Malaria vector and management final.pptx

Malaria vector and management

1. MALARIA -Presented by, Dr. Prashanth.K Dr. Prashanth.R Dr. Pravalika G.R

2. Contents Introduction Epidemiology Vectors of Malaria and transmission Clinical features Diagnosis of Malaria Management of uncomplicated Malaria Management of severe Malaria Vaccination Prevention of Malaria National vector borne disease control program (NVBDCP)

3. Introduction Malaria is a protozoal disease caused by infection with Plasmodium . Transmitted to man by infected female Anopheline mosquito . Globally in 2021, there were an estimated 247 million malaria cases. An increase of 2 million cases compared with 2020. In India about 21.98% population lives in malaria high transmission areas and about 67% in low transmission areas .

4. Countries with indigenous cases of malaria in 2000 and their status by 2021 Division of the world into regions by WHO pertaining to Malaria

5. Distribution of malaria cases by country, 2021 Distribution of malaria deaths by country, 2021

6. In 2021, India accounted for most cases in the South-East Asia Region - 79% South-East Asia is the only WHO Region that reached the GTS 2020 milestones. Trend of number of malaria cases in India

7. Epidemiology Triangle of epidemiology Environment Host: Human Agent: Plasmodium species

8. Agent factors Agent : Plasmodium vivax (most common in the world) Plasmodium falciparum (most common in India) Plasmodium malariae (< 1% of India- Tumkur and Hassan) Plasmodium ovale (rare- Tropical Africa) Life cycle: Two cycles of development: Asexual cycle in human (intermediate host) Sexual cycle in mosquito (definitive host)

9. Life cycle of Plasmodium

10. HOST ENVIRONMENT Age Season Sex Temperature Genetics Humidity Population mobility Rainfall Human habits Drainage of sewage Immunity Socioeconomic development

11. Reservoir of infection Human s harbor sexual forms (gametocytes) of the parasite. Children are epidemiologically important reservoir because they are more likely to be gametocyte carriers than adults R eservoir must harbor both sexes of mature, viable gametocyte in his blood in sufficient quantity t o infect mosquitoes Period of communicability Communicable when mature gametocytes exist in circulating blood in sufficient density to infect vector mosquitoes In vivax , it is 4- 5 days ; in falciparum , it is 10- 12 days Relapses Vivax and ovale malaria relapse more than 3 years after patient's first attack. Relapses in P. falciparum and P. malariae infections is due to persistent erythrocytic schizogony .

12. Epidemiological types of Malaria 1. Tribal Malaria: E ngaged in forest-related activities. Limited health infrastructure and lack of drugs account for high morbidity and mortality . 2. Rural Malaria: Include s irrigated areas of arid and semiarid plains An. culicifacies is the main vector and P.vivax is predominant 3.Urban Malaria: Health infrastructure is well developed. I nflu enced by poor sanitary conditions and low socio-economic groups living in unplanned settlements

13. 4. Malaria in project areas: Disturb ing the eco-system and increased man-mosquito contact Limited health facilities for prompt treatment 5. Border Malaria: Along the international borders and state borders. Mixing of population and poor administrative control 6. Forest Malaria: Forests and settlements in recently deforested areas Vectors after biting return to the forest, avoiding residual insecticides sprayed indoors in the shelters. 7. Floods and Malaria: Flooding initially flush es mosquito breeding, later result in pools of water creating mosquitogenic conditions

14. Transmission of Malaria in India Seasonal Intensity related to rain As a result, Most of the population has no or little immunity toward malaria. Majority of Indians living in malarious areas are at risk of infection . I n forested areas tr ansmission is intense and the disease burden is to a large extent concentrated in children.

15. Vectors of Malaria Vectors Distribution An. culicifacies Rural, Peri -urban areas and Peninsular India An. stephensi Urban and industrial areas An. fluviatilis Eastern hilly areas, forests and forest fringes An. minimus Foot hills of North-Eastern states An. dirus Forests in the North-East An. epiroticus Andaman and Nicobar Islands

16. Mode of transmission MODE Vector transmission Bite of infected, female anopheles Sporozoites must be present in its salivary glands. Direct transmission I ntramuscular and intravenous injections. I nfectivity retained for 14 days in blood bottles stored at - 4 C . Congenital transmission Infection of the newborn from infected mother. Persons who have lived in an endemic area and anyone who has had malaria should not be accepted as blood donor until 3 years afterwards.

