Malaria

Introduction

Malaria is a protozoa disease caused by infection with parasites of the genus

Plasmodium and transmitted to man by certain species of infected female
Anopheline mosquito

Problem statement

WORLD

According to the latest estimates, there were about 198million (124-283

million) cases of malaria in the year 2013 and an estimated 584,000 deaths
(367,000-755,000)

Approximately half of the world's population is at risk of malaria. Most

malaria cases and deaths occur in sub Saharan Africa.

Asia, Latin America, and to a lesser extent the Middle East and parts of
Europe are also affected. In 2013, 97 countries and territories had ongoing
malaria transmission

Malaria affects mainly poor, underserved and marginalized populations in

remote rural areas which are characterized by inadequate control measures
and limited access to health care

INDIA

Malaria continues to pose a major public health threat in India, particularly

due to Plasmodium falciparum which is prone to complications.

In India about 21.98 per cent population lives in malaria high transmission
(2: 1 case/1000 population) areas and about 67 per cent in low transmission
(0-1 case/1000 population) areas (2).

About 92 per cent of malaria cases and 97 per cent of deaths

due to malaria is reported from North-eastern states, Chhattisgarh,
Jharkhand, Madhya Pradesh, Orissa, Andhra Pradesh, Maharashtra, Gujarat,
Rajasthan, West Bengal and
Karnataka.

India is predominantly characterized by unstable malaria transmission.

Transmission is seasonal with increased intensity related to rains.
There are six primary vectors of malaria in India :
{1) An. Culicifacies

{2) An. Stephensi

(3) An. Fluviatilis

(4) An. Minimus

(5) An. Dirus

(6) An. Epiroticus

Prevalent major epidemiological types of malaria in India

TRIBAL MALARIA : The population of tribal areas are contributing about 50

per cent of P. falciparum cases of the country

RURAL MALARIA : These include irrigated areas of arid and semiarid plains
An. culicifacies is the main vector and P. vivax is
predominant during lean period and P.falciparum during periodic
exacerbation.

URBAN MALARIA : 15 major cities including 4 metropolitans account for

nearly 80 per cent of malaria cases covered under urban malaria control
scheme

MALARIA IN PROJECT AREAS : Project areas are those areas where

construction and developmental activities are taken up and temporary
tropical aggregation of labourers takes place bringing in different strains of
malaria parasite and non-immune population

BORDER MALARIA : These are the high malaria transmission belts along
the international borders and state borders.

Epidemiological determinants

Agent factors

(a) AGENT
Malaria in man is caused· by four distinct species of the malaria parasite - P.
vivax, P. falciparum, P. malariae and P. ovale. Plasmodium vivax has the
widest geographic distribution throughout the world
Life history

The malaria parasite undergoes 2 cycles of development the human cycle

(asexual cycle) and the mosquito cycle (sexual cycle). Man is the
intermediate host and mosquito the definitive host
(b) RESERVOIR OF INFECTION
With the possible exception of chimpanzees in tropical Africa, which may
carry the infection with P. malariae, no other animal reservoir of human
plasmodia is known to exist.A human reservoir is one who harbours the
sexual forms (gametocytes) of the parasite.
(c) PERIOD OF COMMUNICABILITY
Malaria is communicable as long as mature, viable gametocytes exist in the
Circulating blood in sufficient density to infect vector mosquitoes. In vivax
infections, gametocytes appear in blood 4-5 days after the appearance of
the asexual parasites; in falcipanim infections, they do not appear until 10-
12 days after the first appearance of asexual parasites.

Host factors

The main variables of the human element that have an influence on malaria
epidemiology include the following :
1.AGE : Malaria affects all ages

2. SEX: Males are more frequently exposed to the risk of acquiring malaria
than females because of the outdoor life they lead
3. RACE : Individuals with AS haemoglobin (sicklecell trait) have a milder
illness with falciparum infection than do those with normal (AA) haemoglobin
4. PREGNANCY: Pregnancy increases the risk of malaria in women
5. SOCIO-ECONOMIC DEVELOPMENT Malaria has demonstrated the
relationship between health and socio-economic development.
6. HOUSING: Housing plays an important role in the epidemiology of malaria
7. POPULATION MOBILITY : People migrate for one reason or other from one
country to another or from one part of a country to another.
8. OCCUPATION Malaria is predominantly a rural disease and is closely
related to agriculture practices
9.IMMUNITY: The epidemic of malaria is influenced by the immune status of
the population

