Namp National Anti Malaria Program

NAMP National Anti Malaria Program

Topics Discussed

Organisation & Implementation of National Anti Malaria Program in the District Techniques of blood examinations; Staining & Identification techniques Spraying techniques & Strategies Monitoring of the program

Organisation & Implementation

N A M P is a Cat II centrally sponsored Venture

50 : 50 cost sharing

Central --- Drugs, Insecticides / Larvicides, Technical assistance State

--- Operational costs including staff salary

RBM 98

NMCP 53 ---- NMEP 58 ---- UMS 71 ---- MPO 77 ---- MAP 95 ---- EMCP 97 ---- NAMP 99 Integration of the malaria maintenance phase under NMEP with the General Health Services --- Chadha Committee 63 Along with MPO 77,the MPW Scheme (Kartar Sing Committee) & VHG Scheme 77 took shape Carry out active & Passive Surveillance ; 1 H.I (Surveillance Inspector) for 4 MPW The PHC Medical Officers have a key role in the execution of the program In addition to the District Health Officer, the existing unit officers have been designated District Malaria Officers – entrusted with the operational & evaluation aspects of the program The DMO is assisted by Asst. Malaria Officers Lab services decentralised; Lab technicians posted at each PHC; come under the DMO

Malaria Trend across the centuries, in India

Six elements of Roll Back M a l a r i a 1. Evidence-based-decisions using surveillance, appropriate responses and building community awareness 2. Rapid diagnosis and treatment 3. Multiple prevention. Better multipronged protection using insecticide treated mosquito nets, environmental management to control mosquitoes and making pregnancy safer 4. Focussed research to develop new medicines, vaccines and insecticides and to help epidemiological and operational activities 5. Coordinated action for strengthening existing health services, policies and providing technical support. 6. Harmonised actions to build a dynamic global movement.

N A M P Control Strategies API >2

API<2 Focal Spraying

Spraying Entomological assessment Surveillance ( active & passive ) Treatment

Active surv once in 15 days

Surveillance ( active & passive ) Treatment Follow up Epidemiological Investigation

Treatment Presumptive Tab. Chloroquine 600 mg ( 10 mg/kg ) + Tab. Primaquine 15 mg ( 0.25 mg/kg ) Vivax

Radical

Tab. Chloroquine 600 mg ( 10 mg/kg ) + Tab. Primaquine 15 mg ( 0.25 mg/kg ) on day 1 Tab. Primaquine 15 mg on day 2, 3, 4 and 5 Falciparum Tab. Chloroquine 600 mg ( 10 mg/kg ) + Tab. Primaquine 45 mg ( 0.25 mg/kg )

MALARIA INCIDENCE IN RURAL AND URBAN AREAS OF TAMILNADU Year

State Cases

Rural Cases

Chennai Cases

Chennai %

Other UMS Cases

Other UMS %

1990

120029

48478

51272

42.7

20279

16.9

1991

144762

57403

67013

46.3

20346

14.1

1992

151633

52298

72314

47.7

27021

17.8

1993

148057

42908

76749

51.8

28400

19.2

1994

104964

39736

48352

46.1

16876

16.1

1995

92375

40739

41822

45.3

9814

10.6

1996

80586

27249

45930

57.0

7407

9.2

1997

72426

23429

41735

57.6

7262

10.0

1998

63915

16023

40475

63.3

7417

11.6

1999

56366

12141

38165

67.7

6060

10.8

2000

43053

7574

31861

74.0

3618

8.4

31551

5121

23652

75.0

2778

8.8

2002

34523

5490

27205

78.8

1828

5.3

2002 (Jan to Nov)

31385

5017

24725

78.8

1643

5.2

39423

11105

26429

67.0

1889

4.8

2001

2003(Jan to Nov)

The control strategies adopted by the TamilNadu Public Health dept : 1) Malaria case detection is being carried out by house to house visit by collection of blood smears from fever cases and giving treatment for those who are found positive for malaria. 2) Two rounds of residual insecticidal spray during transmission period using synthetic pyrethroid in malaria endemic areas. 3) Passive surveillance and anti-larval work in urban. 4) Creating awareness among the community for their participation. 5) Whenever imported cases recorded , the same is cross notified by the concerned Medical Officer to the respective Health Authorities of State for further remedial action at their end. 6) Mass and contact Blood survey are being carried out to prevent the occurrence of secondary cases. 7) Whenever necessary, focal spray is being carried out. Active surveillance has become a problem all over the country in the recent past. In Tamil Nadu, IEC activities have made a great impact on surveillance, that more number of cases are being identified under passive surveillance than Active surveillance. Geographical Information system (GIS) is being developed in Tamilnadu for carrying out epidemiological mapping of the villages and for identifying vulnerable areas and seasonal pattern of disease outbreak. www.tnhealth.org/dphpm/dbmal

