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Dr Tariq Mahmood
MSPH 2009-10
Health Services Academy

 Malaria1 is the most important of the parasitic diseases of humans, with 107 countries & territories having
areas at risk of transmission containing close to 50 % of the world’s population (Hay & others 2004; WHO

In Uncomplicated cases
 Intermittent fever
 Chills
 Headache
In Complicated cases
 Altered consciuosness
 Generalized seizures
 Severe anemia

Person has intermittent fever, chills & headache. Severe or complicated malaria may be suspected if patient
has any of these signs such as altered consciousness, generalized seizures, difficulty in breathing, low urinary
output, dark urine, severe anemia

Malaria can be confirmed by identification of the malarial parasite in the peripheral blood film.
In 2001, the WHO ranked malaria as the 8th -highest contributor to the
global disease burden as reflected in disability-adjusted life years (DALYs),
& 2nd highest in Africa (WHO 2002a). The DALYs attributable to malaria
were estimated largely from effects of P. falciparum infection as a direct
cause of death (Murray & Lopez 1996, 1997).

 Malaria accounts for 2.0% of global deaths2 & 2.9% of global DALYs. In the
African region of WHO, 9.0% of deaths & 10.1% of DALYs are attributable
to malaria. Recent analysis of falciparum malaria morbidity concludes that
515 (IQR 298 to 659) million cases occur yearly. (Snow & others 2005).

 Recent estimates of malaria deaths have varied from 0.5 to 3.0 million per
year (Breman 2001; Breman, Alilio, & Mills 2004; Snow & others 2003). In
1998, an analysis of malaria mortality by WHO, used malaria risk maps to
capture measures of disability, morbidity, & mortality associated with P.
falciparum prevalence rates among African populations & yielded an
estimate of about 1 million (Korenromp & others 2003; Snow & Marsh 2003;
Snow & others 2002).

In EMRO region of WHO, deaths due to

malaria were 55000 (4.9 %) & 1.2 %, which
were malarial deaths as a percentage of all
deaths, & the DALYs were 2.05 million (4.8
%), & 1.5 % which were Malarial DALYs, as a
percentage of all DALYs, in the year 2000.

Source: Breman, Alilio & Mills 2004

Distribution of Malaria in the World

Malaria Morbidity & Mortality
Malaria Situation
The National Malaria Control Program reported a total of 131,179 confirmed
cases of malaria from public sector sources in 2003. During the same year,
the API in Pakistan was reported at 0.8/1000 population with significant
regional variations; the highest being for Balochistan (5.81/1000 population).

Malaria control was initiated in Pakistan in the 1950s & has passed through
several evolutionary phases. In 1975, a malaria control strategy was adopted
with provincial commitment to implementation & in 1998, Pakistan joined the
global Roll Back Malaria (RBM) initiative. This led to the development of a
five-year RBM project in 2001 as part of which efforts were intensified in the
28 high-risk districts. More recently, a Strategic Plan for 2005-10 based on
the RBM strategy has been developed & a number of steps taken for its
implementation. The MDG-6 Combat HIV/AIDS Malaria & other diseases
targets for malaria prevention – implying an average increase in malaria
prevention of 4-5% p.a for 10 years– although ambitious, may be achievable
with recent expansion of RBM strategy.
Disease pattern in Pakistan
Falciparum as % of
all malaria cases, 2001

Falciparum % NWFP
Orange 40-85 %
Pink 8-40 % PUNJAB
Green 1-8 %


Percentage of Plasmodium Falciparum from 1997- 2001
1997 1998 1999 2000 2001
Punjab S indh N W FP & FA TABaluchistan P A KIS TAN
1997 28.8 63.7 17.1 29.6 32.6
1998 25.1 63.8 22.9 29.2 33.9
1999 24.2 62.1 24.2 24.8 33.1
2000 21.9 57.3 23.4 32 33.2
2001 26.2 49.9 21.9 37.4 33.8
Chart showing
Annual Falciparum Incidence
International Statistical Classification of Diseases & Related Health Problems
10th Revision
Version for 2007

ICD 10 Definition
ICD-10 was endorsed by the Forty-third World Health Assembly in
May 1990 and came into use in WHO Member States as from 1994
Chapter 1
Certain infectious and parasitic diseases (A00-B99)
 Protozoal diseases (B50-B64)
 B50 Plasmodium falciparum malaria Includes: Mixed infection
of Plasmodium falciparum é any other Plasmodium species

(B50.0 Plasmodium falciparum malaria with cerebral complications Cerebral

malaria NOS
 B50.8 Other severe and complicated Plasmodium falciparum malaria Severe or
complicated Plasmodium falciparum malaria NOS
 B50.9 Plasmodium falciparum malaria, unspecified)
History of Malaria
Disease has been known since antiquity - one of first reports
described fevers in 1550 BC

Malaria was commonly

found in swampy areas &
was thought to be
contracted by breathing in
"bad air" (= mal aria) in the
Much effort was directed
towards finding a causative
agent in the water or air of
these swamps. We now
know that the mosquitoes
that vector5 the disease lived
in these swamps.
History of Malaria

On August 20th, 1897, Ronald Ross, a British

officer in the Indian Medical Service, was the first
to demonstrate that malaria parasites could be
transmitted from infected patients to mosquitoes

Italians scientist Amico Bignami (1898)

experimentally transmitted malaria from
mosquitoes to humans.