17. Incubation period Length of time between the infective mosquito bite and the first appearance of clinical signs. U sually not less than 10 days. Varies with species: 12 (9-14) days for falciparum malaria 14 (8-17) days for vivax malaria 28 (18-40) days for quartan malaria 17 (16-18) days for ovale malaria

18. Clinical features Febrile paroxysm: Fever is intermittent. 1.Every fourth day for P. malariae 2.Every third day for other three species. Co rresponds to the release of merozoites into the bloodstream. Cold stage : Lassitude, headache, nausea, intense cold, chills and rigor. Hot stage : High grade fever of 39–41°C, dry burning skin, headache Sweating stage : Fever comes down with profuse sweating. Skin becomes cold and moist. Anemia Splenomegaly

19. Diagnosis The diagnosis depends on demonstration of parasites in blood Microscopy Thick slide - More reliable in seaching for parasite Thin slide - More reliable for identifying the species Serological test Usually becomes positive two weeks or more after primary infection Valuable for epidemiological studies Rapid diagnostic test Detection of circulating parasite antigens with a simple dipstick format

20. General recommendations for management of uncomplicated malaria The first dose should be given under observation Dose should be repeated if the vomiting occurs within 15 minutes; if the patient vomits again then it should be considered as Severe case of Malaria and refer the patient immediately to The nearest Block PHC/CHC/ Hospital Explain to the patient or caretaker that a) if the treatment is not completed as prescribed the disease may manifest again with more serious features b) to come back immediately if there is no improvement after 24hours or if the situation gets worse c) regular use of a mosquito net is the best way to prevent malaria

21. Guidelines for diagnosis and treatment of Malaria in India - 2013 Scenario 1- Microscopy result is available within 24hrs Plasmodium vivax - a) Chloroquine : 25mg/kg body weight divided over three days i.e. 10mg/kg on day 1 10mg/kg on day 2 & 5mg/kg on day 3 b) Primaquine : 0.25mg/kg body weight daily for 14 days Primaquine is contraindicated in infants,pregnant women & individuals with G6PD deficiency

22. 2. Plasmodium falciparum - Atemenisin combination therapy Artesunate 3 days + Sulphadoxine-Pyrimethamine 1 day + Single dose of Primaquine (0.75mg/kg) on day 2 However, considering the reports of resistance to SP( Sulfadoxine-Pyrimethamine ) drug in North Eastern States, the Techincal Advisory Committee has recommended to use the coformulated tablet of Artemether (20mg) + Lumefantrine (120mg) as per age specific dose

23. 3. Mixed Infection - Artesunate 3 days + Sulphadoxine-Pyrimethamine 1 dayArtemether (20mg) + Lumefantrine (120mg) for 3days + Primaquine (0.25mg/kg) for 14 days

24. Scenario 2 - Where Microscopy result is not available within 24hrs Do rapid diagnostic test for detection Pf%>30% in any of last 3 years Positive for P.falciparum NE states- ACT-AL for 3days+ PQ single dose on 2nd day Other states- ACT-SP for 3 days + PQ single dose on 2ndday If rapid diagnostic test is negative : Give Chloroquine 25mg/kg over 3 days,if high suspicion of malaria is present

25. Treatment of malaria in pregnancy P.falciparum - ACT should be given for treatment of Malaria in second and third trimester of Pregnancy. Quinine is recommended in the first trimester P.vivax - It can be treated with chloroquine PRIMAQUINE IS CONTRAINDICATED IN PREGNANT WOMEN

26. Treatment of severe Malaria C/F : Severe manifestations can develop in P.falciparum infection over a span of time as short as 12-24 hours and may lead to death, if not treated promptly and adequately.