Environmental factors

India's geographic position and climatic conditions had been, for long,
favourable to the transmission of malaria.
(a) SEASON : Malaria is a seasonal disease. In most parts of India, the
maximum prevalence is from July to Nov
(b) TEMPERATURE: Temperature affects the life cycle of the
malaria parasite. The optimum temperature for the development of the
malaria parasite in the insect vector is between 20 deg. to 30 deg.C
(c) HUMIDITY: The atmospheric humidity has a direct effect on the length of
life of the mosquito, although it has no effect on the parasite
d) RAINFALL : Rain in general provides opportunities for the breeding of
mosquitoes and may give rise to epidemics of malaria.
(e) ALTITUDE: As a rule, Anophelines are not found at altitudes above 2000-
2500 metres, due to unfavourable climatic conditions
(f) MAN-MADE MALARIA: Burrow pits, garden pools, irrigation channels and
engineering projects like construction of hydroelectric dams, roads, bridges
have led to the breeding of mosquitoes and an increase in malaria.

Mode of transmission

(a) VECTOR TRANSMISSION: Malaria is transmitted by the bite of certain

species of infected, female, anopheline mosquitoes
(b) DIRECT TRANSMISSION: Malaria may be induced accidentally by
hypodermic intramuscular and intravenous injections of blood or plasma,
e.g., blood transfusion, malaria in drug addicts

Incubation period

It is the period between the bite of the mosquito, (inoculation of the

sporozoite) and the onset of first symptom, i.e. fever.
This period varies depending upon the parasite as follows:
Pl. vivax—14 days
Pl. falciparum—12 days
Pl. malariae—28 days
Pl. ovale—17 days

Measurement of malaria

PRE-ERADICATION ERA

In the pre-eradication era, the magnitude of the malaria problem in a

country used to be determined mostly from the reports of the clinically
diagnosed malaria cases
(a) SPLEEN RATE : It is defined as the percentage of children between 2 and
10 years of age showing enlargement of spleen. Adults are excluded from
spleen surveys, because causes other than malaria frequently operate in
causing splenic enlargement in them.
(b) AVERAGE ENLARGED SPLEEN: This is a further refinement of spleen rate,
denoting the average size of the enlarged spleen

(c) PARASITE RATE : It is defined as the percentage of children between the

ages 2 and 10 years showing malaria parasites in their blood films.

(d) PARASITE DENSITY INDEX : It indicates the average degree of

parasitaemia in a sample of well-defined group of the population

(e) INFANT PARASITE RATE : It is defined as the percentage of infants below

the age of one year showing malaria parasites in their blood film

(f) PROPORTIONAL CASE RATE : Since the morbidity rate is difficult to

determine, except in conditions when the diagnosis and reporting of each
case is carried to perfection, proportional case rate is used

ERADICATION ERA (current incidence levels)

During the eradication era, the microscopic diagnosis of malaria cases

became the main method of diagnosis. The parameters used for the
measurement of malaria were mostly parasitological in nature
The following parameters are in use at present :
a. Annual parasite incidence (API)
b. Annual blood examination rate (ABER)
c. Annual falciparum incidence (AFI)
d. Slide positivity rate (SPR)
e. Slide falciparum rate (SFR).

a. Annual parasite incidence (API)

API is given by the formula :

Areas with API less than 2 per 1000 population per year have been
classified as high risk areas in India
b. Annual blood examination rate (ABER)

ABER is given by the formula:

ABER is an index of operational efficiency. The annual parasite incidence

c. Annual falciparum incidence

Since the emergence of P. fa/ciparum problem in India, data are collected

separately for total malaria cases and P. falciparum cases

VECTOR INDICES

• Adult vector density (Mosquito density): It is the number of

mosquitoes per man-hour catch.
• Human blood index: It is the percentage of female anopheline
mosquitoes containing human blood in the stomach. It indicates the degree
of anthrophilism.
• Sporozoite rate: It is the percentage of female anopheline mosquitoes
containing sporozoites in their salivary glands.
• Biting density (Man biting rate): It is the average incidence of
anopheline bites per day per person. It is determined by catching the
vectors using a human–bait.
• Inoculation rate: It is the product of biting density and the sporozoite
rate.

