INTRODUCTION

Malaria is a major public health problem in India, accounting for sizeable morbidity, mortality and
economic loss. Apart from preventive measures, early diagnosis and complete treatment are the important
modalities that have been adopted to contain the disease. In the pre independence days, malaria was killer number
one. It was an important cause of infant mortality. It used to cause a loss to the national exchequer of 75.000 million
rupees annually. It was responsible for reduced work capacity and fall in agricultural and industrial output.

DEFINITION

Malaria is a protozoal disease caused by infection with parasites of the genus plasmodium and transmitted
to man by certain species of infected female anopheline mosquito.

HISTORY OF MALARIA

2700 BCE: The Nei Ching(Chinese Canon of Medicine) discussed malaria symptoms and the relationship between
fevers and enlarged spleens.

•1550 BCE: The Ebers Papyrus mentions fevers, rigors, splenomegaly, and oil from Balantines tree as mosquito
repellent.

•6th century BCE: Cuneiform tablets mention deadly malaria-like fevers affecting Mesopotamia.

•Hippocrates from studies in Egypt was first to make connection between nearness of stagnant bodies of water and
occurrence of fevers in local population.

•Romans also associated marshes with fever and pioneered efforts to drain swamps.

•Italian: “aria cattiva”= bad air; “mal aria”= bad air.

•French: “paludisme”= rooted in swamp.

•1847: Meckelidentified pigment in blood of insane person.

•1848: Virchowpictured and described pigmented bodies in blood of malarial patient

•1850: Hischlconnected presence of pigment and intermittent fever

•1880: Laveranidentified pigment in body of living parasite in 26 patients. He is credited with describing the
etiologic agent of malaria.

•In the 1890's British scientist Patrick Manson theorized that mosquitoes may be involved in malaria transmission.
Manson had recently found that mosquitoes could vector filarial worms that caused elephantiasis.

•Two Johns Hopkins medical students Opieand MacCallumwho were the first to describe sexual reproduction of
Plasmodiumin birds and man.
MAGNITUDE OF THE PROBLEM

Malaria transmission occurs in all six WHO regions. Globally, an estimated 3.2 billion people in
97 countries and territories are at risk of being infected with malaria and developing disease (Figure 1.1), and 1.2
billion are at high risk (>1 in 1000 chance of getting malaria in a year). According to the latest estimates, 198
million cases of malaria occurred globally in 2013 (uncertainty range 124–283 million) and the disease led to 584
000 deaths (uncertainty range 367 000–755 000), representing a decrease in malaria case incidence and mortality
rates of 30% and 47% since 2000, respectively. The burden is heaviest in the WHO African Region, where an
estimated 90% of all malaria deaths occur, and in children aged under 5 years, who account for 78% of all deaths.

India

Malaria is a public health problem in several parts of the country. About 95% population in the country
resides in malaria endemic areas and 80% of malaria reported in the country is confined to areas consisting 20% of
population residing in tribal, hilly, difficult and inaccessible areas. Directorate of National Vector Borne Disease
Control Programme (NVBDCP) has framed technical guidelines/ policies and provides most of the resources for
the programme. Indicators have been developed at national level for monitoring of the programme and there is
uniformity in collection, compilation and onward submissions of data. Passive surveillance of malaria is carried out
by PHCs, Malaria Clinics, CHCs and other secondary and tertiary level health institutions that patients visit for
treatment. Apart from that, ASHA- a village volunteer is involved in the programme to provide diagnostic and
treatment services at the village level as a part of introduction of intervention like Rapid Diagnostic Tests and use
of Artemisinin Combination Therapy (ACT) for the treatment of Pf cases.
India 2012 2014

Blood Slide Examination 109044798 108713958

Malaria cases 1067824 974652

Pf cases 533695 630618

Deaths 519 372

Tamilnadu 2012 2014

Blood Slide Examination 7682917 8210119

Malaria cases 18869 8272

Pf cases 576 313

Deaths 0 0
 Kerala 2012 2014

Blood Slide Examination 2414705 2448720

Malaria cases 2036 1627

Pf cases 236 278

Deaths 3 5
Andhra Pradesh 2012 2014

Blood Slide Examination 9423964 8787037

Malaria cases 24699 22216

Pf cases 15695 16787

Deaths 2 0

Pondicherry 2012 2014

Blood Slide Examination 233078 161760

Malaria cases 143 73

Pf cases 2 2

Deaths 0 0

10 FACTS ON MALARIA BY WHO

1. Malaria is caused by parasites that are transmitted to people through the bites of infected
mosquitoes

Malaria is caused by Plasmodium parasites that are spread to people through the bites of infected
Anopheles mosquito vectors. Of the 5 parasite species that cause malaria in humans, Plasmodium
falciparum is the most deadly.
 2. Half of the world's population is at risk of malaria

Every year, 3.2 billion people are at risk of malaria. This leads to about 198 million malaria cases
(uncertainty range: 124 million to 283 million) and an estimated 584 000 malaria deaths (uncertainty
range: 367 000 to 755 000). People living in the poorest countries are the most vulnerable.

3. Every minute, a child dies from malaria

In 2013, 90% of the world’s malaria deaths occurred in Africa and over 430 000 African children
died before their fifth birthdays.

4. Malaria mortality rates are falling

Increased malaria prevention and control measures are dramatically reducing the malaria burden
in many places. Malaria mortality rates have fallen by 47% globally since 2000 and by 54% in the WHO
African Region.

5. Early diagnosis and prompt treatment of malaria prevents deaths

Early diagnosis and treatment of malaria reduces disease and prevents deaths. It also contributes
to reducing malaria transmission. Access to diagnostic testing and treatment should be seen not only as a
component of malaria control but as a fundamental right of all populations at risk.

6. Emerging artemisinin resistance is a major concern

Parasite resistance to artemisinin, the core compound in WHO-recommended combination

treatments for uncomplicated malaria, has been detected in 5 countries of south east Asia: Cambodia,
Laos, Myanmar, Thailand and Viet Nam. However, artemisinin-based combination therapies remain
effective in almost all settings, as long as the partner drug in the combination is locally effective.

7. Sleeping under long-lasting insecticidal nets protects against malaria

These nets provide personal protection against mosquito bites. They can be used as protection for
people most at risk of malaria, such as young children and pregnant women in high malaria transmission
areas. The nets are effective for 3-5 years, depending on the model and conditions of use. In 2013, an
estimated 49% of the population at risk in Africa had access to a bed net.
 8. Indoor residual spraying is the most effective way to rapidly reduce malaria transmission

The full potential of indoor residual spraying is obtained when at least 80% of houses in targeted
areas are sprayed. Indoor spraying with insecticides kills the mosquito vector and is effective for 3–6
months, depending on the insecticide used and the type of surface on which it is sprayed. Longer-lasting
forms of insecticides are under development.