Spraying techniques & Strategies

SPRAYING Rapidly reduce populations of flying insect pests and vectors ( A D U L T S ) Exacting, periodical & continuous efforts vital for the success of operations Space spray treatments

Outdoor

No Residual Effects Space spray equipment

Hand-carried Thermal fog / Cold fog

Vehicle-mounted Aircraft application

Residual Spray Treatments

Indoor

Residual Effects Sound knowledge on the Vector breeding sites, lifespan, feeding habits, seasonal trends (Ecology) essential for successful, cost-effective anti-adult spraying campaigns Dose and residual effect are important considerations in determining the number of spray rounds needed to protect a population during the whole, or only the peak, of the transmission season.

SPACE SPRAYS A space spray – technically a fog (sometimes referred to as an aerosol) – is a liquid insecticide dispersed into the air in the form of hundreds of millions of tiny droplets A very important characteristic of space sprays is the size of the droplets being Dispersed, since this determines the time that they remain in suspension in the air and their ability to penetrate into spaces that are not fully open. Sprays, measured by their volume median diameter (VMD), are divided in accordance with their droplet size into Coarse sprays

with a VMD over 400 µm

Fine sprays

with a VMD between 100 and 400 µm

Mists

with a VMD between 50 and 100 µm

Fogs or ultra-low volume (ULV) sprays

with a VMD below 50 µm

WHO Classification of Pesticides by Hazard (WHO/UNEP/ILO, 1994)

Class 1a

Extremely hazardous

Class 1b

Highly hazardous

Class 2

Moderately hazardous

Class 3

Slightly hazardous

UH

Unlikely to be hazardous

The technical products listed in Table 1 as recommended for malaria control belong to class II, with the exception of malathion and pyrimiphos-methyl, which belong to class III. In fact, all the formulations used, at the dilutions actually applied, belong to class III.

Techniques of blood examinations

MICROSCOPIC DIAGNOSIS Conventional light microscopy is the established method for the laboratory confirmation of malaria. Microscopy offers many advantages It is sensitive.

It is informative.

It is relatively inexpensive.

It is a general diagnostic technique that can be shared with other disease control programmes, such as those against tuberculosis or sexually transmitted diseases. It can provide a permanent record (the smears) of the diagnostic findings and be subject to quality control. Microscopy suffers from three main disadvantages It is labour-intensive and time-consuming, normally requiring at least 60 minutes from specimen collection to result. It is exacting and depends absolutely on good techniques, reagents, microscopes and, most importantly, well trained and well supervised technicians. There are often long delays in providing the microscopy results to the clinician, so that decisions on treatment are often taken without the benefit of the results.

Monitoring

Monitoring and evaluation Monitoring measures the implementation of the range of strategic activities

Monitoring, which is a continuous on-going activity allows step-by-step recording of the progress made by health programmes

Evaluation measures the extent to which the objectives are being reached Evaluation is concerned with impact indicators, which allow periodic assessment of the way in which strategies and implemented activities reach the planned objectives.

Parameters of Malaria Surveillance API

ABER

=

=

Confirmed cases during the Yr

X 1000

Population under surveillance # of slides examined

X 100

Population under surveillance

Index of Operational Efficiency

WHO – 1 % of Pop / month ; MPO – 10 % of Pop / Yr Vector Indices :

Monthly blood examn rates

1. Human Blood Index

Transmission season Non-transmission season (July – oct) 2. Sporozoite Rate

Active 2% 3. Mosq density ( # of mosq/man-hour-catch )

1% 4. Inoculation Rates

Passive as % of new OPD cases 20 % 5. Man biting Rate ( biting density – bites/day/person )

Annual Falciparum Incidence

15 %

pf proportion

Slide Positivity Rate Spleen Rate Slide Falciparum Rate

Measure of Endemicity of Malaria

Malaria Situation in Coimbatore district ( 1998 – 2002 )

Year

Total Population

Blood smears examined

Total +ve

pf

ABER

SPR

SFR

API

Death

Radical Rx given

1998

24,92,219

2,42,036

21

5

10.7

0.08

0.002

0.01

-

21

1999

25,14,963

2,42,984

125

54

9.51

0.05

0.02

0.05

-

91

2000

25,20,557

2,48,424

7

1

9.4

0.003

0.004

0.002

-

7

2001

25,44,766

2,43,099

10

-

9.6

0.004

-

0.003

-

10

2002

25,94,943

2,66,647

12

-

10.1

0.004

-

0.005

-

12

Source : District Malaria Officer, Coimbatore

National Surveillance Programme of Communicable Diseases Communicable disease surveillance is important to develop strategies for control and prevention of disease. It helps to forecast epidemics outbreak. The National Surveillance Programme of Communicable Diseases was started as a Pilot scheme in 1997. In Tamil Nadu, a National Surveillance Programme for Communicable Diseases has been launched in Dharmapuri, Villupuram, Coimbatore, Madurai and Salem.