27. Initial parenteral treatment for at least 48 hours: Choose one of the following four options Follow-up treatment, when patient can take oral medication following parenteral treatment Quinine : 20 mg quinine salt/kg body weight on admission (IV infusion or divided IM injection) followed by maintenance dose of 10 mg/kg 8 hourly; infusion rate should not exceed 5 mg/kg per hour. Loading dose of 20 mg/kg should not be given, if the patient has already received quinine. Quinine 10 mg/kg three times a day with: doxycycline 100 mg once a day OR clindamycin in pregnant women and children under 8 years of age. - to complete 7 days of treatment. Artesunate : 2.4 mg/kg IV or IM given on admission (time=0), then at 12 hand 24 h, then once a day. OR Artemether : 3.2 mg/kg bw IM given on admission then 1.6 mg/kg per day. OR Full oral course of area-specific ACT: In North-Eastern states: Age-specific ACT-AL for 3 days + PQ single dose on second day In other states: Treat with: ACT-SP for 3 days + PQ single dose on second day

28. Resistance to Anti-Malarial drugs Resistance can be defined as either the ability of a parasite strain to survive and/or multiply despite the administration and absorption of a drug given in doses equal to or higher than those usually recommended, but within the limits of tolerance of the patient. Most common reason for development of drug resistance is that the parasites are exposed to insufficient amount of the drug due to: low prescription dosage Lesser amount of drug dispended Lesser amount of drug dispended Incomplete treatment taken by the patient Drug vomited out or low absorption of drug

29. Treatment failure After treatment patient is considered cured if he/she does not have fever or parasitaemia till day 28th Early treatment failure [ETF] Development of danger signs or severe Malaria on Day 1, 2 or 3 in the presence of parasitaemia Parasitaemia on Day 2 higher than on Day 0, irrespective of axillary temperature Parasitaemia on day 3 with axillary temperature >37.5 c Late parasitological failure [LPF] Presence of parasitaemia on any day between day 7 and day 28 with axillary temperature <37.5c in patients who did not previously meet any of the criteria of early treatment failure

30. Such cases of falciparum malaria should be given alternative ACT or quinine with Doxycycline . Doxycycline is contraindicated in pregnancy, lactation and in children upto 8 years. Treatment failure with chloroquine in P. vivax malaria is rare in India.

31. Vaccination Since October 2021, WHO recommends broad use of the RTS,S/AS01 malaria vaccine among children living in regions with moderate to high P.falciparum malaria transmission. The vaccine has been shown to significantly reduce malaria and severe malaria among young children.

32. PREVENTION OF MALARIA Neither chemotherapy nor chemoprophylaxis will be able to reduce significantly the malaria prevalence or transmission. It can be obtained only when proper anti mosquito measures are introduced. Active Intervention Measures- 1.STRATIFICATION OF THE PROBLEM 2.VECTOR CONTROL STARTEGIES

33. a)Anti-adult measures (i)Residual spraying (ii)Space application (iii)Individual protection b)Anti-larval measures (i)Larvicides (ii)Source reduction (iii)Integrated control

34. NATIONAL VECTOR BORNE DISEASE CONTROL PROGRAM

35. Launched in 2003-04 by convergence of three ongoing programs on malaria,filaria & kala Azar and inclusion of Japanese encephalitis and dengue. In 2007 Chikungunya fever added to this programme due to re-emergence of the disease in 2006. This program is now runs under the umbrella of NHM.

36. Organisation of the Program The Directorate of National Vector Borne Disease Control Programme is the national level Technical Nodal office. Every state has state vector borne diseases control component under the Directorate of Health Services. At the district level, District Malaria offices have been established under District Chief Medical and Health offices by the states. Delivery of malaria control services by ASHAs and other volunteers at the community and household level in high endemic areas. Enhancing supportive supervision and monitoring by engaging DVBDC consultants at district level and malaria technical supervisors at sub district level.

37. Main activities of Directorate of NVBDCP Formulating policies and guidelines Providing technical guidance to the states Planning Logistics Monitoring and evaluation Coordination with international organisations Training Facilitating research through NCDC, NIMR, RMRC etc Coordinating control activities in inter state and inter country border areas

38. Strategies of NVBDCP

39. Miles stones in the field of Malaria Control 1.National malaria control Programme -1953 2.National malaria eradication programme-1958 3.Urban malaria scheme -1971 4.Modified plan of operation (MPO) -1977 5.Malaria action Programme -1995 6.Enhanced malaria control project -1997 7.National Anti malaria Programme -1999 8.NVBDCP -2002