9. Pregnant women are particularly at risk of malaria

Pregnant women are at high risk of dying from the complications of severe malaria. Malaria is
also a cause of spontaneous abortion, premature delivery, stillbirth and severe maternal anaemia, and is
responsible for about one third of preventable low-birth-weight babies. WHO recommends intermittent
preventive treatment for pregnant women living in areas of high malaria transmission.

10. Malaria causes significant economic losses in high-burden countries

In high-burden settings, malaria can trap families and communities in a downward spiral of
poverty, disproportionately affecting marginalized and poor people who cannot afford treatment or who
have limited access to health care.

EPIDEMIOLOGICAL DETERMINANTS

Agent

FACTORS

Host Environment

AGENT FACTORS:

 Agent: malaria in man caused by four species,

In India 50% of infection are reported due to P.falciparum. 4-8% due to mixed infections. Rest due to
p.vivax. P.malaria is less than 1% of infection. P.ovale is very rare parasite of man, mostly confined to
tropical Africa.
HOST FACTORS:

Age: it affects all age.

Newborn infants have resistance to the infection with p. falciparum due to high concentration of foetal
hemogloubin.

Sex: males are frequently exposed than females due to outdoor life.

Race: sickle cell anemia have milder infection with falciparum.

Pregnancy: it increases the risk of malaria in women and causes IUD ,premature labour and abortion.

Socio economic development: malaria has disappeared from most developed countries.

Housing: ill-ventilated and ill-lighted houses provide ideal indoor resting place for mosquitoes.

Population mobility: migrating people from other country and labourers reintroduce malaria into areas
where it has been controlled

Occupation: malaria is closely related to agricultural practices

Immunity: immunity to malaria in humans is acquired only after repeated exposure over several years.

ENVIRONMENTAL FACTORS:

 Season: it is a seasonal disease. Most prevalence is from July to November.

 Temperature: it affects the life cycle of malarial parasite. The optimum temperature for the
development of ,malaria is between 20deg c to 30 deg c.
 Humidity: a relative humidity of 60% is necessary for mosquitoes to live their normal span of life.
if humidity is high they become more active but if it is less they do not live long.
 Rainfall: it provides oppourtunity for breeding of mosquito,but heavy rain will flush out the
breeding places.
 Man made malaria: burrow pits, garden pools, irrigation channels, and engineering projects lead
to the breeding of mosquitoes.

HOST FACTORS:

Age: it affects all age. Newborn infants have resistance to the infection with p. falciparum due to high
concentration of foetal hemogloubin.

Sex: males are frequently exposed than females due to outdoor life.

Race: sickle cell anemia have milder infection with falciparum.

Pregnancy: it increases the risk of malaria in women and causes IUD ,premature labour and abortion.
Socio economic development: malaria has disappeared from most developed countries.

Housing: ill-ventilated and ill-lighted houses provide ideal indoor resting place for mosquitoes.

Population mobility: migrating people from other country and labourers reintroduce malaria into areas
where it has been controlled

Occupation: malaria is closely related to agricultural practices

Immunity: immunity to malaria in humans is acquired only after repeated exposure over several years.

ENVIRONMENTAL FACTORS:

o Season: it is a seasonal disease. Most prevalence is from July to November.

o Temperature: it affects the life cycle of malarial parasite. The optimum temperature for the
development of ,malaria is between 20deg c to 30 deg c.
o Humidity: a relative humidity of 60% is necessary for mosquitoes to live their normal span of life.
if humidity is high they become more active but if it is less they do not live long.
o Rainfall: it provides oppourtunity for breeding of mosquito,but heavy rain will flush out the
breeding places.
o Man made malaria: burrow pits, garden pools, irrigation channels, and engineering projects lead
to the breeding of mosquitoes.

CAUSES

Malaria in man is caused by four distinct species of malaria parasite

 Plasmodium vivax
 Plasmodium falciparum
 Plasmodium malariae
 Plasmodium ovale

The vectors of major importance are An. Culicifacies in rural areas and An. Stephensi in urban areas.

MALARIA VECTORS OF INDIA

The important malaria vectors in India are:
a. Anopheles culicifacies: The most common vector in India, especially in rural areas and is widely
distributed in India. Occurs sporadically in N.E. India. Not reported in Andaman & Nicobar Islands and
Lakshadweep.
b. Anopheles fluviatilis: Important vector in hilly and forested areas. Widelydistributed in the foothill
areas including both peninsular and North East India
c. Anopheles stephensi: Distributed throughout India except at higher altitudes. Found only sporadically
in the North East. Almost all urban malaria is due to this species.
d. Anopheles sundaicus: Typical of seashores; low importance except on islands. Responsible for malaria
transmission in Andaman & Nicobar islands only.
e. Anopheles minimus: Of great importance in the north east India, breeding in slow- moving streams
with grassy margins, mainly in foothills.
f. Anopheles dirus: Vector in forested and forest fringe area in the northeast. Highly exophilic and
exophagic and difficult to ). Breed in small, transient, partly shaded pools in forest areas (eg. Elephant
footprints)
g. Anopheles annularis: Mainly a secondary vector, which is common in central India and Orissa.
h. Anopheles philippinensis: It is incriminated as a vector in deltaic West Bengal and N.E. India. Breeds
mainly in paddy fields.
i. Anopheles varuna: Secondary vector in Andhra Pradesh, Jharkhand and Orissa.

FACTORS DETERMINE THE VECTORIAL IMPORTANCE OF MOSQUITOE

1. DENSITY: “critical density”- a sudden increase in density of vector cause epidemic outbreak.

This level varies with different species’ An. Culicifacies a high density is required in case of An. Fluviatilis a much
lower density would suffice.

2. LIFE SPAN: the vector of mosquito must live for atlest 10-12 days after an infective blood meal to become
infective.

3. CHOICE OF HOST: some mosquito prefer human blood and some for animal blood ie. An. Culicifacies an
important vector in India ,human blood feed are better vector of malaria than zoophilic species.

4. RESTING HABITS: mosquitoes rest indoors-endophily, mosquitoes rest outdoors-exophily

Endophilism are the most malarial vectors.

5. BREEDING HABITS: some breed in moving water-an.fluviatilis, some breed in brakish water and some in
wells, fountains and overhead tanks

6. TIME OF BITTING: anopheline mosquitoes have nocturnal feeding habits

7. RESISITANCE TO INSECTICIDES: alternative insecticides have to be used

MODE OF TRANSMISSION

a) Vector transmission: transmitted by the bite of certain species of infected female, anopheline
mosquitoes . The mosquito is not infective unless the sporozites are present in its salivary glands.
b) Direct transmission: malaria may be induced accidently by hypodermic, intramuscular, and
intravenous injection of infected blood or plasma.

LIFE CYCLE:

The malarial parasite undergoes 2 cycles of development .

 Human cycle (asexual cycle)
 Mosquito cycle (sexual cycle)
Man is the intermediate host and mosquito the definitive host.

