A Comprehensive presentation on malaria control in India starting from history of malaria control to latest updates under NRHM.

1. Control of Malaria
in India
Dr.M.Vijay Kumar
M.D.(Community Medicine)

2. • Introduction
• Burden of Malaria at State, National and
International level.
• Historical aspect of Malaria Control in India
• Malaria Control Strategies at State and National
level
• Surveillance in Malaria
• Recent advances
• Monitoring and Evaluation
• SWOT Analysis

3. • Intermittent fever, with high incidence during the
rainy season, coinciding with agriculture, sowing
and harvesting, was first recognized by Romans
and Greeks who associated it with swampy areas.
• They postulated that intermittent fevers were
due to the 'bad odour' coming from the marshy
areas and thus gave the name 'malaria'
('mal'=bad + 'air') to intermittent fevers.
• In spite of the fact that today the causative
organism is known, the name has stuck to this
disease.

4. - Malaria is one of the major public health
problems of the country.
-Around 1.5 million confirmed cases are
reported annually by the National Vector
Borne Disease Control Programme (NVBDCP).
-Malaria is curable if effective treatment is
started early. Delay in treatment may lead to
serious consequences including death.

5. • In 2010 there were an estimated 216 million
cases of malaria of which 91% were due to
P.falciparum.
• The vast majority of cases (81%) were in the
African Region followed by the South-East
Asia (13%) and Eastern Mediterranean
Regions (5%).
• There were an estimated 6,55,000 malaria
deaths worldwide in 2010

6. SEARO website:
http://www.searo.who.int/en/Section10/Section21/Section340_4018.htm

7. SEARO (South East Asia Regional Office) website:
http://www.searo.who.int/en/Section10/Section21/Section340_4018.htm

8. National Vector Borne Disease Control Project (NVBDCP) official website:
http://www.nvbdcp.gov.in/malaria9.html

9. Blood Slide Examination 9368740
Total Malaria Cases 34949
Plasmodium
falciparum(Pf) cases
24089
P.f. % 69%
Slide Positivity Rate(SPR) 0.49
Slide falciparum Rate(SfR) 0.36
Deaths 05
NVBDCP website: Malaria situation in India PDF file
http://www.nvbdcp.gov.in/Doc/malaria-situation-august12.pdf

10. - No organized National Malaria Control Programme
1945 -Insecticide properties of DDT identified
- Estimated malaria cases in India - 75 million
estimated Deaths due to malaria – 1 million
1953 -Launching of National Malaria Control Programme
1958 - Launching of National Malaria Eradication Programme
- Resurgence of malaria
- Malaria cases 6.46 million highest in post DDT era
(one of the reasons for resurgence was insecticide resistance in malaria
vectors)

11. - Modified Plan of Operations Implemented
- World Bank Assisted Enhanced Malaria Control
Project (EMCP)
- Renaming of programme to National Anti Malaria
Programme (NAMP)
- Renaming of NAMP to National Vector Borne
Disease Control Programme
– The NVBDCP became an integral part of the
NRHM
Global Fund assisted Intensified Malaria Control
Project (IMCP) launched
- ACT extended to high Pf predominant districts
covering about 95% Pf cases NMCP launched

12. 1. Surveillance and case management:
Case detection (passive and active)
Early Diagnosis and Complete Treatment
Sentinel surveillance
2. Integrated Vector Management (IVM)
Indoor Residual Spray (IRS)
Insecticide Treated bed Nets (ITNs) / Long Lasting Insecticide treated Nets
(LLINs)
Antilarval measures including source reduction
3. Epidemic preparedness and early response
4. Supportive Interventions
Capacity building
Behaviour Change Communication (BCC)
Intersectoral collaboration
Monitoring and Evaluation (M & E)
Operational research and applied field research

14. • Microscopy: Stained thick and thin blood
smears remains the gold standard for
confirmation of diagnosis of malaria.
• Advantages-
1) The sensitivity is high.
2) It is possible to distinguish the various
species of malaria parasite and their different
stages

16. • Rapid Diagnostic Test(RDT): Rapid Diagnostic
Tests are based on the detection of circulating
parasite antigens.
• Presently, NVBDCP supplies RDT kits for
detection of P. falciparum at locations where
microscopy results are not obtainable within
24 hours of sample collection.