Clinical features

The primary fever is marked by paroxysms which correspond to the

development of the parasites in the red blood cells. The typical attack
comprises three distinct stages,

COLD STAGE : The onset is with lassitude, headache, nausea and chilly
sensation followed in an hour or so by rigors.The temperature rises rapidly
to 39-41°C.
HOT STAGE : The patient feels burning hot and casts off his clothes. The
skin is hot and dry to touch. Headache is intense but nausea commonly
diminishes.
SWEATING STAGE : Fever comes down with profuse sweating. The
temperature drops rapidly to normal and skin is cool and moist
The complications of P. falciparum malaria are cerebral malaria, acute renal
failure, liver damage, gastro-intestinal symptoms, dehydration, collapse,
anaemia, blackwater fever etc. The complications of P. uivax, P. ovale and P.
malariae infections are anaemia, splenomegaly, enlargement of liver,
herpes, renal complications etc.

Diagnosis

The diagnosis of malaria depends on demonstration of the parasite in the

blood
1. Microscopy
Two types of blood films are useful in searching for and identification of
malaria parasite. The "thin film" and the "thick film".
Thick blood smear shows whether the slide is positive for MP or not.
Thin smear shows the species of the MP and the stage of the development in
the red cells
2. Serological test
The malarial fluorescent antibody test usually becomes positive two weeks
or more after primary infection, by which time the infection may have been
cured. A positive test is therefore, not necessarily an indication of current
infection
3. Rapid diagnostic test (RDT)
Rapid Diagnostic Tests are based on the detection of circulating parasite
antigens with a simple dipstick format. Several types of RDTs are available.
Some of them can only

GUIDELINES FOR DIAGNOSIS AND TREATMENT OF

MALARIA IN INDIA-2013

Treatment of Uncomplicated Malaria

All fever cases diagnosed as malaria by microscopy or RDT should promptly
be given effective treatment.
General recommendations for the management of
uncomplicated malaria

1. Avoid starting treatment on an empty stomach. The first dose should be

given under observation. Dose should be repeated if vomiting occurs within
15 minutes by opening a new blister pack (discard what remains of old
pack). If the patient vomits the first dose again, it is considered a severe
case of malaria and refer the patient immediately to the nearest Block
PHC/CHC/Hospital.

2. Explain to the patient or caretaker that :

(a) if the treatment is not completed as prescribed, the disease may
manifest again with more serious features and more difficult to treat;
(b) To come back immediately, if there is no improvement after 24 hours, if
the situation gets worse or the fever comes back;

(c) that regular use of a mosquito net (preferably insecticide treated net) is
the best way to prevent malaria.

3. Patient should also be examined for concomitant illness.

Treatment of severe malaria

CLINICAL FEATURES

Severe manifestations can develop in P. falciparum infection over a span of

time as short as 12-24 hours and may lead to death, if not treated promptly
and adequately. Severe malaria is characterized by oni; or more of the
following features:
(1) Impaired consciousness/coma
(2) Repeatd generalized convulsions
(3) Renal failure (Serum Creatinine >3 mg/di)
(4) Jaundice (Serum Bilirubin >3 mg/di)
(5) Severe anaemia (Hb <5 g/dl)
(6) Pulmonary oedema/acute respiratory distress
syndrome
(7) Hypoglycaemia (Plasma glucose <40 mg/di)
(8) Metabolic acidosis
(9) Circulatory collapse/shock (Systolic BP<80 mm Hg,
< 50 mm Hg in children)
(10) Abnormal bleeding and disseminated intravascular
coagulation.
( 11) Haemoglobinuria
(12) Hyperthermia (Temperature > 106°F or 42°C)
(13) Hyperparasitaemia ( <5% parasitized RBCs in low
endemic and > 10% in hyperendemic areas)

Criteria for immediate referral are as follows:

(a) Persistence of fever after 24 hours of initial treatment;

(b) Continuous vomiting and inability to retain oral drug;
(c) Headache continues to increase;
(d) Severe dehydration
(dry, parched skin, sunken eyes etc.);
(e) Too weak to walk in the abscence of any other obvious reason;
(f} Change in sensorium e.g. confusion, drowsiness, blurring
of vision, photophobia, disorientation;
(g} Convulsion or
muscle twitchings;
(h) Bleeding and clotting disorder;
(i) Suspicion of severe anaemia;
(j) Jaundice; and
(k) Hypothermia
- Pregnant women with severe malaria in any trimester can be treated with
artemisinin derivatives, which, in contrast to qumme, do not risk
aggravating hypoglycaemia.

The parenteral treatment should be given for minimum of 24 hours.

Once the patient can take oral therapy; give: Quinine 10 mg/kg three times
a day with doxycycline 100 mg once a day or clindamycin in pregnant
women and children under 8 years of age, to complete 7 days of treatment,
in patients started on
parenteral quinine.