Asexual cycle in human being

The asexual cycle begins when an infected anopheles mosquito bites a person and injects sporozoites.
There are 3 phases in the human cycle.
1. Hepatic Phase
The sporozoites disappear within 60 minutes from the peripheral circulation. Many of them are destroyed
by phagocytes, but some reach the liver cells. After 1-2 weeks of development (depending upon the
species), they become hepatic schizonts, which eventually burst releasing a shower of merozoites. The
number of merozoites produced from a single sporozoite varies . as many as 40,000 in P. falciparum,
whereas only 200 . 15,000 in other species. In P. falciparum, the
intrahepatic schizonts rupture almost simultaneously and there is no persistent tissue phase (exo-
erythrocytic phase). In other species, the hepatic forms may remain dormant (hypnozoites) for long
periods, liberating merozoites at various intervals, causing relapses of malaria.
2. Erythrocytic Phase
Many of the merozoites released from the liver cells are quickly destroyed, but a significant
number attach themselves to specific receptor sites on the RBCs, penetrate them and pass through various
stages of trophozoite and schizont. The erythrocytic phase ends with the liberation of merozoites, which
infect fresh RBCs. The clinical feature of fever with chills coincides generally with the rupture of RBCs.
The cycle is repeated over and over again until the condition worsens
or when it may be slowed down by the immune response of the host. The duration of each erythrocytic
cycle varies between species . 48 hours for P. falciparum, P.vivax and P. ovale; and 72 hours for P.
malariae.
3 Gametogony
Some of the erythrocytic forms of plasmodia do not divide further but develop into male and female
gametocytes. Not all infected persons are infectious (can infect anopheline mosquitoes). The blood of the
person has to have mature male and female gametocytes and the density should be minimum 12/ cumm
of blood to be infective. These gametocytes take over a week to appear in the blood. Gametocytes do not
cause any symptoms in humans. Most drugs like chloroquine kill the asexual forms that cause the fever
but leave intact the sexual forms that are infective especially in case of P falciparum. Thus an apparently
normal person may harbour the disease and contribute to its spread.

Spread of malaria

The plasmodia spread from person to person by the bite of mosquitoes. This process is called the
transmission of the disease, and the mosquitoes are the vectors of malaria. However, not all mosquitoes
can act as malaria vectors. It is only mosquitoes belonging to the genus Anopheles - and that too the female
of the species which can carry the parasite and infect. Male Anopheles mosquitoes only feed on plant
juices and nectar and cannot transmit malaria.

Sexual Cycle in Mosquito

The mosquito cycle (sporogony) begins when gametocytes are ingested by the vector mosquito
while feeding on an infected person. The male gametocytes, after reaching the stomach of the mosquito
and develop into 4-8 filaments called microgametes.. The female gametocyte undergoes maturation to
become a macrogamete.. The microgametes get attracted to the macrogamete, and one of the
microgametes fertilizes the macrogamete. The resulting zygote is at first motionless, but within 18-24
hours, becomes a motile ookinete, which penetrates the stomach wall of the mosquito and develops into
an oocyst on the outer surface of the stomach. The oocyst further develops into numerous sporozoites,
when the oocyst ruptures and releases the sporozoites into the body cavity of the mosquito. Many of the
sporozoites migrate to the salivary glands and the mosquito becomes infective to man. The period required
for the development of the parasite from the gametocyte stage to sporozoite stage is about 10-20 days
depending on atmospheric temperature and humidity. This period is known as the extrinsic incubation
period.. The sporozoites (the infective stage of Plasmodium) are injected with saliva when the mosquito
next feeds.In falciparum malaria, there may be involvement of the brain and coma in addition to life
threatening complications including kidney or liver failure. With early and effective treatment, the case
fatality rates in P.falciparum malaria can be brought down from above 5% to close to zero. Malaria cases
can be classified according to the parasite species causing them and according to the severity of the
disease, as either uncomplicated or severe malaria. It should be understood that severe vivax malaria is
very rare.

Reservoir of infection:

A human reservoir is one who harbours the sexual forms of the parasites. A patient can be a carrier
of several plasmodial species at same time. Children are more likely to be a gametocyte carriers then
adults. Certain conditions for a person to be a reservoir are;

 Person must be harbor for both sexes

 The gametocytes must be mature
 The gametocytes must be viable
 The gametocytes must be present in sufficient density to infect mosquito

Period of communicability:Malaria is communicable as long as mature, viable gametocytes

exist in the circulating blood inn sufficient density to infect vector mosquitoes.

 In vivax infection, gametocytes appear in blood 4 -5 days after asexual parasite.

 In falciparum infections it may take 10 -12 days after asexual parasite.

Relapses: It is usual for vivax and ovale malaria to relapse more than 3 y ears after the
patient’s first attack. Recurrences of falciparum malaria usually disappear within 1 -2 years.

INCUBATION PERIOD

12 days for falciparum malaria

14 days for vivax malaria

28 days for quartan malaria

17 days for ovale malaria
TYPES OF MALARIA
1. Benign tertian malaria: It is caused by plasmodium vivex, it has a cycle of hours which causes fever,
recurring after every 2 days.
2. Malignant tertian malaria: It is caused by plasmodium falciparum. In this type fever is very irregular
which may occur after every 48hours. Its symptoms are very severe and are of malignant type, i.e high fever,
delirium and sometimes coma.

3. Plasmodium ovale: It is a parasite which produces a mild form of tertian malaria. This type of malaria is
not found in india, but it is found in Africa.

4. Plasmodium malariae: Which is known as quartan parasite, causes fever which is recurring after every
three days and has a cycle of 72 hours.

PREVALENT MAJOR EPIDEMIOLOGICAL TYPES OF MALARIA IN INDIA:

1. Tribal malaria

2. Rural malaria

3. Urban malaria

4. Malaria in project areas

5. Border malaria

Tribal malaria

Infant, young children, and pregnant women have been identified as malaria high risk group followed by
mobile tribal population engaged in forest- related activities. Limited health infrastructure and lack of drugs at
village level. High endemic area

Rural malaria

Malaria is moderate to low endemicity. P.vivax and P. falciparum are predominant during lean period and
period of exacerbation. In these health infrastructure is moderately developed.

Urban malaria

Malaria is moderate to low endemicity. P.vivax and P. falciparum are predominant. An. Stephensi is the
main vector. Health infrastructure is well developed.

Malaria in project areas

Those areas where constructions and developmental activities are taken up. Due to tropical aggregation of
labourers,bringing different strains of malarial pararsite, one or more malarial vectors are involved in transmission.

Border malaria:- Areas have problem because of mixing of population and poor administrative control.

SYMPTOMS OF MALARIA

 Typically, malaria produces fever, headache, vomiting and other flu-like symptoms.
  The parasite infects and destroys red blood cells resulting in easy fatigue-ability due to anemia,
fits/convulsions and loss of consciousness.
 Parasites are carried by blood to the brain (cerebral malaria) and to other vital organs.
 Malaria in pregnancy poses a substantial risk to the mother, the fetus and the newborn infant. Pregnant
women are less capable of coping with and clearing malaria infections, adversely affecting the unborn fetus.