18. • Chemoprophylaxis is recommended for travellers,
migrant labourers and military personnel exposed to
malaria in highly endemic areas.
• Short-term chemoprophylaxis (less than 6 weeks)
Doxycycline: 100 mg daily in adults and 1.5 mg/kg body
weight for children more than 8 years old. The drug
should be started 2 days before travel and continued for
4 weeks after leaving the malarious area.
• Note: Doxycycline is contraindicated in pregnant and
lactating women and children less than 8 years.

19. Long-term chemoprophylaxis (more than 6 weeks)
• Mefloquine: 5 mg/kg body weight (up to 250 mg)
weekly and should be administered two weeks
before, during and four weeks after leaving the area.
• Note: Mefloquine is contraindicated in cases with
history of convulsions, neuropsychiatric problems
and cardiac conditions.

20. Measures for vector control and protection
include:
1) Indoor Residual Spray(IRS)
2) Insecticide Treated Bed Nets(ITN’s)/ Long
Lasting Insecticidal Nets(LLIN’s)
3) Antilarval measures including source
reduction

21. BREEDING HABITATS OF
ANOPHELES MOSQUITOES

22. • 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.
• IRS remains a valuable intervention in malaria control when
certain conditions are met.

23. 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
Strategies of Delay the onset of Resistance
Note: Recently GHMC in Hyderabad have introduced
Synthetic Pyrethroid for IRS

24. • 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. To
ensure its continued insecticidal effect, the net should be re-
treated after three washes, or at least once a year.
• 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..

26. • Specific Objectives: Reduce Human contact,
Reduce morbidity, Prevent deaths, Promote
Community participation, Modalities for social
marketing trough Public-Private Partnership.
• Assessment of community needs by rapid
surveys, size of the nets and number of nets
according to size.
Synthetic Pyrethroids mainly two
Deltamethrin(2.5%) at a dosage of 25mg/m2 and
cyfluthrin (5%) at 50mg/m2.

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

28. :
Bacillus thuringiensis and
B. sphaericus
- Predatory mosquito larvae
(Toxorhynchites)
- Copepods (Macrocyclops
albidus)

29. • OBJECTIVES: The main aim is the reduction of the
disease to a tolerable level in which the human
population can be protected from malaria transmission
with the available means.
• The Urban Malaria Scheme aims at :
a) To prevent deaths due to malaria.
b) Reduction in transmission and morbidity.
• NORMS :

30. Control Strategies under Urban Malaria Scheme:
Vector Control –
1) Source Reduction
2) Anti-larval methods- Chemical
Recurrent anti-larval measures at weekly intervals with
approved chemical larvicides like Temephos.
3) Use of larvivorous fish like gambusia and guppy
4) Aerosol space spray –
5) Minor engineering&Legislative measures

31. • Confirmation of an Outbreak
• Preparatory aspects like Constitution of Rapid
Response Team(RRT) and Logistics
• Control of malaria epidemic by
1. Delineation of the affected area
2. Estimation of population involved
3. Measures for liquidation of foci
4. Follow-up Action

33. • Monitoring Malaria incidence trends and
geographic distribution.
1) Active Surveillance(Active case detection)
2) Passive Surveillance(PCD)
3) Sentinel Surveillance

34. • Malaria is under Regular Surveillance in
Integrated Disease Surveillance Project(IDSP).
• Case Classification:
Suspect case- Any case of fever(in an endemic
area).
Probable case- A case that meets the clinical
case description.
Confirmed case- A suspect case with malaria
parasites in blood film.

35. 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.

36. • 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.

37. • 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).

38. • 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,
Long Lasting Insecticidal Nets(LLIN’s),
Provision of additional manpower.

39. • Malaria control: reducing the malaria disease burden to a
level at which it is no longer a public health problem.
• Malaria elimination: the interruption of local mosquito-borne
malaria transmission; reduction to zero of the incidence of
infection caused by human malaria parasites in a defined
geographical area as a result of deliberate efforts.

40. • Certification of malaria elimination: the chain of local human
malaria transmission by Anopheles mosquitoes has been fully
interrupted in an entire country for at least 3 consecutive
years.
• Malaria eradication: permanent reduction to zero of the
worldwide incidence of infection caused by a particular
malaria parasite species.