Last name important in the history of malaria is

that of William Crawford Gorgas, a sanitation
officer (ENPH!) in the Panama Canal Zone, who
developed an integrated program of vector &
malaria control.
Plasmodium Falciparum in Pregnant woman

 Malaria in pregnancy3 is an obstetric, social & medical problem

requiring multidisciplinary and multidimensional solution. Pregnant
women constitute the main adult risk group for malaria & 80% of deaths
due to malaria in Africa occur in pregnant women. Malaria in pregnancy
is a Priority Area in Roll Back Malaria strategy.

 Malaria & pregnancy are mutually aggravating conditions. The

physiological changes of pregnancy & the pathological changes due to
malaria have a synergistic effect on the course of each other, thus
making the life difficult for the mother, the child & the treating physician.
P. falciparum malaria can run a turbulent & dramatic course in pregnant
women. The non- immune, primi gravidae are usually the most affected.
In pregnant women the morbidity due to malaria includes anemia, fever
illness, hypoglycemia, cerebral malaria, pulmonary edema, puerperal
sepsis & mortality can occur from severe malaria & haemorrhage.
Malaria in Pregnancy
Double Trouble
 More common
in pregnancy compared to the general population. Immuno suppression and loss of
acquired immunity to malaria could be the causes.
 More atypical
Due to the hormonal, immunological and hematological changes of pregnancy.
 More severe
Due to the hormonal & immunological changes, the parasitemia tends to be 10 times
higher & all the complications of falciparum malaria are more common in pregnancy.
 More fatal
P. falciparum malaria mortality (13 %) compared to (6.5%) in non-pregnant population
 Selective treatment
Some anti malarials are contra indicated in pregnancy & may cause severe adverse
effects. Therefore the treatment may become difficult, particularly in cases of severe P.
falciparum malaria.
 Other problems
Management of complications of malaria may be difficult due to the various
physiological changes of pregnancy. Careful attention has to be paid towards fluid
management, temperature control, etc. Also decisions regarding induction of labour
may be difficult and complex. Foetal loss, IUGR, & premature labour are common.
Malaria in Pregnancy
 The impact of malaria on a pregnant woman & her fetus differs with the intensity of
malaria transmission but in any case represents a significant burden on the health of
mother and child. In order to reduce maternal morbidity & mortality, malaria in
pregnancy will remain an essential part of the malaria control strategy with the three
elements of
 • Intermittent preventive treatment (IPT)
 • Prevention with ITNs
 • Prompt treatment of clinical malaria episodes with drugs or drug combinations
adequate for the stage of pregnancy.

 The delivery of IPT will be part of focused ANC services coordinated by the
reproductive health program of the MOH. Emphasis will be on at least 4 visits for
each pregnant woman in order to provide all services needed & allow timely delivery
of at least 2 doses of IPT.
 Pregnant women will be targeted for the distribution with ITN/LLIN particularly
through ANC services.
 Treatment of clinical malaria cases during pregnancy & the management of severe
malaria are part of the general approaches towards case management.
Key Determinants of Malaria
Roll Back Malaria’s Strategy & Goals for 2010
 The goal of Roll Back Malaria6 Partnership is to halve the burden of malaria by 2010. The following
targets for specific intervention strategies were established at the Abuja Malaria Summit in April 2000.

 Strategy Abuja target (by 2010)

• Prompt access to effective treatment • 60 percent of those suffering with malaria
should have access to and be able to use
correct, affordable, and appropriate treatment
within 24 hours of the onset of symptoms.
• Provision of ITNs • 60 percent of those at risk for malaria, particularly
children under 5 & pregnant women, will benefit
from a suitable combination of personal &
community protective measures, such as ITNs.
• Prevention and control of malaria in • 60 percent of pregnant women at risk of malaria
pregnant women will have access to IPTa.
• Epidemic and emergency response • 60 percent of epidemics are detected within two
weeks of onset. •
60 percent of epidemics are responded to within
two weeks of detection.
 Source: WHO 2003b, 2005.
 a. The original Abuja declaration included the recommendation for chemoprophylaxis as well, but
current WHO & Roll Back Malaria policy strongly recommends IPT & not chemoprophylaxis for
preventing malaria during pregnancy.