SYMPTOMS OF SEVERE AND COMPLICATED MALARIA

The priority requirement is the early recognition of signs and symptoms of severe malaria that
should lead to prompt emergency care of patient. The signs and symptoms that can be used are non-
specific and may be due to any severe febrile disease, which may be severe malaria, other severe febrile
disease or concomitant malaria and severe bacterial infection.

The symptoms are a history of high fever, plus at least one of the following:-

 Prostration (inability to sit), altered consciousness lethargy or coma

 Breathing difficulties
 Severe anaemia
 Generalized convulsions/fits
 Inability to drink/vomiting
 Dark and/or limited production of urine

Patients with prostration and/or breathing difficulties should, if at all possible, be treated with
parenteral antimalarials and antibiotics. Oral treatment should be substituted as soon as reliably
possible. Frequent monitoring of laboratory parameters is essential - blood sugar, blood urine, fluid
balance, associated infection, etc. Drugs that increase gastro intestinal bleeding should be avoided.

SIGNS OF SEVERE AND COMPLICATED MALARIA

 Cerebral malaria, defined as unarousable coma not attributable to any other cause in a patient with
falciparum malaria.
 Generalized convulsions.
 Normocytic anaemia.
 Renal failure.
 Hypoglycaemia.
 Fluid, electrolyte and acid-base disturbances.
 Pulmonary oedema.
  Circulatory collapse and shock ("algid malaria").
 Spontaneous bleeding (disseminated intravascular coagulation).
 Hyperpyrexia.
 Hyperparasitaemia.
 Malarial haemoglobinuria.

RISK FOR SEVERE COMPLICATIONS

 In areas of low transmission - all age groups are vulnerable but adults develop more severe and multiple
complications. The transmission pattern in most parts of India is usually low, but intense transmission is
seen in north-eastern states and large areas of Orissa, Chattisgarh, Jharkhand and Madhya Pradesh.
 In areas of high transmission - children below 5 years, visitors, migratory labour.
 Association of pregnancy-pregnant women are less capable of coping with and clearing malaria
infections, adversely affecting the unborn fetus.

Uncomplicated Malaria

The classical (but rarely observed) malaria attack lasts 6-10 hours. It consists of:

Cold stage :- sensation of cold, headache, nausea , shivering and chilly sensation followed in an hour or
so by rigors.. Temperature rapidly rises to 39-41 degree Celsius. Headache and vomiting, rapid weak
pulse. This stage lasts for ½ - 1 hour.

Hot stage :- fever, headaches, vomiting; seizures in young children, headache is intense but nausea
diminishes. Rapid respiration. This stage lasts for 2 – 6 hours.
Sweating stage:-fever comes down, return to normal temperature, tiredness, profuse sweating,
temperature drops rapidly to normal and skin is cool and moist. This stage lasts for 2 – 4 hours.

DIAGNOSIS
Early diagnosis and treatment of cases of malaria aims at:
• Complete cure
• Prevention of progression of uncomplicated malaria to severe disease
• Prevention of deaths
• Interruption of transmission
• Minimizing risk of selection and spread of drug resistant parasites.
  Clinical diagnosis depends upon recurrent Chills with fever, spleenomegaly, secondary anemia
with palpable spleen and mild icterus
 Blood films are useful in searching for and identification of malarial parasite. Both ‘thin’ and
‘thick’ films to be prepared and examined under microscope field.
 Malarial fluorescent antibody test to determine whether a person had malaria in the
past.(serological test)
 Dipstick ( antigen capture ) assay for detection of plasmodium falciparum

Microscopy
Microscopy of stained thick and thin blood smears remains the gold standard for confirmation of
diagnosis of malaria.
The advantages of microscopy are:
• The sensitivity is high. It is possible to detect malarial parasites at low densities. It also helps to quantify
the parasite load.
• It is possible to distinguish the various species of malaria parasite and their different stages.
“Thin film”- it is more valuable for identifying the species of the parasite present.
“Thick film”- it is more reliable in searching for parasite, as large volune of blood is examined under
microscope field
Rapid Diagnostic Test
Rapid Diagnostic Tests are based on the detection of circulating parasite antigens. Several types
of RDTs are available some of them can only detect P. falciparum, while others can detect other parasite
species also.The latter kits are expensive and temperature sensitive. Presently, NVBDCP supplies RDT
kits for detection of P. falciparum at locations where microscopy results are not obtainable within 24 hours
of sample collection.

MANAGEMENT
The objectives of malaria case management are:
 To prevent severe disease and death in patients presenting with uncomplicated malaria
 To shorten the duration of symptoms
 To reduce malaria transmission
 To prevent relapses of vivax malaria
ACTIVE SURVEILLANCE: a malaria field worker carries out active surveillance. He takes a thick and thin
blood smer from him or her and sends the slide to the unit laboratory. He administers chloroquine to the individual
as presumptive treatment. If blood report is positive, carries out radical treatment.

PASSIVE SURVEILLANCE: in this medical officers of hospitals and dispensaries and even private practitioners
are requested to obtain blood smears from every febrile case and hand over slides to the surveillance worker.

Antimalarial drugs used in public health in India

1. Schizonticidal drugs:- Chloroquine, quinine, sulfadoxine-pyrimethamine, artemisinin derivatives:

artesunate, arte-mether and arte-ether.

2) Gametocytocidal and anti-relapse drug:- Primaquine.

Selection of drugs

All fever cases diagnosed positive by either RDT or microscopy need to be promptly started on
effective treatment. The treatment will depend upon the species of Plasmodium diagnosed.

Treatment of uncomplicated falciparum malaria

Artesunate 4mg/kg daily for 3 days plus sulfadoxine-pyrimathamine 25mg/kg(sulfadoxine)+ 1.25

mg/kg(pyrimathamine) as a single dose on the first day (ACT-Artemisinin Combination Therapy) plus
primaquine (PQ) in a single dose on the first day.

In low-risk areas with PV predominance and Pf is sensitive to chloroquine resistance, the

Pf cases will be treated with chloroquine and primaquine. Similarly, the clinical cases (unconfirmed cases)
will also be treated with chloroquine in situations where diagnosis is not possible within reasonable time,
no later than the day after fever is reported to the health facility.

Treatment of uncomplicated P.falciparum cases in pregnancy:

1st Trimester : Quinine salt 10mg/kg 3 times daily for 7 days.

Quinine may induce hypoglycemia; pregnant women should not start taking quinine on an empty stomach
and should eat regularly, while on quinine treatment.

2nd and 3rd trimester: Area-specific ACT as per dosage schedule given above.