40. 9.Intensified Malaria control project launched-2005 10.ACT-2008 11.World bank supported National malaria control project-2008 12.Introduction of LLINs-2009 13.New drug policy-2010 14.Introduction of bivalent RDT-2012 15.New drug policy 2013 16.National framework of malaria elimination in India -2016

41. Malaria Control Strategies 1.EPIDEMIOLOGICAL surveillance and case management Case detection active and passive Early diagnosis and complete treatment Sentinel surveillance 2.Integrated vector management (IVM) ANTILARVAL MEASURES Environmental control Chemical control Biological control

42. ANTIADULT MEASURES Residual sprays Space sprays Genetic control PERSONAL PROTECTION Mosquito nets Screening Repellants 3.Epidemic preparedness and early response 4.STRENGTHENING OF REFERRAL SERVICES

43. 5.Supportive interventions Behavioural change communication(BCC) Public Private Partnership & intersectoral convergence Human Resource development through Capacity building Operational research including studies on drug resistance & insecticide susceptibility Monitoring & evaluation through periodic reviews/field visits

44. Early diagnosis and treatment of Malaria aims at 1.Complete cure 2.Prevention of progression of uncomplicated malaria to severe diseases 3.Prevention of deaths 4.Interruption of transmission 5.Minimizing risk of selection and spread of drug resistant malaria parasite

45. NATIONAL FRAMEWORK FOR MALARIA ELIMINATION IN INDIA (2016-2030) VISION Eliminate malaria nationally & contribute to improved health,quality of life & alleviation of poverty. GOALS Eliminate malaria throughout the entire country by 2030 Maintain malaria free status in areas where malaria transmission has been interrupted and prevent reintroduction of malaria

46. URBAN MALARIA SCHEME (UMS) It was launched in 1971 to over come the increasing incidence of malaria in urban areas where the vector was found to be An.Stephansi. Intensive anti larval measures and drug treatment are the mainstay of UMS. Reorganisation- Malaria units under NMEP were reorganised to conform to the geographical boundaries of the district and the CDMO was made responsible for implementation of the programme. Decentralisation of Laboratory services- Laboratory Technicians with the necessary facilities is now located at each PHC Establishment of Drug Distribution Centres (DDCs) and Fever Treatment Depots(FTDs).

47. National Antimalaria Programme In April 1953, Govt. of India launched a National Malaria Control Programme (NMCP) with the following objectives: 1. To bring down malaria transmission to a level at which it would cease to be a major public health problem; and 2. Thereafter an achievement was to be maintained by each state to hold down the malaria transmission at low level indefinitely.

48. Strategies under NMCP were: 1. Principal operational activities under the control programme comprised of residual insecticide spray of human dwelling and cattle sheds; 2. Malaria control teams were organised and directed by the state anti-malaria organisation to carry out surveys and to monitor the malaria incidence in the control areas; and 3. Anti-malarial drugs were made available for patients reporting to an Institution.

49. Modified Plan of operation In 1977 attempts at malaria eradication were given up and under the review policy, a Modified Plan of Operation (MPO) was adopted. Objectives 1. Elimination of malaria deaths 2. Reduction of malaria morbidity 3. Maintenance of the gains achieved so far by reducing transmission of malaria Areas were divided on the basis of API into two groups and separate strategies were suggested accordingly.

50. Malaria Action Program Due to occurrence of many epidemics of malaria in the country, an expert committee was formulated to identify epidemiological parameters for high risk areas. Following areas were identified: Problem Area A. Hardcore areas (Tribal Areas) B. Epidemic Prone Areas C. Project Areas D. Triple Insecticide resistant Areas E. Urban Areas

51. REFERENCES 1. CodeHunk . National ANTI-MALARIA programme [Internet]. [cited 2023 Jun 27]. Available from: http://www.nihfw.org/NationalHealthProgramme/NATIONALANTI_MALARIAPROGRAMME.html 2. World Malaria Report 2022 [Internet]. World Health Organization; [cited 2023 Jun 27]. Available from: https://www.who.int/news-room/fact-sheets/detail/malaria 3. Park K. Epidemiology of communicable diseases. In: Park’s textbook of Preventive and Social Medicine. 26 th edition ed. India: Bhanot Publishers; 2022.