Malaria- epidemiology, prevention and control

1. EPIDEMIOLOGY, PREVENTION AND
CONTROL - MALARIA
Speaker Swati Singh

2. CONTENTS
• Introduction
• Problem statement
• Epidemiology
• Lifecycle
• Prevention
• Clinical presentation
• Diagnosis and treatment
• Milestones
• Roll back malaria
• Malaria vaccine
• References

3. • The term malaria originates from Italian: mala aria — "bad
air“ in 18th century.
• Formerly called ague or marsh fever due to its association
with swamps and marshland.
• In 1897, Ronald Ross established the life cycle of
plasmodium and identified that infection was transmitted by
Anopheles.

4. PROBLEM STATEMENT
• 198 million cases of malaria occurred globally in 2013 (uncertainty range
124–283 million) and the disease led to 5,84,000 deaths.
• Roughly half the world’s population (3.3 billion people) is at risk of malaria.
About 90% of deaths from malaria occur in Africa.
• Global estimated malaria case incidence rates fell by 30% between 2000
and 2013, while estimated mortality rates fell by 47%.
• Thirty-five countries (30 in sub-Saharan Africa and 5 in Asia) account for
98% of global malaria deaths. In Africa, malaria is the second leading cause
of death from infectious disease, after HIV/ AIDS.
• 7% of under 5 mortality (cerebral malaria & anaemia).

6. INDIA
• 95 % malaria prone area
• 1.5 – 2 million cases annually.
• The incidence of malaria in India accounted for 58% of cases in the South
East Asia Region of WHO.
• In 2014, there were 1.07 cases of malaria in million, 0.70 cases of
plasmodium falciparum in million and 535 deaths due to malaria.
• 21.98% - high transmission areas.
(High transmission >1 case/ 1000 popln)
• 92% of cases & 97% of death – north-eastern states, Chhattisgarh,
Jharkhand, M.P, Gujarat, Orissa, A.P, W.P, Karnatka.
• API has declined from 3.29 (1995) to o.85 (2012)

7. VECTORS:
 LIFE SPAN: 10- 12 days
 CHOICE OF HOST : anthrophilic species
 RESTING HABITS : endophily, exophily
 BREEDING HABITS: moving water, wells, fountain, garden
pools (clean water)
 TIME OF BITING : night time
An. culicifacies- rural ,
periurban
An. fluviatilis- forest, hilly
area
An. stephensi – urban,
industrial
An. minimus – foot hills
An. philippinensis
An. sundaicus

8. MALARIA TREND IN INDIA

10. LIFE CYCLE OF MALARIA PARASITE

11. MODE OF TRANSMISSION
• Malaria is caused by a type of
microscopic parasite that's
transmitted most commonly
by mosquito bites.
• Other transmission:
• From mother to unborn child
• Through blood transfusions
• By sharing needles used to
inject drugs

12. CLINICAL PRESENTATION
• Early symptoms
• Headache
• Malaise
• Fatigue
• Nausea
• Muscular pains
• Slight diarrhea
• Slight fever, usually not intermittent
 Acute febrile illness, may have periodic febrile paroxysms every 48 – 72
hours with afebrile asymptomatic intervals.
 Tendency to recrudesce or relapse over months to years.
 Anemia, thrombocytopenia, jaundice, hepatosplenomegaly, respiratory
distress syndrome, renal dysfunction, hypoglycemia, mental status changes,
tropical splenomegaly syndrome, cerebral malaria.

13. MALARIAL PAROXYSM
• Can get prodrome 2-3 days before
• Malaise, fever, fatigue, muscle pains, nausea, anorexia.
• Can mistake for influenza or gastrointestinal infection.
• Slight fever may worsen just prior to paroxysm.
• Paroxysm
• Cold stage - rigors
• Hot stage – Max temp can reach 40-41o C, splenomegaly easily palpable
• Sweating stage - Lasts 2-4 hours, start between midnight and midday
 Periodicity
 Days 1 and 3 for P.v., P.o., (and P.f.) - tertian
 Usually persistent fever or daily paroxyms for P.f.
 Days 1 and 4 for P.m. - quartian

14. Disease Severity and Duration
vivax ovale malariae falciparum
Initial Paraoxysm
Severity
moderate to
severe
mild
moderate to
severe
severe
Average
Parasitemia
(mm3)
20,000 9,000 6,000
50,000-
500,000
Symptom
Duration
(untreated)
3-8weeks 2-3 weeks 3-24 weeks 2-3 weeks
Maximum
Infection
Duration
(untreated)
5-8 years
12-20
months
20-50 years 6-17 months
Anemia ++ + ++ ++++
Complications renal cerebral

