Anti malaria month june 2013

Workshop on Malaria Control Programme

1. MD KABIUL AKHTER ALI VBD Consultant, Public Health Wing,Malda Workshop on Malaria control program management 19 June 2013

2. Goal of Anti Malaria Month Anti –Malaria month is being observed all over India  in the month of June. June, being the pre Monsoon month has been selected for creating awareness among the masses against Malaria, a fever caused by a parasite transmitted ensure appropriate public health focus to improved access to primary health care, pre by mosquito bite. The AMM campaign is also an attempt to enlarge and vention and control of communicable diseases Including vector borne diseases, reduction of infant mortality rate and maternal mortality ratio by 50% by year 2012 and promotion of healthy life styles as per the goals of the National Rural Health Mission launched by the GoI in April 2005 .

3. Objective of Anti malaria Month The specific objectives of the Anti Malaria Month campaign strategy through BCC are as under: 1.Enhance awareness regarding source and transmission risk reduction, treatment, availability of services at different levels   2.Promote attitudinal and value changes among target audiences leading to informed decisions, modified behaviour , desirable practices at individual and societal level   3.Stimulate increased and sustained demand for quality prevention and care services and optimal utilization of available health care services   4.Build support for the programme across inter- sectoral partner organizations, influential sectors of society (corporate houses, political representatives, social activists, media, civil society organizations, etc.) and health care service providers and elicit commitment for action   5.Ensure availability of services.

4. PHASING OF ANTI MALARIA MONTH CAMPAIG Phase I - Preparatory phase: 3 months (December - February) Drawing up of Action Plans for the current AMM through BCC following inputs from States/UTs. Finalization of BCC materials. Distribution of BCC materials to different levels of implementation. Compilation of AMM report of the previous year. Phase II – Advocacy: 3 months (March - May) Organization of Advocacy workshops/conferences. Organization of Task Force for observance of AMM at all levels of programme implementation Finalization of BCC materials and printing for distribution to inter- sectoral partners. Phase III – Intensive campaign: 3 months (June – August) Umbrella campaign Localized campaign On ground initiatives Phase IV –Evaluation and Report submission: 3 months (June - August) Concurrent evaluation Consecutive evaluation Phase V – Localized follow up campaign: 3 months (September – November) Localized campaign On ground initiatives

5. Strategies for malaria control in rural areas Early case diagnosis and prompt treatment: through village based community volunteers designated as: Drug Distribution Centre (DDCs), who distribute chloroquine tablets to patients with fever. and ii) Fever Treatment Depots (FTDs), who collect blood smears from fever cases and provide appropriate treatment after slide examination at a microscopy facility.

6. Algorithm for diagnosis and treatment of malaria

7. Algorithm for diagnosis and treatment of malaria

8. Treatment of uncomplicated P. vivax malaria Chloroquine 25 mg/kg divided over 3 days(10 +10+ 5). Primaquine 0.25 mg/kg daily for 14 days. Primaquine contraindicated in Infants Pregnant women & Known G6PD deficient patients - do test if available, Stop PQ if patient develops dark colored urine, yellow conjunctiva, blue discoloration of lips, nausea, vomiting or abdominal pain & report to doctor

9. Treatment of uncomplicated malaria (P. Vivax) Age Chloroquine (150 mg) Primaquine (2.5 mg) (years) Day 1 Day 2 Day 3 No. of tablets < 1 ½ ½ ¼ Nil 1 – 4 1 1 ½ 1 5 – 8 2 2 1 2 9 – 14 3 3 1½ 4 > 15 4 4 2 6 Primaquine given for 14 days in confirmed P vivax Contraindicated in infants, pregnant women & patients with G6PD deficiency

10. Treatment of uncomplicated malaria P. falciparum All cases confirmed by microscopy/ RDT should get Artemisinin Combination Therapy (ACT) – Artesunate (4 mg/ Kg BW)/ day for 3 days & SP (Sulphadoxine – 25 mg/Kg BW & Pyremethamine 1.25 mg/Kg BW) single dose - day 0 & Primaquine single dose (0.75 mg/kg BW) on 2 nd Day. Oral artemisinin monotherapy banned - can lead to drug resistance.