Contra-indications

Primaquine is contraindicated in pregnancy, children under one year and persons with a history of
haemolysis following primaquine treatment. Patients belonging to these categories should not receive primaquine.
Precautions

Sulfadoxine-pyrimethamine can, in rare,cases cause serious cutaneous or mucocutaneous eruptions and/or

agranulocytosis. Any patents with a cutaneous or mucocutaneous reaction within a month after taking sulfadoxine-
pyrimethamine should, if there is not an obvious alternative explanation be considered allergic to sulphonamides
and not be given sulfonamide treatment again.

Suspected cases of ACT side effects should be reported to NVBDCP with individual case reports.
Treatment failures

Treatment failures are expected to be very rare with ACT. Most cases of apparent treatment failures will
probably be caused by inadequate patient compliance. Therefore, apparent treatment failures should be re-treated
with ACT, if they occur at least 14 days after initial treatment. Earlier treatment failures should be treated with
quinine to minimize the risk of side-effects from repeated treatment with sulfadoxine pyrimethamine.

Treatment of uncomplicated vivax malaria

Chloroquine (CQ) for 3 days (Day 1: 10mg/kg + Day 2: 10mg/kg + Day 3: 5mg/kg) plus primaquine 0.25mg/kg
daily for 14 days as per prescribed guidelines(vivax malaria relapse due to the presence of hypnozoites in the liver,
for its prevention primaquine may be given))

P.vivax in India remains fully sensitive to chloroquine. This is monitored by NIMR. In recent years,
controlled trials have failed to demonstrate any anti-hypnozoite (antirelapse) effect of primaquine, when given for
5 days. NVBDCP has therefore adopted the 14 day regimen recommended by WHO.

Primaquine is contraindicated in infants, pregnant women and individuals with G6PD deficiency.

Day 1 Day 2 Day 3 Day 4 to 14

CQ CQ CQ
Age PQ PQ PQ
(150 (150 (150 PQ
mg (2.5 mg (2.5 mg (2.5
(2.5 mg)
base) mg) base) mg) base) mg)

Less than 1 yr ½ 0 ½ 0 ¼ 0 0
1-4 years 1 1 1 1 ½ 1 1
5-8 years 2 2 2 2 1 2 2
9-14 years 3 4 3 4 1½ 4 4
15 yrs or more* 4 6 4 6 2 6 6
Pregnancy 4 0 4 0 2 0 0
Treatment of uncomplicated mixed infections (of PF and PV)

In North-Eastern States: Treat with: Age-specific ACT-AL for 3 days + Primaquine 0.25 mg per kg body weight
daily for 14 days.

In Other States: SP-ACT 3 days + Primaquine 0.25 mg per kg body wt. daily for 14 days.

Artesunate for 3 days plus sulfadoxine-pyrimathamine in a single dose on the first day plus primaquine for
14 days

TREATMENT BASED ON CLINICAL CRITERIA WITHOUT LAB CONFIRMATION

(a) When microscopic results are not available within 24 hrs and RDT only falciparum is used,negative case
with s/s of malaria- considered as “clinical malaria” and treat with chloroquine 25mg/kg divided over three
days.
(b) If neither microscopy nor RDT is available, clinical malaria should be treated with chloroquine in full
therapeutic dose.

General Recommendations for the management of Uncomplicated Malaria

-Avoid starting treatment on an empty stomach. The first dose should be given under observation.Dose
should be repeated if vomiting occurs within 30 minutes.
-The patient should report back, if there is no improvement after 48 hours or if the situation deteriorates.
-The patient should also be examined for concomitant illness.

SEVERE MALARIA

In severe malaria cases, a parenteral artemisinin derivative or quinine is the drug of choice. It has been shown that
intravenous artesunate is the most effective treatment for severe malaria in adults in Asia. It is presently being
investigated whether this is so for young children also, but there is no reason to assume a priori that it is inferior. If
injectable artesunate and the facilities for IV administration are available, this should therefore be the preferred
treatment in all patients.

The management of severe malaria is possible in health facilities which are equipped with

the following:

 Parenteral Antimalarials , antibiotics, anticonvulsants, antipyretics

 Intravenous infusion equipment and fluids
 Special nursing for patients in coma
 Facilities for blood transfusion
 Well equipped laboratory
 Oxygen respirator
Dosage regimens

Artesunate: 2.4 mg/kg IV/ IM followed by 2.4 mg/kg after 12 and 24 hours then once daily.

Arte-mether: 3.2 mg/kg IM followed by 1.6 mg/kg once daily.

Arte-ether: 150 mg daily IM in adults only for 3 days

Artesunate is dispensed as a powder of artesunic acid. This is dissolved in sodium bicarbonate (5%) to form
sodium artesunate. The solution is then diluted in approximately 5 ml of 5% dextrose and given by intravenous
injection or by intramuscular injection to the anterior thigh. The solution should be prepared freshly for each
administration and should not be stored.

Parenteral treatment should continue until the patient is able to take oral treatment. When that is the case,
full course of ACT should be administered to patients treated with artemisinine derivatives.

Quinine: 20 mg salt/kg as a loading dose, then 10mg salt /kg 8 hourly in 5% dextrose or dextrose saline. The
infusion rate should not exceed5 mg salt/kg per hour. Loading dose may not be given if the patient has already
received quinine or if Clinician feels inappropriate. As soon as the patient is able to take orally, oral quinine should
be given. The total duration of treatment should be 7 days including parentral dose.

Pregnant women with severe malaria should be treated like any other adult patient. In these patients, the
benefits of the artemisinin derivatives outweigh the theoretical hazards. Particular attention should be given to the
high risk of hypoglycaemia in pregnancy.
 Chemotherapy of severe and complicated malaria

Initial parenteral treatment for at least Follow-up treatment, when patient can
take oral medication following
48 hours:
parenteral treatment
CHOOSE ONE of following four
options
Quinine: 20mg quinine salt/kg body Quinine 10 mg/kg three times a day
weight on admission (IV infusion or
divided IM injection) followed by with:
maintenance dose of 10 mg/kg 8
hourly; infusion rate should not doxycycline 100 mg once a day or
exceed 5 mg/kg per hour. Loading
dose of 20mg/kg should not be clindamycin in pregnant women and
given, if the patient has already children under 8 years of age,
received quinine.
- to complete 7 days of treatment.

Artesunate: 2.4 mg/kg i.v. or i.m. given

on admission (time=0), then at 12 h and Full oral course of Area-specific ACT:
24 h, then once a day.
In NorthEastern states: Age-specific
or ACTAL for 3 days + PQ Single dose
on second day
Artemether: 3.2 mg/kg bw i.m. given on
admission then 1.6 mg/kg per day. In other states: Treat with: ACT-SP
for 3 days + PQ Single dose on
or
second day
Arteether: 150 mg daily i.m for 3 days in
adults only (not recommended for
children).

CHEMOPROPHYLAXIS

It is recomemded for travelers from non endemic areas to highly endemic areas for soilders, police, and
labour forces.