- Full course of ACT to patients started on artemisinin derivatives.

Use of mefloquine should be avoided in cerebral malaria due to
neuropsychiatric complications associated with it.

Prevention and Control

• Elimination of reservoirs
• Breaking the channel of transmission
• Protection of susceptibles
Elimination of Reservoirs

This consists of making the infectious cases noninfectious by giving

treatment. The treatment consists of presumptive treatment, radical
treatment and mass treatment. The current treatment, under the National
Antimalaria Program, since 1999, is as follows:

Presumptive treatment: All fever cases attending hospitals for the

treatment, are assumed to be the cases of malaria and treated accordingly,
depending upon whether that area is a low-risk area or high-risk area
Mass treatment: This is recommended in highly endemic areas, where API
is more than 5 per 1000 population. This will be more effective, when
supplemented by anti-mosquito measures

Chemoprophylaxis: With the development of drug resistance, this has

become unreliable. However, it may be recommended for the following
groups. Drug recommended is chloroquine.

Breaking the Channel of Transmission

This measure consists of control of vectors. The different

methods of control of vectors are:
a. Antiadult measures
b. Antilarval measures.

a. Antiadult measures

i Residual spraying: This consists of spraying of indoor surfaces of houses,

cattle sheds with residual insecticides like DDT, malathion, fenitrothion

ii. Space spraying: This consists of out-door spraying of the insecticides

b. Antilarval measures:
This consists of bioenvironmental control strategy components are:
• Source reduction.
• Environmental modification and manipulation.
• Biological control.
i. Source reduction: This consists of elimination of nonessential water
bodies, which includes periodical emptying of domestic water container,
sealing of water tanks, filling pot holes, puddles,
burrow–pits

ii. Environmental modification and manipulation:

This consists of leveling of land or filling of depressions and making of

soakage pits help in prevention of mosquito breeding.
iii. Biological control: Mosquitoes (Larvae) can also be controlled by
employing their natural enemies such as fish, bacteriae and fungi

• Larvivorous fish: Use of larvivorous fish are the most promising ones

Use of bacteriae (i.e. Biocides): The best known biocides are Bacillus
sphaericus and Bacillus thuringiensis.
Personal Protection

These measures are directed against mosquito bites:

a. Bednets: Nylon nets are preferred over cotton nets, because of their
durability and longer stay of insecticide on nylon fiber
b. Use of mosquito repellents: They are applied on the skin.
They repell the mosquitoes by their smell and protect the individual from the
mosquito bites
c. Malaria vaccines: They are under trial. Following are the types
i. Asexual blood stage vaccines (merozoite vaccine):
ii. Sporozoite vaccines
iii. Gamete vaccines
iv. A synthetic cocktail vaccine
v. Transmission blocking vaccine

MALARIA CONTROL PROGRAMME

National Malaria Control Programme – 1953

National Malaria Eradication Programme – 1958
Urban malaria scheme – 1971
Modified plan of operation, 1977
RBM, 1998
Malaria action plan, 1995
Enhanced malaria control project, 1997
National Anti-malaria Programme – 1999
NVBDCP, 2004
Intensified malaria control project, 2005

The main activities of the programme are :

1. Formulating policies and guidelines.
2. Technical guidance.
3. Planning.
4. Logistics.
5. Monitoring and evaluation.
6. Coordination of activities through the States/Union Territories and in
consultation with national organizations such as National Centre for Disease
Control (NCDC), National Institute of Malaria Research (NIMR).
7. Collaboration with international organizations like the WHO, World Bank,
GFATM and other donor agencies.
8. Training.
9. Facilitating research through NCDC, NIMR, Regional Medical Research
Centres etc.
10. Coordinating control activities in the inter-state and inter-country border
areas

Strategic action plan for malaria control in India (2012-2017)

The vision of 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

Objective

To achieve APl < 1 per lOOO population by the end of 2017.

Goals

The national goals for strategic plan are:

1. Screening all fever cases suspected for malaria (60% through quality
microscopy and 40% by rapid diagnostic test.
2. Treating all P. fa/ciparum cases with full course of effective ACT and
primaquine, and all P. vivax cases with 3 days chloroquine and 14 days
primaquine.
3. Equipping all health institutions (PHC level and above), especially in high-
risk areas, with microscopy facility and RDT for emergency use and
injectable artemisinin derivatives.
4. Strengthening all district and sub-district hospitals in malaria endemic
areas as per IPHS with facilities for management of severe malaria cases.