11. Treatment of uncomplicated malaria (P. falciparum) Age (years) Number of tablets For AS & SP Primaquine (7.5 mg) Day 1 Day 2 Day 3 Day 2 <1 AS SP ½ ¼ ½ Nil ½ Nil Nil 1 – 4 AS SP 1 1 1 Nil 1 Nil 1 5 – 8 AS SP 2 1½ 2 Nil 2 Nil 2 9 – 14 AS SP 3 2 3 Nil 3 Nil 4 15 & above AS SP 4 3 4 Nil 4 Nil 6

12. Treatment of mixed infections Mixed infections with Pf should be treated as falciparum malaria. Anti-relapse treatment with Primaquine to be given for 14 days. Treatment of malaria in pregnancy Pf cases: ACT in 2 nd & 3 rd trimesters & quinine in 1 st trimester (if quinine NA, use ACT). P. vivax treated with Chloroquine in all trimesters. No anti relapse treatment (Primaquine)

13. General recommendations Avoid treatment on an empty stomach. First dose under observation & repeat if vomiting occurs within 30 minutes. Ask to report back, if no improvement after 48 hrs or situation deteriorates (Not responding to treatment). Also examine for concomitant illnesses.(an illness that occurs during the same time as another illness.)

14. b. Integrated vector management : Indoor residual spray in selected pockets at high risk of malaria Promotion of use of insecticide treated bed nets (ITBNs) through free or subsidized supply to below poverty line (BPL) population living in remote, inaccessible areas with high risk of malaria as well as insecticide treatment of community owned bed nets Use of biological vector control measure as larvivorous fish Environmental and minor engineering methods.

15. c. Capacity building: Of the medical and non-medical personnel as well as inter- sectoral partner organizations, community volunteers for imparting knowledge and strengthening skills in respect of prevention and control initiatives including innovative technology. d. Information , Education and Communication ( IEC 1 IEC 2) To enhance awareness among members of the target communities and health care service providers about causes, prevention and treatment of malaria, availability of facilities.

16. Steps in Behaviour Change

17. Internal Stimulus Change Agent Innovation Policies Technology Mass Media Community Dialogue Recognition of a Problem Identification & Involvement of Leaders & Stakeholders Clarification of Perceptions Expression of Individual & Shared Interests Vision of the Future Conflict-Dissatisfaction Action Plan Consensus of Action Options for Action Setting Objectives Assessment of Current Status Collective Action Assignment of Responsibilities Mobilisation of Organisations Implementation Outcomes Participatory Evaluation Individual Change Skills, Knowledge, Attitudes, Perceived Risks, Self-Image, Emotion, Self-Efficacy, Social Influence, Personal Advocacy, Intention, Behaviour Social Change Leadership, Degree and equity of participation, information equity, collective self-efficacy, sense of ownership, social cohesion, social norms Societal Impact E x T E R N a l C O n s t R a I N t s & S U P P o r t Catalyst The Integrated Model of Communication for Social Change

18. e. Epidemic preparedness and response: Under NVBDCP, it is visualized that every district in the country should have rapid response teams for undertaking prompt remedial measures in the event of an outbreak of malaria.  

19. f. Monitoring and Evaluation of the Program Monthly Computerized Management Information System(CMIS) Field visits by Program Officers / personnel Field visits by Malaria Research Centers and other ICMR Institutes Feedback to states on field observations for correction actions.

20. Logistic and Anti Malarial Drug Management The norms for calculation of Anti-malarial drugs to avoid stock-outs even in the circumstances like unforeseen outbreaks and procurement delays are as follows: The data of positive malaria cases of the last completed year is taken as basis for calculation. 25% additional quantity is to be taken as buffer on the technical requirement. In declining trend of malaria cases, the chance of outbreak is always there. Therefore the maximum possible deviation may be up to maximum number of cases reported in any of the years during the decade may be considered. This figure should also be considered for calculation of requirements of anti-malaria's. This factor is also considered especially when under reporting is known.