I. Short term chemoprophylaxis (less than 6 weeks)

 Dosing schedule for children based on body weight
 Anti malarial have to take daily (Eg:-Doxycycline) should be stared day before arrival of
endemic area
 Weekly chloroquine started one week before arrival
 Weekly mefloquine 2-3 weeks before departure
  All prophylactic drugs should be taken with unfailing regularity for the duration of the stay
in the malaria risk area and should be continued for 4 weeks after the last possible exposure
to infections, since parasites may still emerge from the liver during this period.

For children the dose is:

 Weight over 45kg 1 tablet weekly

 31-45kg three-quarters of a tablet weekly
 20-30kg half a tablet weekly
 5-19kg quarter of a tablet weekly

Again continued for 4 weeks after leaving a malaria area.

Side effects of mefloquine are: nausea, vomiting, abdominal pain, diarrhoea, headache, dizziness,
abnormal heart rhythm and liver dysfunction.

It is contraindicated in patients with liver abnormality, heart conduction abnormalities, psychiatric

disorders and epilepsy.

II. Long term chemoprophylaxis(more than 6 weeks) Long term travelers where appropriate eg.
Military & Paramilitary Troops on night patrol duty etc in malarious areas.The decision of Medical
Authority is to be followed. Drug of choice is Mefloquine 250 mg weeky for adults & 5 mg/kg for
children once a week; beginning 1 week before - 4 weeks after exposure
 300mg of chloroquine weekly for over five years, should be screened twice yearly for
retinal damage
 If daily dose of 100mg chloroquine screening should start after 3 years for retinal damage.

ALTERNATIVE DRUGS FOR CHEMOPROPHYLAXIS

Doxycycline: Dosage 100mg daily for 2 days before departure and continued for 4 weeks after return from a malaria
zone. It is contraindicated in children under 8 years of age. Side effects include nausea, vomiting, abdominal pain
and in women it may cause frequent vaginal candida infections. It is contraindicated during pregnancy.

ACTIVE INTERVETION MEASURES

1. Stratification of the problem

2. Vector control strategies

1. STRATIFICATION OF THE PROBLEM

It has become an essential features for the planning and development of a sound control strategy to
maximize the utilization of available resources.
VECTOR CONTROL STRATEGIES

a) Anti-adult measures

• Residual spraying : DDT,malathion-effective measure to kill adult mosquitoes

• Space application: it is an anti-epidemic measure in mosquito borne diseases. It involves the application of
pesticides in the form of fog or mist using special equipment.

• Individual protection: repellents, protective clothing, bed nets, mosquito coils, screening of houses etc.

b) Anti - larval measures

• Parricides: oiling the collection of standing water or dusting them with paris green

• source reduction: it is techniques used to reduce the breeding sites, such as drainage, deepening or flusing,
management of water level , changing the salt content of water and intermittent irrigation.

• Integrated control: it includes bioenvironmental and personal protective measures, in order to reduce too
much dependence on residual insecticides.

c) Control measures

• Isolate patient in screened room or use mosquito net to prevent spread of this diseases.

• Investigate source of infection, contracts and find out history of previous attack of malaria from the person

• Report about the case to the health authorized immediately

• Infected places should be disinfected by spraying effective insecticide.

• As far as possible rigid ant mosquito sanitation should be maintained within the mosquitoes fight range of
all parts and airports.

• Survey should be done to know about the number of cases to find out hyper endemic and endemic areas.

Initiation of treatment and advice to the patient/caretaker

Once a suspected case is diagnosed positive by RDT or microscopy, treatment is started. The first
dose is always taken in the presence of the health volunteer/worker. The blister pack with remaining
tablets is given to the patient/caretaker to take home with clear instructions. Caution: If the patient is a
child under 5 years or pregnant, ask the patient to wait for 15 minutes after taking the first dose. If it is
vomited within this period, let the patient rest for 15 minutes, then give the first dose again i.e. open a
new blister-pack and discard what remains of the old. If the patient vomits the first dose again, it is
considered a case of severe malaria, refer the patient immediate to the nearest Block PHC/ CHC/ Hospital.
Explain to the patient/caretaker

 That if the treatment is not completed as prescribed, the disease may manifest again with more serious
features and more difficult to treat.
 To come back immediately, if there is no improvement after 24 hours, if the situation gets worse or the
fever comes back.
 That regular use of a mosquito net (preferably insecticide treated net) is the best way to prevent malaria.

COMPLICATIONS

1. Falciparum malaria can cause renal failure, liver failure, heart failure, pulmonary edema, disseminated
intravascular coagulation, circulatory collapse, severe normocytic anemia, seizure, hypoglycemia, splenic rupture,
cerebral dysfunction and death.

2. During pregnancy, malaria can lead to premature delivery, spontaneous abortion, still birth and low birth
weight infants.

3. Malaria related immunosuppressant could possibly lead to an infection with lymphoma viruses such as the
Epstein-Barr virus (burkitt’s lymphoma)

Others…

 spleen enlargement
 liver enlargement
 cerebral malaria
 myocarditis
 dysfunction of kidney
 gastro- intestinal disturbances
 secondary anemia
 mild icterus

Requirements for management of complications:

The management of severe malaria requires immediate administration of life saving drugs.

Therefore essential requirements for management of severe malaria are as follows:

 A person trained in nursing serious/ comatose cases

 Antimalarials which can be given parenterally: Artesunate, arte-ether, arte-mether or quinine
 Supportive treatment: Antipyretics, anticonvulsants, diuretics, antibiotics,
 Saline/dextrose for intravenous transfusion
 Intravenous infusion equipment
  Facilities for blood transfusion
 Well equipped laboratory: Blood smear examination & parasite count with result
 within one hour, Routine examination of urine, haemoglobin, blood glucose
 Oxygen respirator, Oxygen

NURSING CARE

 Complete bed rest, enough blankets, hot water bags, hot drinks in cold stage
 During hot stage, watch for rise of body temperature; general condition of the patient; give cold
compress and ice bags
 During height of fever, take blood slide and send it for examination
 During sweating stage, wipe the body with clean cloth and change his clothes and bed linen. If
necessary, remove blankets
 Record time of onset and duration of each stage and record it. This helps in diagnosing the types
of malaria
 Give general nursing care
 Observe and report any untoward symptoms
 Give treatment as prescribed
 Follow preventive and control measures
 carefully
 Provide health education.
 Avoid water stagnation
 Provision of drainage facilities
 Application of residual insecticides such as DDT
 Using mosquito nets
 Local application of insect repellents
THE ROLE OF PERIPHERAL WORKERS
The community comes in contact with ASHA and MPW (M&F) as a routine. They depend on
these persons for advice and treatment of different diseases, malaria being one of them. Therefore, while
training these workers the need to recognize a serious case of malaria should be emphasized. These workers
should be conversant with the signs and symptoms of malaria and those which are likely to indicate serious
complications. Severe malaria may be suspected, if the patient does not get relief from symptoms of malaria
within 24 hours, and/or headache/fever continues to increase. Such patients should be referred immediately
to the nearest PHC/CHC/Hospital.
Criteria for immediate referral to Primary Health Centre:
a) Persistence of fever after 24 hours of initial treatment.
b) Continuous vomiting and inability to retain oral drugs.
c) Headache continues to increase
d) Severe dehydration – dry, parched skin, sunken face
e) Too weak to walk in the absence of any other obvious reason
f) Change in sensorium e.g. confusion, drowsiness, blurring of vision, photophobia, disorientation
g) Convulsions or muscle twitchings
h) Bleeding and clotting disorders
i) Suspicion of severe anaemia
j) Jaundice
k) Hypothermia