15. MALARIAL INDICES
• ABER = No. of blood smears examined during the year x 100
Population covered under surveillance
• API = Confirmed cases of malaria during one year x 1000
Population covered under surveillance
• SPR= No of blood smears found positive for malaria parasite x 100
No. of blood smear examined

16. DIAGNOSIS
• Malaria diagnosis is carried out by microscopic examination of
blood films collected by active and passive agencies.
• Health agencies and volunteers treating fever cases in
inaccessible areas are being provided with Rapid Diagnostic Test
(RDT) kits (Pf specific so far and now Bivalent RDT) for diagnosis
of Malaria cases so as to provide full radical treatment to the
confirmed cases.
• The malarial fluorescent antibody test becomes positive two
weeks or more after primary infection.

17. TREATEMENT

18. Where Microscopy Result Is Not Available Within 24 Hours And
Monovalent RDT Is Used

20. • Treatment during pregnancy :
• 1st Trimester : Quinine salt 10mg/kg 3 times daily for 7
days
• 2nd and 3rd trimester: Area-specific ACT as per dosage
schedule given above.
i.e. ACT-AL in North Eastern States
ACT-SP in Other States

22. CHEMOPROPHYLAXIS
• Short term chemoprophylaxis (up to 6 weeks) Doxycycline : 100
mg once daily for adults and 1.5 mg/kg once daily for
children(contraindicated in children below 8 years). The drug
should be started 2 days before travel and continued for 4 weeks
after leaving the malarious area.
• Chemoprophylaxis for longer stay (more than 6 weeks)
Mefloqiune: 250 mg weekly for adults and should be
administered two weeks before, during and four weeks after
exposure.

23. MILESTONES
 Sir Bhore Committee Report 1946
 National Malaria Control Program 1953
 National Malaria Eradication Program 1958
 Urban Malaria Scheme 1971
 Modified Plan Of Operation 1977
 Malaria Action Program 1995
 Enhanced Malaria Control Program 1977
 National Anti Malaria Program 1999
 National Health Policy 2002
 National Vector Borne Disease Cont Program 2004
 Intensified Malaria Control Project 2005
 National Rural Health Mission 2005

24. NATIONAL MALARIA CONTROL
PROGRAMME 1953
OBJECTIVES
• To bring down malaria transmission
• To hold down malaria transmission at low level
STRATEGIES
•INDOOR RESIDUAL SPRAY
•TREATMENT OF PATIENTS REPORTING TO HEALTH
ACHIEVEMENT
•Decline in incidence from 75 million to only 2 million in 1958

25. NATIONAL MALARIA ERADICATION
PROGRAMME 1958
OBJECTIVE
To eradicate malaria from India in 7 to 9 years
ACTIVITIES
Spraying operation
Fortnightly active case detection
Radical treatment
Investigation of positive cases and remedial measures
ACHIEVEMENTS
Lowest ever incidence of 0.1 million in 1965
No reported deaths due to malaria

26. URBAN MALARIA SCHEME 1971
In 139 towns in 19 states and union territories.
OBJECTIVES
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 strictly implement the civic by-laws to
prevent/eliminate domestic and peri-domestic breeding places.

27. Control Strategies under Urban Malaria Scheme:
-Parasite control
-Vector control
Parasite control: Treatment is done through passive agencies viz. hospitals, dispensaries both in
private & public sectors and private practitioners. In mega cities malaria clinics are established
by each health sector/ malaria control agencies viz. Municipal Corporations, Railways, Defence
services
Vector control comprises of the following components
Source reduction
Use of larvicides
Use of larvivorous fish
Space spray
Minor engineering
Legislative measure
Aerosol Space Spray
Space spraying of pyrethrum extract (2%) in 50 houses in and around every malaria and
dengue positive cases to kill the infective mosquitoes is recommended.
Town –biologist
State-additional director (malaria/filaria)
Central level-director NVBDCP

28. •Re-classification Of Endemic Areas
•Based On Annual Parasite Incidence
• API Less Than 2 API Greater Than 2
•Areas With API > 2
•Spraying
•Entomological Assessment
•Surveillance
•Treatment Of Cases
•Decentralization Of Laboratory Services At-phc
•Establishment Of Ddcs And Ftds
MODIFIED PLAN OF OPERATION 1977
OBJECTIVES
•Prevention Of Death Due To Malaria
•Reduction Of Morbidity Due To Malaria
•Retention Of Achievements Gained So Far