21. Objectives - to prevent deaths due to malaria - to reduce malaria morbidity - to maintain agriculture and Industrial - production through intensive anti malaria measures in such areas -to consolidate the gains achieved so far Areas were reclassified based on the Annual Parasitic Incidence (API) as those having API > 2 and those having < than 2 for operational purposes ‘Modified Plan of Operation’

22. 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 Active and passive surveillance is carried outon regular basis every fortnight Presumptive Treatment to all fever cases and radical treatment to all slide positive cases is given Areas having Annual Parasite Index (API) > 2

23. Regular spray is not carried out but ‘focal’ spray is carried out around falciparum cases detected during surveillance Regular passive surveillance once in a fortnight Treatment –All positive cases to receive radical treatment Follow up- All positive cases to be followed up for 1 year at monthly intervals after completion of radical treatment Epidemiological investigation of all malaria positive cases .This may also include mass blood survey. Areas having Annual Parasite Index (API) < 2

24. Investigation of all Malaria Deaths- All cases suspected to have died due to malaria are to be investigated Monitoring and control of all epidemics and focal out breaks of malaria – Any increase in the number of fever cases suggestive of malaria should be promptly investigated and measures to contain the outbreak should be instituted .

25. Definition: Anti-larval operations causing the reduction or permanent elimination of mosquito breeding places or sites are defined as source reduction methods. Source reduction primarily aims to prevent development of aquatic stages of mosquito larvae reducing breeding source. These methods are environment friendly, economical in the long run with minimum maintenance and surveillance. Guidelines on Source Reduction

26. Source reduction methods are further classified into Elimination or reduction of breeding sites primarily involving engineering methods. Environmental manipulation.

27. Advisory for Control - Vectors of malaria, dengue and chikungunya 1. Sou rce Reduction. Elimination of breeding sites by removing potential breeding places like water bottles, solid waste, coconut shells, tyres , etc.Weekly cleaning/Drying of water containers, Room coolers. Extensive IEC activities for social mobilization of the community on preventive measures and destroying breeding habitats. Minor Engineering measures like proper placing of lids of overhead tanks, underground tanks, repairing of leakage from pipeline and preventions of over flowing tanks, channelizing of water collections in roof and cleaning of gutters/water outle ts . Overall general sanitation in and around domestic environment. 2. Anti larval Measures: Application of weekly anti- larval ( Temephos , Bti . etc.) in water collections in and around domestic environments. Release of larvivorous fish in permanent water bodies, ornamental tanks etc. 3. Adult Control Measures: Indoor Space spray with DDT. Outdoor fogging with malathion

28. GUIDELINES FOR ITBNS AND LLINS Preface: Malaria transmitted by the bite of mosquitoes and the protozoa completes life cycle . Pregnant women, babies and young children are at the greatest risk of dying of malaria. Sleeping under a bed net reduces the risk of man-vector contact as mosquitoes bite at night and is thus an effective preventive measure. But ordinary mosquito nets provide limited physical barrier between mosquito and man and protection as they may still bite through the net or get inside the net following improper use. The Insecticide Treated Bed nets (ITBNs) or Long Lasting Impregnated Bed nets (LLINs) provide better and effective protection by keeping away mosquitoes as well as killing them. ITNs and LLINs also kills or keeps away other nuisance insects . cockroaches, bedbugs, houseflies, fleas, etc.

29. INSECTICIDE TREATED BED NETS (ITBNS) Insecticide treatment is recommended for synthetic nets (nylon, polyester), as treatment of cotton nets is not cost-effective and effect of insecticide is not long lasting. Insecticides used for mosquito nets are not harmful to people, if used correctly. Direct skin contact with the insecticide on a still wet net may cause a tingling sensation on the skin. This is not harmful, even for small children. After treatment, the net may smell of insecticide. This will go away in a few days and is not harmful to people who sleep under the net.

30. LONG LASTING INSECTICIDAL NETS (LLINS) LLINs are mosquito nets which have the insecticide incorporated in their fibre , so that it is not removed by as many as 20 washes. Because these nets have an even and quality controlled insecticide application, they are generally more effective than conventional ITNs. Furthermore the LLIN is more cost-effective (as it can be used for 3-5 years) than distribution of conventional bed nets and treating them with insecticide once or twice a year. Conventional ITNs are therefore only a rational option in areas, where the population already has so many nets that at least 50% of people sleep under one.