PROGNOSIS

 Depends on the type of parasite, degree of immunity of the host and whether the treatment is
given earlier or later
 Fatality rate also varies
 Patient may have relapse of malaria at irregular intervals for several years
 Mortality rate in untreated cases ids upto 25 %
If the patients are treated in time, prognosis is good.
 MALARIA CONTROL IN INDIA

Milestones of malaria control activities in India

Year Milestone
Prior to 1953 Estimated malaria cases in India 75 million;
Deaths due to malaria 0.8 million
1953 Launching of National Malaria Control Programme (NMCP)
1958 NMCP was changed to National Malaria Eradication Programme
1965 Cases reduced to 0.1 million
Early 1970 s Resurgence of malaria
1976 Malaria cases 6.46 million
1977 Modified Plan of Operations implemented
1997 World Bank assisted Enhanced Malaria Control Project (EMCP) launched
1999 Renaming of programme to National Anti Malaria Programme (NAMP)
2002 Renaming of NAMP to National Vector Borne Disease Control Programme
2005 Global Fund assisted Intensified Malaria Control Project (IMCP) launched
2005 Introduction of RDT in the programme
2006 ACT introduced in areas showing chloroquine resistance in falciparum
malaria
2008 ACT extended to high Pf predominant districts covering about 95% Pf cases
2008 World Bank supported National Malaria Control Project launched
2009 Introduction of LLINs

NATIONAL MALARIA ERADICATION PROGRAMME

National malaria control programme in 1953, during five year plan was converted in 1958
into eradication programme, for the following reasons;

With the spectacular decline in malaria, its eradication was near at sight

India was guided by the example of successful malaria eradication by some countries of the world.

There was need to prevent mosquitoes becoming resistant to insecticides.

The main activities of programme are;

1. formulating policies and guidelines

2. technical guidance
3. planning
4. logistics
5. monitoring and evaluation
6. coordination of activities through the state/ union territories and national organization such as
NCDC
7. collaboration with international organisation such as WHO, GFATM, WORLD BANK
 8. Training
9. Facilitating research thro NCDC, NIMR(NATIONAL institute of malaria research)
10. Coordinating control activities in the inter-state and inter- country border areas.

RECLASSIFICATION OF ENDEMIC AREAS

The report of the consultative committee of experts indicated that in order to stabilise the malaria situation
in the country, areas with Annual Parasite Incidence 2 and above should taken up for spray operations.
This led to classification of areas according to Annual Parasite Influence.

AREAS WITH API MORE THAN 2

(a) SPRAYING: All areas with API 2 and above are brought under regular insecticidal spray with 2
rounds o: DDT, unless the vector is refractory. Where the vector is refractory to DDT, 3 rounds of
malathion are recommended. Areas refractory both to DDT and malathion are to be treated with 2 rounds
of synthetic pyrethroids spray at intervals of 6 weeks. DDT, malathion and pyrethroids dosage applied are
1.0,2.0 and 0.25 g per sq. metre surface respectively. BHC has been discontinued since 1.4.7997 in view
of its adverse environmental effects. Whenever an honest effort has been made to spray insecticides
systematically, malaria has either been brought down, or at least kept at low levels.

(b) ENTOMOLOGICAL ASSESSMENT: This is done by entomological teams. They carry out
susceptibility tests and suggest appropriate insecticide to be used in particular areas.

(c) SURVEILLANCE: The collection and examination of blood smears is a key element of the Modified
Plan of Operation. Active and passive surveillance activities are carried out fortnightly in all areas with
API 2 and above.

(d) TREATMENT OF CASES: Great emphasis is laid on the presumptive and radical treatment of cases.

AREAS WITH API LESS THAN 2

(a) SPRAYING : These areas will not be under regular insecticidal spraying. However, "focal spraying"
is to be undertaken only around P. falciparum cases detected during surveillance.

(b) SURVEILLANCE : As these areas will not be under regular spraying, active and passive surveillance
operations will have to be carried out vigorously every fortnight.

(c) TREATMENT : All delected cases should receive radical treatment as prescribed

(d) FOLLOW-UP : Follow-up blood smears are to be collected from all positive cases on completion of
the radical treatment, and thereafter at monthly intervals for 72 months.
 (e) EPIDEMIOLOGICAL INVESTIGATION: All malaria positive cases are to be investigated. This
may include mass surveys.

DRUG DISTRIBUTION CENTRES AND FEVER TREATMENT DEPOTS

With the increasing number of malaria cases, the demand for antimalarial drugs has increased
tremendously. It became clear that drug supply only through the surveillance workers and medical
institutions was not enough. This led to the establishment of a wide network of Drug Distribution Centres
and Fever Treatment Depots. Drug Distribution Centres are only to dispense the antimalarial tablets as
per NMEP schedules. Fever Treatment Depots collect the blood slides in addition to the distribution of
antimalarial tablets. About 4.49 lakhs of such centres are functioning all over the country in rural areas
till 2006 (1). These centres are manned by voluntary workers from the community.

URBAN MALARIA SCHEME

The urban malaria scheme was launched in 1971 to reduce or interrupt malaria transmission in towns and
cities. The methodology comprises vector control by intensive antilarval measures and drug treatment.
About 10 per cent of the total cases of malaria are reported from urban areas. Control of urban malaria
lies primarily in the implementation of civil byelaws to prevent mosquito breeding in the domestic and
per domestic areas. Use of larvivorous fish in the water bodies such as slow moving streams, ornamental
ponds etc. is recommended. Larvicides are used for water bodies which are unsuitable for fish use.