41. • Key factors proposed for eradicating malaria:
1) Reducing Malaria Burden
2) Vector Control
3) Malarial Vaccine

42. • 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,
currently in Phase III
Challenges facing vaccine development

43. • Remote Sensing is a tool for surveillance of
habitats, density of vector species and prediction
of Incidence of diseases.
• It is likely to become a rapid epidemiological tool
for surveillance of vector borne diseases and
Malaria in particular.
• Coupled with GIS(Geographical Information
System), will play a key role in Macro
stratification for Prioritizing control measures in a
cost-effective way.

44. • World Malaria Day - which was instituted by
the World Health Assembly at its 60th session
in May 2007.
• World Malaria Day 2012
marks a
decisive juncture in the history of malaria
control.

46. • Monitoring & Evaluation will be an on-going process in the
programme.
• Adoption of newer disease prevention and control
instruments like RDTs, ACTs & LLINs and recruitment of
ASHA, a new frontline worker under NRHM, made it
necessary to restructure the Management Information
System (MIS).
• The NVBDCP also has an online system of data collection
and collation called the National Anti malaria Management
Information System (NAMMIS).
• Objectives - To ensure that 80% of districts in high-disease
burden areas will collect, process, analyze, and effectively
manage malaria data by 2010 and 100% of them by 2012.

47. The following activities will be adopted in the
programme to strengthen the M & E system :
• Strengthening of management information system for
tracking malaria incidence and operational indicators
including the revival of the National Anti Malaria
Management Information System (NAMMIS).
• Sentinel surveillance to collect data on severe malaria,
hospitalized malaria cases and malaria deaths from selected
hospitals in each district.
• Decentralized measurement of outcomes at district and PHC
levels through Lot Quality Assurance Sampling (LQAS).

48. • Large-scale population surveys every second year to assess
malaria prevalence and population coverage with main
interventions.
• Logistic Management Information System for supply chain
management.
• System to monitor the quality of RDTs and medicines to
ensure their quality upon delivery and at point of use.

49. • Strengths
• Weaknesses
• Opportunities
• Threats

50. Strengths
Long experience since 1953
Political commitment
Malaria Surveillance covering all blocks
ASHAs being utilized in all endemic
villages for surveillance.
RDTs for diagnosis of Pf introduced
Microscopy available up to PHC level
ACT for treatment of Pf introduced
LLINs introduced
Research support from NIMR
Weaknesses
RDT coverage needs to be expanded to all
endemic villages.
Delay in conducting microscopic
examination of smears .
ACT needs to be used for all Pf cases in
country.
Requirement of total shift from re-
impregnation of plain nets to LLINs.
Difficulty in distributions of ITN’s in
remote areas with inhibited access.
Deficiency of human resources at all
levels from national to block level.
Opportunities
NRHM strengthening the health structure
and malaria control at all levels.
NURM expected to be launched in 12th
five year plan will strengthen UMS.
Increasing commitment for funds from
international agencies such as GFATM.
NGOs willing to be partners.
Possibility of introduction of pan-specific
RDTs for both Pf & Pv soon.
Threats
Overloading of ASHAs with many
Programmes.
Development of Insecticide resistance.
Development and spread of drug
resistance.
Social and ecological constraints to
effectiveness of standard interventions in
some high risk populations.
Social unrest in some areas.

51. • Park’s Textbook of Preventive and Social Medicine, 21st Edition by
K.Park.
• Health policies and Programmes in India , 10th Edition by
Dr.D.K.Taneja.
• National Health Programmes of India, 10th Edition by Jugul Kishore.
• World Health Organization(WHO) World Malaria report 2011,
http://www.who.int/malaria/world_malaria_report_2011/9789241
564403_eng.pdf
• National Vector Borne Disease Control Project (NVBDCP) official
website: http://www.nvbdcp.gov.in/malaria-new.html
• Guidelines for Diagnosis and Treatment of Malaria in India 2011 by
National Ministry :
http://www.mrcindia.org/Guidelines%20for%20Diagnosis2011.pdf

52. “ THERE IS NO LIMIT TO WHAT WE
ACHIEVE
IF YOU DON’T MIND WHO GETS
THE CREDIT”
….Anonymous

53. Thank you