The Zonal Entomological Team Zonal Entomological Teams attached to all the 72 Zones in the country Carry out Entomological Surveys & Surveillance

Common Tasks are, to find out 1) Which Anopheline Sps are present 2) Which of them are Vectors of Malaria 3) The biology & behaviour of adult vector mosquitoes’ nesting habits (in/outdoors), feeding habits, seasonal changes in the numbers biting humans, duration of adult life and the areas in which they are found 4) Breeding Habits of the Mosquitoes 5) Which Vectors are Susceptible (or) Resistant to Insecticides

Distribution of Pf % in India, 1986-97

Last Modified : 15 October, 2003 WHO Regional Office for South-East Asia

Chloroquine Resistance Status Of India,1997

Last Modified : 15 October, 2003 WHO Regional Office for South-East Asia

Dynamics of P.falciparum in India,1985-99

Last Modified : 15 October, 2003 WHO Regional Office for South-East Asia

Status of P.falciparum Resistance to Anti Malarial Drugs In India,1986-95

Last Modified : 15 October, 2003 WHO Regional Office for South-East Asia

Pf Resistance Status of Alternative Anti malarials in India,1997

Last Modified : 15 October, 2003 WHO Regional Office for South-East Asia

Proposed RBM Core Indicators I.IMPACT Crude death rate among target groups. Malaria death rate (probable and confirmed cases) among target groups. % of probable and confirmed malaria deaths among patients with severe malaria admitted to a health facility. Number of cases of severe malaria (probable and confirmed) among target groups. Number of cases of uncomplicated malaria (probable and confirmed) among target groups. Annual Parasite Incidence (API) among target groups (by region/according to the epidemiological situation). II.MALARIA PREVENTION AND DISEASE MANAGEMENT Prevention % of countries having introduced pyrethroids for public health use and insecticide-treated materials in the list of essential drugs and materials. % of service providers (health personnel, CHW…) trained in techniques of treatment of nets and/or indoor spraying according to the national policy. % of households having at least one treated bednet. % of pregnant women who have taken chemoprophylaxis or intermittent drug treatment, according to the national drug policy. % of antenatal clinic staff trained in preventive intermittent antimalarial treatment for pregnant women. Prevention and control of epidemics % of countries with epidemic prone areas/situation having a national preparedness plan of action for early detection and control of epidemics. % of malaria epidemics detected within two weeks of onset and properly controlled. Early diagnosis and Prompt Treatment % of health personnel involved in patient care trained in malaria case management and IMCI. % of health facilities able to confirm malaria diagnosis according to national policy (micro s c o py, rapid test etc.). % of patients hospitalised with a diagnosis of severe malaria and receiving correct antimalarial and supportive treatment according to the national guidelines. % of patients with uncomplicated malaria getting correct treatment at health facility and community levels according to national guidelines within 24 hrs of onset of symptoms.

III.HEALTH SECTOR DEVELOPMENT Health Policy % of districts with plans of action reflecting national health policy. % of districts using health information for planning. % of countries having a policy of universal coverage for all with a basic package including relevant malaria control activities. Service Delivery % of health facilities reporting no disruption of stock of antimalarial drugs, as specified in the national drug policy, for more than one week during the previous three months. Community Action % of countries having national guidelines for malaria prevention and treatment including training of all the informal health providers and recommendations for home treatment of febrile illness/suspected malaria, recognition of the most frequent signs of danger for children, prevention of malaria during pregnancy and use of insecticide treated materials. % of villages/communities with at least one Community Health Worker trained in management of fever and recognition of severe febrile illness. % of mothers/caretakers able to recognise signs and symptoms of danger of a febrile disease in a child < 5 years. IV. INTERSECTORAL LINKAGES % of countries with multisectoral and inter-agencies partnership established. % of countries having established official linkages, including the elaboration of research agenda of public health interest, between research institutions and Ministry of Health. V. SUPPORT/PARTNERSHIP % of countries with agreed national RBM budget met by donor funding. % of countries with functional sentinel sites for surveillance efficacy of 1st and 2nd line antimalarial drugs. Number of antimalarial drugs which have progressed to the level of phase III trials.

National Malaria Eradication Programme Programme Achievements $

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PARASITOLOGICAL DIAGNOSIS- SMEAR

PARASITOLOGICAL DIAGNOSIS- SMEAR