Sachin

INTRODUTION •Malaria is protozoal disease caused by

the infection with parasites of the genus Plasmodium transmitted to man by certain species of infected female anopheline mosquito. • Clinical features:-Mild to severe and complicated ,according to the species of parasite, patient’s immune status, intensity of infection.

History • Malaria has infected human for over

50,000 years . • In the beginning of 2700 BC in China the term Malaria originate from Medieval Italian: mala aria which means “bed air”. • Also called Ague & Mast fever due to it’s association with swamps. • Scientific study starts in 1880, French army doctor Charles Louis

Laveran observed parasite in side the red blood cells of people suffering from malaria & he was awarded with Nobel Prize for Physiolgy and medicine.

CLASS OF MALARIA According to region Tribal malaria:• found in tribal areas of AP, MP, Bihar etc. • Contribute 50% of P. falciparum case in country. • Limited infrastructure & lack of drugs.

Rural Malaria • Arid & semiarid plains of Hryana,

Panjab, U.P.,M.P. • An.culicifacies is main vector & P. vivax is main causative agent. Urban Malaria • 15 major cities & 4 metropolitan cities contribute 80% of malaria cases • Delhi, Mumbai, Chennai, Kolkata, Banglore, Ahmedabad, Jaipur etc. • P. vivex & P.falciparum

• Health infrastructure is well devloped • Low socio-economic group living in unplanned settlement prone to periodical epidemic. Border Malaria • Due to military conflicts. • Mixing of population. • Poor administrative control.

CAUSATIVE AGENT • P.vivex:- Contribute 70% of malaria

infection. • P.falciparum:- Contribute about 2530% of malaria infection. • P.malariae:- contribute less than 1% cases of malaria in India. • P.ovale:- This is very rare parasite in man. Mostly found in Africa.

LIFE CYCLE OF PLASMODIM

VECTOR OF MALARIA

Out of 45 species of anapheline mosquito few are regarded as vector for the transmition, they are as follows, • Anapheline culicifacifacies • Anapheline fluviatiatilis • Anapheline stephensi • Anapheline minimus • Anapheline pihilippinensis • Anapheline sundaicus and • Anapheline maculatus

Symptoms • COLD STAGE

-lassitude, headache, nausea, chilling. • HOT STAGE -burning sensation, rapid respiration, full pulse • SWEATING STAGE -fever comes down with sweating, temp. drops to normal & skin is cool & moist, slower pulse rate, patient feels sleepy. • FEBRILE PAROXYSMS occurs with definate period repeating every third or fourth day.

CLASSIFICATION OF ANTIMALARIAL DRUGS • 4-Aminoquinoline (chloroquine) • Quinoline methanol (mefloquine) • Acridine (mepacrin) • Cinchona alkaloids (quinine) • Biguanides (proguanil) • Diaminopyrimidines (pyrimethamine) • 8-Aminoquinoline (primaquine) • Sulfonamides & sulfones (sulfodoxine) • Tetracycline (tetracycline) • Sesquiterpine lactone (arthesunate) • Naphoquinone (atovaquone)

HOW BIG PROBLEM IS? WORLD WIDE • About 100 countries in the world are

considered as malarious. • Out of 300-500 million clinical cases each year, 90% are from subsaharan africa caused by p. falciparum. • Kills 1.1-2.7 million people worldwide/year of whom 1 million r children under age of 5yrs. • Means 1 death in every 30sec.

Estimate of mortality & DALYs lost due to malaria REGION selected AFRICA

MORTALITY [000]

DALYs [000]

1136

40855

AMERICAS

1

111

EAST MEDITERRANEAN

59

1196

EUROPE

0

21

SEAR

65

2777

WESTERN PACAFIC

11

371

TOTAL

1272

46481

Malaria incidence & mortality in SEAR COUNTRY

Malaria Cases (per 100,000 population)

Malaria related mortality rate (per 100,000 population) All Ages

Children aged 0-4 ages

INDIA

7

3

6

BANGLADESH

40

1

1

BHUTAN

285

5

8

INDONESIA

920

1

0

MYANMAR

224

20

3

NEPAL

33

8

11

1110

9

4

SRI LANKA

IN INDIA • During 2003 abot 1.65 million cases were reported with 943 deaths, 0.7 million cases of p.falciparum. • Prevalence of malarial vector sever in north eastern states due to geography, climate condition.

DIAGNOSIS • Depends on demonstration of parasites in blood. • Thin & Thick blood flims are prepared on same slide. • Thick flim is more relable in searching of parasite. • Thin slide is more valuable for identifying species of parasite. • Malaria Fluorescent antibody test. • Dipstick antigen capture test.