29. •Areas With Api < 2
•Focal Spraying
•Surveillance And Treatment
•Follow Up
•Epidemiological Investigation

30. MALARIA ACTION PROGRAMME
1995
RESURGENCE OF MALARIA
(RAJASTHAN/MANIPUR/NAGALAND/ASSAM/WB/MAHARASHTRA)
EXPERT COMMITTEE 1994
HIGH RISK AREAS IDENTIFIED
FTD MICROSCOPY FACILITY
1,000 POPULATION 30,000 POPULATION

31. ELEMENTS
Early diagnosis and prompt treatment
Sustainable preventive measures including vector control
Prevention of epidemics
Regular assessment
HIGH RISK AREAS
High API
High proportion of pf cases
Reported death due to malaria
SPR doubled
SPR >5%

32. ENHANCED MALARIA CONTROL PROJECT 1997
•With World Bank Assistance
•1997-2003, Extn To 2005
Objectives
Effective control of malaria
Bring down malaria morbidity
Prevention of death due to malaria
Consolidation of gain achieved so far
Selection Of Phc-criteria
API>2 for last 3 yrs
P. Falciparum >30% of cases
25% tribal population
Death due to malaria

33. MAIN COMPONENTS
•Early case detection and treatment
•Selective vector control and personal protection
•Health education and community participation
PLAN OF ACTION
•Synthetic pyrethroids
•Bed nets
•Rapid diagnostic kits
•Arteether injections
•Blister packs
•Funds for training

34. NATIONAL ANTI-MALARIA PROGRAMME 1999
OBJECTIVES
•Reduce malaria morbidity and mortality by 50%
•TARGETS AND INDICATORS
•ABER>10%
•API 1.3 or less
•25% reduction in morbidity and mortality by 2010
•50% reduction in morbidity and mortality by 2012

35. NATIONAL VECTOR BORNE DISEASE CONTROL
PROGRAMME
•Launched in year 2003-04
•Major vector borne diseases-
•Malaria
•Filaria
•Kala-azar
•Japanese Encephalitis
•Dengue / Dengue Hemorrhagic fevers
•Chikungunya
Integrated accelerated action towards
•Reducing mortality on account of Malaria, Dengue and JE by half

38. INTENSIFIED MALARIA CONTROL PROJECT
Launched in July 2005 with assistance of global fund for AIDS,TB and
malaria in NE states,Odisha,Jharkhand and WB.
OBJECTIVES:
1-Increase access rapid diagnosis and treatment through community
participation
2-Reduce transmission by used of insecticide treated bednets and
larvivorous fish
3-Enhance awareness about malaria control
4-To promote community,NGO,private sector participation

40. • Indoor residual spraying or IRS is the process of spraying the inside of
dwellings with an insecticide to kill mosquitoes that spread malaria.
• The main purpose of IRS is to reduce transmission by reducing the
survival of malaria vectors entering houses or sleeping units.
Effectiveness of IRS depends on:
• Target area
• Selection of Insecticides
• Change of Insecticide
• Insecticide formulations used under NVBDCP
1. DDT( Dichloro-diphenyl-trichloroethane)
2. Organophosphorus (OP) compounds
3. Synthetic Pyrethroids

41. • An insecticide-treated net is a mosquito net that repels,
disables and/or kills mosquitoes coming into contact with
insecticide on the netting material. There are two
categories of ITNs:
• • A conventionally treated net is a mosquito net that
has been treated by dipping in a WHO-recommended
insecticide.
• • A long-lasting insecticidal net is a factory-treated
mosquito net made with netting material that has
insecticide incorporated within or bound around the
fibres.

42. • Specific Objectives: Reduce human contact, reduce morbidity,
prevent deaths, promote community participation, modalities for
social marketing through public-private partnership.
• Synthetic Pyrethroids mainly two Deltamethrin(2.5%) at a
dosage of 25mg/m2 and cyfluthrin (5%) at 50mg/m2.

43. • Environmental control: Good water management practices are
best. Could be Temporary and Permanent.
• Biological control: Fishes, Insects, Protozoans, Arthropods,
Bacteria, Fungi & viruses.
• Genetic control: Genetic Engineering like Transgenic Mosquito.
• Chemical control: Given high priority in Operational Measures.