31. For a given village the number of LLINs to be provided is usually equal to the number of households multiplied by 2 or the total population divided by 2.5. However, some villages may have many large households, which will need additional nets. It is therefore prudent to add 20%, i.e. plan: ►Number of LLINs = Number of households x 2.4. This will normally ensure a sufficient quantity for the following schedule: 1-2 persons: 1 LLIN 3-5 persons: 2 LLINs 6-7 persons: 3 LLINs 8-10 persons: 4 LLINs DISTRIBUTION OF LLINS

32. Generally, for a targeted village, the required number of LLINs should be distributed in one single operation. However, if LLINs are not in sufficient supply, it can be considered to distribute one per household per year over a period of two years, i.e. with two rounds of distribution separated by 12 months. Timing of LLIN distribution is less critical than the timing of IRS or re-treatment of nets. However, for educational as well as logistical reasons, distribution shortly before the start of the rainy season may be optimal. In addition to distribution to targeted high-risk villages aiming at complete population coverage, LLINs should be given to pregnant women in high risk areas and to special groups such as children in tribal schools and hostels. These children should take the nets home with them during vacations.

33. Insecticides Used in Vector Control

34. I t is essential that residual insecticidal spray should be planned and implemented with sound technical skill under expert guidance . It should not be entrusted to non-technical personnel like contractors, voluntary bodies etc. In the revised approach to malaria control, it has been decided to spray human dwellings and mixed dwellings. Cattle sheds are not to be sprayed with a view to conserve insecticide, improve coverage of human dwellings and the present diversion of mosquitoes from sprayed cattle sheds to human dwellings. Insecticide spray operations:

35. Planning for spray operations: Spray operations are to be carried out in all area with API 2 or above. However, the priority of spray will be given to High Risk areas all over the country. S.No . Name of high risk PHC Population of PHC No. of high risk sub- centres in PHC High risk population for spray Remarks PHC and sub- centres of “High risk” areas for spray operations

36. S.No . Name of the PHC Population of PHC Number of sub- centres having API 2 & above Population of sub- centres having API 2 & above qualified for spray Remarks In sub- centres with API 2 above (excluding the high risk sub- centres ) population of qualifying sub- centres only to be considered for spray in a PHC is segregated in the following format : While planning for spray, the epidemiological data of preceding three years are considered for selecting the population to be protected.

37. The spray lance should be kept 45 cms (18 inches) away from the wall surface. The swath should be parallel. Spray is applied in vertical swath of 53 cm (21 inches) wide. Successive swaths should overlap by 7.5 cm (3 inches). Spray is done from roof to floor, using downward motion, to complete one swath; then stepping sideways and spraying upwards from floor to roof. Do not let the spray drip to the floor. Spraying is done on inner surfaces including eaves and roofs. Important points to be remembered during IRS

38. The discharge rate should be 740 to 850 ml per minute. To obtain the above discharge rate, the pump man should give 20 to 26 strokes per minute with 10-15 cms plunger movement at a pressure of 10 PSI (0.7 kg/sq.cm) at the nozzle tip. Spraying into a bucket for one minute and measuring the quantity of the suspension in a graduated mug should check the correct discharge rate (740 to 850ml/minute). The nozzle tip should be discarded if the discharge rate exceeds 850 ml per minute. Important points to be remembered during IRS

39. If the spray stops due to a blockage in the nozzle, the nozzle cap be unscrewed to remove the blockage and replaced with a new one. The blocked nozzle should be put in a container with water for a few hours before the blockage is removed A good quality spray should lead to uniform deposit on walls and other sprayable surfaces. This is easy to verify for DDT on sprays as the insecticide deposits are clearly visible. The supervisor through physical verification should verify the quality and coverage of spray randomly. It takes about 5 minutes to spray a house with an average surface area of 150 sq. metres . Important points to be remembered during IRS

40. Concurrent supervision T he following should be checked during such inspections: Date of advance notification and the maintenance of time table for spray operations Turn out of spray crew Nozzle tip discharge rate Conditions of spray pumps Preparation of insecticide suspension Actual spraying operation including the technique, speed and coverage etc. Extent of refusal to accept spray and the numbers and percentage of locked houses Maintenance of spray records Consumption of insecticide as determined by the quantity issued and stock in hand Date and time of checking of the squad by Inspectors/ Supervisors and other supervisory personnel and their remarks, if any Arrangements for mopping up Future programme and time schedule

41. Consecutive supervision The following is to be checked in consecutive supervision Evidence of insecticide deposit on sprayable surface particularly on the ceiling and wooden material like windows etc. Dispersal of the insecticide deposits on the walls to verify uniformity of deposits Number of rooms in each house sprayed satisfactorily, partially and not at all Percentage of refusals and locked houses Factors responsible for not spraying any area as elicited through enquiries from the residents Attempts made for mopping up operation in the event of high refusal Extent of mud plastering on the walls, if any and other relevant matters.