MEASUREMENT OF MALARIA • TWO CLASSES 1.Pre-Eradication - Spleen rate - Average enlarged spleen - Parasite rate - Parasite density index - Infant parasite rate

2. Eradicatin era - Annual parasite incidence (API) - Annual blood examination rate (ABER) - Annual falciparum rate (AFR) - Slide possitive rate - Slide falciparum rate

WORK DONE IN PAST FOR ERADICATION •

ROLL BACK MALARIA initiative was launched by WHO, UNICEF, UNDP and the WORLD BANK in 1998.

•

Strengthen health system to ensure better delivery of health care, especially at district and community level. Ensure the proper and expanded use of insecticide treated mosquito nets. Ensure adequate access to basic health care and training of health care workers.

• •

SURVEILLANCE • Active survillance paid worker, alloted for the populatuon of 10,000 & for every 4 surv. There is surv. Inspector Jobs-visit each house under his area & enquire a) fever cases b) collect blood & administration of chloroquine c) make entry in house card & dispatches bld slide to lab. For examination d) if test is +ve he returns to patient & administer a course of radical treatment for

• Passive surveillance Search malaria cases in local health agencies e.g. PHC, hosp., dispensaries Cases of fever which escape the net of active surveillance workers are screened by the passive surveillance agencies & rest of job is same as active surveillance.

MALARIA CONTROL THROUGH PHC

• This new approach was approved by WHO in 1978 bcoz antimalarial drug distribution is effectively carried out in PHC • 1045 PHC’s are working predominantly in 8 states under enhanced Malaria Control Prog.

VACCINES No. of vaccines controlling malaria are currently under development • Asexual Blood-stage vaccine -Antigen derived from the blood stage of P. falciparum persent in man. • 2nd type of vaccine is designed to arrest the development of parastie of mosquito & thus reduce transmission of disease. Research supported by UNDP/WORLD BANK/WHO

• Synthetic cocktail vaccine for

P.falciparum called SP166 developed by Dr. M Patarroyo in Colombia. • ST vaccine - A team backed by the Gates Foundation and the pharma giant GlaxoSmithKline have announced results of a Phase IIb trial for RTS,S/AS02A, a vaccine which reduces infection risk by approximately 30% and severity of infection by over 50%.

Countries who have eradicated malaria & steps they have applied • Mexico, the third largest country in Latin

America, has made substantial inroads in decreasing its malaria burden. Has won the NOBEL PRIZE. • Intensive surveillance & fouced combined intervention in areas where transmission is identified & patients are treated with antimalarial drugs. Breeding sites for mosquito larvae are destroyed or treated; and pyrethroid insecticides are sprayed as needed, inside houses and outdoors

LONDON • Sterile insect technique is emerging as a potential mosquito control method. Progress towards transgenic, or genetically modified, insects suggest that wild mosquito populations could be made malariaresistant.

Work going on currently for the eradication of Malaria

• APPROACH TO MALARIA ERADICATION • Case management (diagnosis and

treatment) of patients suffering from malaria • Prevention of infection through vector control • Prevention of disease by administration of antimalarial drugs to population groups such as pregnant women and infants.

Case Management • The clinical management of malaria

cases (i.e diagnosis and treatment) to reduce morbidity and mortality ought to be first priority. • The government have also established drug distribution centers and fever treatment depots all over the country in rural areas to cope with problem of detecting and treating malaria cases in endemic areas.

Prevention of infection • Infection is prevented when malariacarrying Anopheles mosquitoes are prevented from biting humans. • Vector control reduce contact betn. Mosquitos & humans by destruction of larval breeding sites & insectiside spraying inside house. • Insectiside treated bed nets are also used for prevention.

Prevention of Disease • Antimalarial drugs are used to

prevent the disease by eliminating the parasite that are in the blood

Disease control strategies

• Case detection • Treatment

chloroquine was the antimalarial drug of choice for many years in most parts of the world. There are many drugs which are used for treatment & prophylaxis. Currently available antimalarial drugs • include Artemether-lumefantrine (Therapy only, commercial name Coartem) • Artesunate-amodiaquine (Therapy only) • Artesunate-mefloquine (Therapy only) • Artesunate-Sulfadoxine/pyrimethamine (Therapy only)

Activities for malaria control • Health education • Training & supervision of health

workers • Proper supply of equipment to health worker to carry out the intervention.

Why it is not possible till today • Drug resistance in P.falciparum

decreases the efficacy of antimalarial drug. • Insecticide resistance decreases the efficacy on insects such as DDT. • Inadequate health infrastructure in country • Poor socio economic condition & lack of education

What should be done for effective eradication

• Indoor residual spraying malathion,

synthetic pyrethnoids. • Mosquito nets & bed cloths-Mosquito nets help keep mosquitoes away from people, and thus greatly reduce the infection and transmission of malaria. The nets are not a perfect barrier, so they are often treated with an insecticide designed to kill the mosquito before it has time to search for a way past the net.

• Conclusion • Role of pharmacist