spread could not be contained. • P. falciparum showed a steady upward trend during the 1970s and thereafter. • Rising trend of malaria was facilitated by developments in various sectors to improve the national economy under successive 5 year plans.