Outcome Indicators

The outcome indicators of strategic plan are :

1. At least 80% of those suffering from malaria get correct, affordable,
appropriate and complete treatment within 24 hours of reporting to the
health system, by the year 2017.
2. At least 80% of those at high risk of malaria get protected by effective
preventive measures such as ITN/LLIN or IRS by 201 7.
3. At least 10% of the population in high-risk areas is surveyed annually
(annual blood examination rate> 10%).

Impact Indicators

The impact indicators of strategic plan are :

1. To bring down annual incidence of malaria to less than 1 per 1000
population at national level by 201 7.
2. At least 50% reduction in mortality due to malaria by the year 2017,
taking 2010 level as baseline.

Strategies

India's national malaria strategic plan (2012-17) is in line with the following
broad strategies of the regional malaria strategy of WHO/SEARO.

Reform approaches to programme planning and management. Improve and

enhance surveillance and strengthen monitoring and evaluation. Scale up
coverage and proper use of insecticide treated bed nets.

- Target interventions to risk groups.

- Scale up control of P. vivax.

Major activities according to API

For areas having API less than 1

1. Vector control by minor engineering measures like desilting, · deweeding
and cleaning of canals and irrigation channels, biological control by use of
larvicides and environmental management. ·
2. Involving PRIs by sensitizing them in rural areas and municipal bodies in
urban areas.
3. Cooperation from VHSCs and nodal officers from MNREGA.
For areas having API between 1-2
1. Vector control by source reduction and biological control.
2. Active surveillance by ASHA/ANM and positioning of MPW in SCs where
there is provision for 2nd ANM.
For areas having API between 2-5
1. Vector control by distribution of LLIN if acceptability of IRS is low @ 2
LLIN per household of 5 members.
2. For areas which can be supervised and accessible, quality IRS for
selective vector control based on epidemiological impact of earlier vector
control measures, if needed; these areas can also be provided with LLINs.
For areas having API above 5
a. For areas having perennial transmission {more than 5 months in a year)
1. 2 rounds of IRS with DDT and 3 rounds with malathion.
2. Priority distribution of LL!Ns as per the guidelines.
3. Vector bionomics studies for future change of strategy.
b. For areas having seasonal transmission {less than 5 months in a year)
1. 1 round of IRS with DDT before start of transmission.
2. Focal spray whenever and wherever needed.
3. Priority distribution of LLINs as per the guidelines.

Malaria control strategies

The strategies for prevention and control of malaria and its transmission are

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 Insecticidal Nets (LLINs).
- Antilarval measures induding source reduction.
3. Epidemic preparedness and early response
4. Supportive interventions
- Capacity building
-Behaviour change communication {BCC)
-Intersectoral collaboration
- Monitoring and evaluation
-Operational research and applied field research.
Early diagnosis and treatment of malaria aims at :

( 1) Complete cure;
(2) Prevention of progression of uncomplicated malaria to
severe disease;
{3) Prevention of deaths;
(4) Interruption of transmission; and
{5) Minimizing risk of selection and spread of drug resistant malaria
parasite.

Organization

There are 19 Regional Offices for Health and Family Welfare under
Directorate General of Health Services, Ministry of Health and Family
Welfare, located in 19 states, which play a crucial role in monitoring the
activities under NVBDCP.

Every state has a Vector Borne Disease Control Division under its
Department of Health and Family Welfare. It is headed by the State
Programme Officer (SPO) who is responsible for supervision, guidance and
effective implementation of the programme and for coordination of the
activities with the neighbouring States/UTs

At the divisional level, zonal officers have technical and administrative

responsibilities of the programme in their areas under the overall supervision
of Senior Divisional Officers (SDOs).
At the district level, the Chief Medical Officer (CMO)/ District Health Officer
(DHO) has the overall responsibility of the programme.

At the district level, district malaria offices have been established in many
places headed by the DVBDC officer to assist the CMO/DHO. This office is
the key unit for the planning and monitoring of the programme.

Sprayoperations are the direct responsibility of DMO/DVBDC officer in the

entire district under overall supervision of CMO and collaborative
supervision/monitoring by PHC's Medical Officer. There is one Assistant
Malaria Officer (AMO) and Malaria Inspectors (Mis) to assist him

The medical officer PHC has the overall responsibility for surveillance and
laboratory services, and also supervises the spray. Case detection
management and community outreach services are carried out by MPWs as
well as ASHAs and other community health volunteers.