• To reduce the mortality & morbidity due to plasmodium
falciparum malaria in pregnancy in Pakistan

• To have 50% of all pregnant women access IPT by 2011
• To have at least 60% of pregnant women access quality
case management according to national guidelines by 2011
• To have at least 60% of all pregnant women have access to
ITNs by 2011

Malaria control7 can be achieved by

 full coverage,
 access to, & use of antimalarial services by priority groups;
 rapid, accurate diagnosis;
 prompt & effective patient management (diagnosis, treatment,
counseling and education, referral);
 judicious use of insecticides to kill & repel the mosquito vector,
including the use of ITNs; &
 control of epidemics.
Eliminating malaria is a huge task because of the widespread
Anopheles breeding sites; large number of infected people; use
of ineffective antimalarial drugs; & inadequacies of resources,
infrastructure, & control programs. The Roll Back Malaria
Partnership, which began in 1998, aims to halve the burden of
malaria by 2010.
Intervention /
Prevention strategies
1. Drug Use
2. Early Diagnosis and Treatment
3. Timeliness.
4. Location of clinical management.
5. IPT in Pregnancy and Infancy.
6. Chemoprophylaxis.
7. Supervision and Policy Change.
8. Integrated Vector Control Approach
9 Insecticide-Treated-Nets
10. Indoor Residual Spraying (IRS) of Dwellings with Insecticide
11. Civil Engineering.
12. Larviciding and Fogging.
13. Home Repellents and Insecticide Use
14. Health Education and Counseling
National malaria control
strate gies
The key elements of the national malaria control
strategy include:

 Early diagnosis and rapid treatment.

 Multiple prevention.
 Early detection and response to epidemics.
 Effective behavior change communication (BCC).
 Partnerships with international & national
government and NGO’s.
 Focused operational research.
(2007/08 – 2011/12)
 WHOPES (WHO Pesticide Evaluation Scheme) approved long-lasting
insecticide treated bednets (LLINs) will be provided free of charge
 Delivery of LLINs to pregnant women will be through MCH service delivery
 WHOPES approved LLINs will also be provided free of charge to all
confirmed falciparum cases.
 Routine indoor residual spraying (IRS) will be carried out annually.
 All IRS operations will aim to achieve 80% coverage of union council
 IRS will be applied both to dwellings and to animal sheds (walls and
 Routine IRS operations will be carried out during July and August before the
peak transmission period.
 Rational & judicious use of insecticides (Selective Residual Insecticide Spay
 Larviciding (both liquids and granules)
 Use of insecticides treated Bed Nets (LLIN’s & ITNs)
1. IPT in Pregnancy
IPT9 is recommended in pregnancy in areas with high & stable transmission of
P. falciparum malaria; IPT consists of 2 curative doses of antimalarial treatment.
The recommended drug is SP given during the 2nd & 3rd trimesters of
pregnancy during Antenatal visits. In primigravid & secundigravid women, the
incidence of severe maternal anemia, the incidence & density of placental
parasitemia, & the incidence of LBW were 25 to 95 % lower when mothers were
given IPT than when they were not (Kayentao & others 2005; Steketee & others
2001). SP is becoming ineffective for IPT, & health experts are suggesting ACT
as a replacement (White 2005).
2. Drug Use
Proper use of drugs is essential. Early & effective malarial treatment
 Chloroquine (safe during three trimesters)
 Sulfadoxine - pyrimethamine (SP) (2nd & 3rd trimester )
 Artemisian Combination Therapy (ACT) (SP) (2nd & 3rd trimester )
 Artesunate- amodiaquine (3 doses in 48 hours)
 Artemeter- lumefantrine (6 doses in 48 hours)
 3. Insecticide-Treated-Nets
The use of ITNs12 (bednets, curtains, & other
materials) to provide personal protection by killing or
repelling mosquitoes is one of the major strategies of
malaria control (RBM 2002). Pyrethroids are
recommended for the periodic treatment/ retreatment
of protective materials. Over 20 studies in Africa & Asia
have demonstrated more than 50 % protective efficacy
for individual users of ITNs in reducing malaria
episodes, 29 % protection against severe malarial
disease, & substantial protection against anemia
(Lengeler 2004). Widespread use of ITNs resulted in
an overall reduction in mortality of 19 %, protected
against anemia, & had a substantial impact on mild