National Vector Borne Disease Control Programme (NVBDCP)

The NVBDCP is an umbrella programme for prevention and control of vector borne diseases viz.,
malaria, filariasis, kala-azar, Japanese encephalitis, dengue and chikungunya. The Directorate of NVBDCP,
under the Directorate General of Health Services (Dte. GHS), Ministry of Health and Family Welfare
(MOHFW), Government of India (GOI), is the national level unit dedicated to the programme. The
Directorate of NVBDCP is the nodal agency for planning for programme implementation, and oversight in
coordination with the states. It is responsible for formulating policies and guidelines, monitoring, and
carrying out evaluations. It is also responsible for administering GOI s financial assistance to the states in
the context of the program.
The main activities of NVBDCP are:
• Formulating policies and guidelines
• Technical guidance

• Planning and Logistics

• Monitoring and evaluation
• Co-ordination of activities through the states/union territories (UTs) and in consultation with national
organizations such as National Institute of Communicable Diseases (NICD), National Institute of malaria
Research (NIMR)

• Collaboration with international organizations like the WHO, World Bank, GFATM and other donor
agencies
• Training

• Facilitating research through NICD, NIMR, Regional Medical Research Centres etc..Coordinating control
activities in the inter-state and inter-country border areas.
Projects and partnerships
The major externally aided projects of NVBDCP are as follows:
• World Bank aided Enhanced Malaria Control Project (EMCP) (1997-2005) was implemented in
the tribal areas of 100 high malaria burden districts of 8 states, viz., Andhra Pradesh, Chhattisgarh,
Gujarat, Jharkhand, Madhya Pradesh, Maharashtra, Orissa and Rajasthan.
• GFATM Round 4 grant aided Intensified Malaria Control Project (2005-2010) has been
implemented in the 7 North-Eastern states along with parts of Orissa, Jharkhand and West Bengal,
covering a population of about 100 million.
• The New World Bank assisted project (2008-2013) is envisaging coverage of a population of 185
million, in 93 districts of 8 states i.e., Andhra Pradesh, Chhattisgarh, Gujarat, Jharkhand, Madhya Pradesh,
Maharashtra, Orissa and Karnataka.

Interaction of malaria control with the other health programmes

The other main public health programmes related to malaria control are:
• Integrated Disease Surveillance Project (IDSP). The project, with weekly fever alerts is
increasingly providing the early warning signals on malaria outbreaks.
• Other vector borne diseases. Dengue and malaria control activities overlap in many urban areas,
malaria and kala-azar in a few districts of Jharkhand and malaria and filariasis in some areas including a
few districts of Orissa.
• Reproductive and Child health. Ante-natal care services are utilized in distribution of LLINs to
pregnant women in some areas of the country. Janani Suraksha Yojana (JSY) also makes provision for
bed net distribution to pregnant women. Changes in the malaria case management norms have been
included in the Integrated Management of Neonatal and Childhood Illnesses (IMNCI).
 STRATEGIC ACTION PLAN OF MALARIA CONTROL IN INDIA

Strategies

Malaria Free India

The vision of the strategic action plan is a substantial and sustained reduction in the burden of malaria in
the near and mid-term, and the elimination of malaria in the long term, when new tools in combination with
strengthening of health systems will make national elimination possible.

Malaria control deserves particular attention in India at present because:

• Increasing availability of new technologies and tools and international attention to malaria provide
opportunities for formulating more ambitious strategies than has been possible over the last few decades.

• It had been possible in the past to reduce malaria to very low levels with intensive efforts.

• Malaria is also a cause of poverty in many areas and its control will drastically reduce the suffering as
well as loss of productivity of the productive age-groups.

• Malaria is largely concentrated in tribal populations and strengthening of malaria control will be an
important contribution to improving equity in the health system.

Malaria control is now incorporated into the health service delivery programmes under the
umbrella of NRHM. This provides opportunities for strengthening malaria prevention and treatment services
close to the community. All available methods and means are being used to deliver these interventions, at
entry-level facilities (e.g. CHCs, PHCs, and sub-centres), community outreach services using community
health workers and volunteers (ASHAs) at village level, NGOs, private-sector providers and district and
regional health facilities and hospitals.

The priorities and practices of the National Malaria Control Programme continue to reflect a strong
commitment to the following operational principles:

• Delivery of malaria control services by ASHAs and other volunteers/activists 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 (MTSs) at sub-district level.
• Under the externally aided projects supported by World Bank and the Global Fund, the SPOs are
strengthened by project monitoring units
• Well streamlined Procurement and supply-chain management
Malaria Control Strategies

The strategies for prevention and control of malaria and its transmission is:

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

The Goals for the Strategic Plan

The main international and national goals for malaria control are given below:

National Goals

• At least 50% reduction in mortality due to malaria by the year 2010, as per National Health

Policy document-2002

• At least 80% of those suffering from malaria get correct, affordable and appropriate treatment
within 24 hours of reporting to the health system, by the year 2012
• At least 80% of those at high risk of malaria get protected by effective preventive measures such
as ITNs/LLINs or IRS by 2012.

International Malaria Control Goals

Roll Back Malaria (RBM) partnership goal

• To halve malaria-associated mortality by 2010 and again by 2015

JOURNAL REVIEW

Thrombocytopenia as an Indicator of Malaria in Adult Population

Done by:- Shiraz Jamal Khan, Yasir Abbass, and Mumtaz Ali Marwat

Objectives:- To evaluate the predictive value of thrombocytopenia in malaria.

Patients and Methods:- It was a prospective observational study on all febrile patients with
thrombocytopenia presenting to the Medical Unit of Hayat Abad Medical Complex during November
2008 to November 2010.

Results:- Of the total of 228 patients with fever and thrombocytopenia, 121 patients (53%) proved to be
suffering from malaria. Of them 82 patients (68%) had falciparum malaria while 39 patients (32%) had
vivax infection. Of these 121 patients, platelet counts ranged between 25,000 and 150,000/dL with a mean
value of 101,000/dL(S D ± 47, 500) and a median of 75,000/dL. Of the 107 patients who were not
suffering from malaria, the counts ranged between 10,000 and 150,000/dL with a mean value of 58,000/dL
(S D ± 5 4 , 0 0 0) and median of 50,000/dL.

Conclusions:- The presence of thrombocytopenia may be a predictor of malaria in adult population.

THEORY APPLICATION

REFERENCE:
1. Park,K.Textbook of preventive and social medicine.(2011),1st ed, pg: 231-244. BANARSIDAS BHANOT
publishers.
2. Sridhar,R.B.(2011). Textbook for community health nursing.2nd ed; pp.no:196-204, AITBS publishers:
INDIA
3. Kumari.N.(2011). A Textbook of community health nursing.1st ed,pp.no:39-41. VIKAS & company
publishers. INDIA
4. Sunder.L.,Adarsh & Pankaj.(2009). Textbook of community medicine-preventive and social medicine.1st
ed.pp.no:435-463:CBS publisher, NEW DELHI
5. Patney.S.(2011). Textbook of community health nursing.,1st ed;pp.no:312-326. CBS publisher, NEW
DELHI
6. Mathur,J.S.(2008). A Comprehensive Textbook of community medicine preventive and social medicine,
1st ed,pp.243-248; CBS publisher, NEW DELHI
7. http://nvbdcp.gov.in/malaria-new.html
8. http://www.hindawi.com/journals/mrt/2012/405981/
9. http://www.who.int/malaria/publications/world_malaria_report_2014/report/en/
 SEMINAR
ON
MALARIA

SUBMITTED TO, SUBMITTED BY,

MRS.YAMUNA T V JORRY POULOSE

SISTER TUTOR 2ND YEAR MSc NURSING

COLLEGE OF NURSING COLLEGE OF NURSING

JIPMER JIPMER