44. Biological Agents that work well:
1. Mosquito fish: Gambusia and Guppy
2. Bacteria: Bacillus thuringiensis and
B. sphaericus
Other Biological Agents:
- Predatory mosquito larvae
(Toxorhynchites)
- Copepods (Macrocyclops
albidus)
Use of Biological Agents to control
of vector populations

45. INTEGRATION UNDER NRHM
At Village Level
Monthly meetings of Village Health & Sanitation Committee serve
as a platform for health education and counseling of community.
Involvement of ASHA as-
Surveillance worker to inform any increase in fever cases including
Dengue/ Chikungunya and J.E.
FTD for early detection of suspected malaria cases and treatment.
Linkage between ANC services and prevention & treatment of
malaria.
Organizer, motivator and trainer in village level meetings/training
workshops.

46. MDG 6 : COMBAT HIV/AIDS, MALARIA AND
OTHER DISEASES
Target 6c: Halt and begin to reverse the incidence of
malaria and other major diseases
6.6 Incidence and death rates associated with malaria
6.7 Proportion of children under 5 sleeping under
insecticide-treated bed nets
6.8 Proportion of children under 5 with fever who are
treated with appropriate anti-malarial drugs

47. • Integrated Disease Surveillance Project(IDSP) - The
Project with weekly fever alerts is increasingly providing
early warning signals on malaria outbreaks.
• Other Vector borne diseases - Dengue & malaria control
activities overlap in many Urban areas, Malaria & kala-azar
in few districts of Jharkhand.
• Reproductive and Child Health - ANC services utilized in
distribution of LLINs to pregnant women.

48. • Global Fund for AIDS, TB & Malaria(GFATM) supported
Intensified Malaria Control Project(IMCP):
• It was for a period of 5years from July 2005 to June 2010.
Implemented in 106 districts in 10 states.
• It helped to achieve 23.4% decline in Malaria Incidence.
• IMCP-II has been initiated for a period of five years (2010-
2015).

49. • Approved for 5years(March 2009-Dec 2012). Total
financial outlay Rs.1000 Crore.
• Being implemented in 93 malarious districts of eight
states including Andhra Pradesh.
• Provides additional Support for procuring ACT, LLIN’s,
Provision of additional manpower.

50. ROLL BACK MALARIA
• RBM is a global partnership founded in 1998 by (WHO), (UNDP),
(UNICEF) and the World Bank with the goal of halving the
world's malaria burden by 2010.
• It forges consensus among key actors in malaria control,
harmonises action and mobilises resources to fight malaria in
endemic countries and to improve and support capacity to scale
up action against malaria.

51. • RBM's four pillars of action
ROLL BACK MALARIA is promoting four main strategies
to pursue its goal of halving the world's burden of
malaria by 2010. The strategies are evidence-based
• Prompt access to treatment
• Insecticide-treated mosquito nets (ITNs)
• Prevention and control of malaria in pregnant women
• Malaria epidemic and emergency response

52. Vaccines developed are basically of three types:
• Pre-erythrocytic stage vaccine
• Blood stage vaccine and
• Transmission blocking vaccine
• SPf-66—1st malaria vaccine that was tried in clinical trials in 1990s.
• RTS,S - Most successful vaccine candidate.
• On July 25th 2015 World's first malaria vaccine got a green light from
European drugs regulators who recommended it should be licensed for
use in babies in Africa at risk of the mosquito-borne disease.
• The shot, called RTS,S or Mosquirix developed by British drugmaker
GlaxoSmithKline in partnership with the PATH Malaria Vaccine Initiative,
would be the first licensed human vaccine against a parasitic disease.

53. REFERENCES
• AH Suryakant. Community medicine with recent advances. 3rd ed. New
Delhi:Jaypee;2014.
• J.Kishore. National health programs of India. 11th ed. New Delhi:Century
publications;2014.
• K.PARK. Textbook of preventive and social medicine. 23rd ed.
Jabalpur:Banarsidas Bhanot;2015.
• National Drug Policy for Malaria 2010, NVBDCP, MoH&FW, Govt. of India, 2010.
• Operation Manual for Malaria Control for District level Officers. NVBDCP,
2008.
• Website of National Vector Borne Disease Control Programme
http://www.nvbdcp.gov.in/malaria-new.html .
• World Health Organization (2006). WHO Guidelines for the Treatment of
Malaria. Geneva World Health Organization .
• Center for Disease Control and Prevention. How to Reduce Malaria’s
Impact. Center for Disease Control and Prevention.
http://www.cdc.gov/malaria/ malaria_worldwide/reduction/index.html

54. THANK YOU