4. Integrated Vector Control Approach

The reduction of Anopheles breeding involves different methods of insecticide & repellent
application, environmental management, & behavioral change of populations at risk.
Focal residual spray with insecticides, ITN promotion through PP partnership, 20,000
ITNs (WHO), 10,000 (GoP) for implementation, Larval control through larviciding &
source reduction, Monitoring of vector resistance to insecticides
The activities undertaken include
• Distribution of treatment guidelines (IPT and treatment) as well
as other materials (Flow charts, posters) to all government and
NGO health facilities
• Training of health workers for treating malaria in pregnancy
• Development of a training course on malaria in pregnancy for
midwives and nurses
• Procurement and distribution of additional SP to meet the
increased demand
• Adoption of the performance improvement framework to
overcome misconceptions & poor practices by health workers
• Design, piloting and adoption of the new ante natal register
which captures information on IPT
Evaluation will be done through Process & Outcome
 % of facilities with adequate anti malarial treatment
 % of facilities with adequate parasite detection services
 % of pregnant women sleeping under ITNs
 % of pregnant women receiving chemoprophylaxis or
presumptive intermittent treatment
 % of pregnant women receiving anti malarial treatment
during ANC visits
 Presence of technical skilled staff at the required level of
service delivery
Country Activities at Different Levels
Program Leaders District Teams
Develop policies, Operationalize
standards, and National Program Leadership Level guidelines &
guidelines, advocacy, IEC, support super
Support, supervision, -vision, drug
Monitoring & Evaluation District Level supply logistics, &
sensitization of
Facility Level public, promotion
of ITNs, M&E
Facilities Level
Integrated health ed.,
community mobilization,
promotion of ITNs, Communities
provision of IPT, CHWs and TBAs
treatment of complications sensitize about
such as anemia, data malaria control,
collection and feedback referrals, followup
1. Centers for Disease Control and Prevention. Malaria.
2. Alilio,M. S., I. Bygbjerg, & J. G. Breman. 2004. “Are Multilateral Malaria Research & Control Programs the Most Successful?
Lessons from the Past 100 Years.” American Journal of Tropical Medicine & Hygiene 70 (Suppl. 2): 268–78.
3. Curtis, C. F., and A. E. P. Mnzava. 2000. “Comparison of House Spraying and Insecticide-Treated Nets for Malaria Control.”
Bulletin of the World Health Organization 78 (12): 1389–1401.
4. Armstrong-Schellenberg, J. R., S. Abdulla, R. Nathan, O. Mukasa, T. J. Marchant, N. Kikumbih, and others. 2001. “Effect of
Large-Scale Social Marketing of Insecticide-Treated Nets on Child Survival in Rural Tanzania.” Lancet 357: 1241–47.
5. Audibert, M., J.Mathonnat, and M. C.Henry. 2003.“Malaria and Property Accumulation in Rice Production Systems in the
Savannah Zone of Côte d’Ivoire.” Tropical Medicine and International Health 8 (5): 471–83.
6. The Roll Back Malaria Partnership.
7. Kayentao, K., M. Kodio, R. D. Newman, H. Maiga, D. Doumtabe, A. Ongoiba, and others. 2005. “Comparison of Intermittent
Preventive Treatment with Chemoprophylaxis for the Prevention of Malaria during Pregnancy in Mali.” Journal of Infectious
Diseases 191 (1): 109–16.
8. Baird, J. K. 2005. “Effectiveness of Antimalarial Drugs.” New England Journal of Medicine 352: 1565–77.
9. Ballou, R., M. Arevalo-Herrera, D. Carucci, T. L. Richie, G. Corradin, C. Diggs, and others. 2004. “Update on the Clinical
Development of Candidate Malaria Vaccines.” American Journal of Tropical Medicine and Hygiene 71 (Suppl. 2): 239–47.
10. Hung, I. Q., P. J. Vries, P. T. Giao, N. V. Nam, T. Q. Binh, M. T. Chong, and others. 2002. “Control of Malaria: A Successful
Experience from Viet Nam.” Bulletin of the World Health Organization 80 (8): 660–66.
11. Barat, L. M. 2006.“Four Malaria Success Stories: How Malaria Burden was Successfully Reduced in Brazil, Eritrea, India, &
Vietnam.” American Journal of Tropical Medicne & Hygiene 74 (1): 12–16
12. Breman, J. G. 2001. “The Ears of the Hippopotamus: Manifestations, Determinants, & Estimates of the Malaria Burden.
”American Journal of Tropical Medicine & Hygiene 64 (Suppl. 1–2): 1–11.
13. Abdulla, S., J. A. Schellenberg, R. Nathan, O. Mukasa, T. Marchant, T. Smith, & others. 2001. “Impact on Malaria Morbidity of a
Program Supplying ITN’s in Children Age < 2 Years in Tanzania: Community Cross-Sectional Study.” BMJ 322: 270–73.
14. Snow RW, Guerra CA, Noor AM, Myint HY, Hay SI. The global distribution of clinical episodes of Plasmodium falciparum malaria.
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Thank You