Malaria

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Vector borne diseasesVector borne diseases

DR RAHIM IQBALDR RAHIM IQBALMBBS(Pb).MPH(H.S.A) MBBS(Pb).MPH(H.S.A)

Senior DemonstratorSenior DemonstratorRawalpindi Medical college Rawalpindi Medical college

RawalpindiRawalpindi

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Vector borne diseasesVector borne diseases

VectorVectorIt is defined as an arthropod or any It is defined as an arthropod or any

living carrier (e.g. snail) that living carrier (e.g. snail) that transport an infectious agent to a transport an infectious agent to a

susceptible individuals. The susceptible individuals. The transmission by a vector may transmission by a vector may

mechanical or biologicalmechanical or biological

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Arthropods-borne diseases

ArthropodsArthropods Diseases transmittedDiseases transmitted

MosquitoMosquito Malaria, Filariasis, Dengue, Yellow FeverMalaria, Filariasis, Dengue, Yellow Fever

HouseflyHousefly Typhoid, Diarrhea, Gastro-enteritis Typhoid, Diarrhea, Gastro-enteritis

Amoebiasis, Poliomyelitis, TrachomaAmoebiasis, Poliomyelitis, Trachoma

Sand flySand fly Kalaazar, Sand fly fever, Oraya Fever Kalaazar, Sand fly fever, Oraya Fever

Tsetse flyTsetse fly Sleeping Sickness Sleeping Sickness

LouseLouse Epidemic Typhus, Relapsing fever Epidemic Typhus, Relapsing fever

Rat FleaRat Flea Plague, endemic typhusPlague, endemic typhus

Black FlyBlack Fly Onchocerciasis Onchocerciasis

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Arthropods-borne diseases

Hard tickHard tick Viral Hemorrhagic fever, Tick Paralysis , Viral Hemorrhagic fever, Tick Paralysis , Viral Encephalitis Viral Encephalitis

Soft Tick Soft Tick Q fever, Relapsing Fever Q fever, Relapsing Fever

Itch MiteItch Mite Scabies Scabies

Cyclops Cyclops Guinea-worm disease, Fish tape wormGuinea-worm disease, Fish tape worm

Cockroach Cockroach Enteric pathogensEnteric pathogens

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Vector born diseasesVector born diseases Methods in which vectors are involved in Methods in which vectors are involved in

the transmission and propagation of the transmission and propagation of parasites.parasites.

Mechanical transmissionMechanical transmission PropagativePropagative Cyclo-PropagativeCyclo-Propagative Cyclo-developmentalCyclo-developmental Biological transmissionBiological transmission

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MalariaMalaria

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MALARIAMALARIA

Malaria is a protozoal disease caused by Malaria is a protozoal disease caused by

infection with parasites of the genus infection with parasites of the genus

PLASMODIUMPLASMODIUM and transmitted to man by and transmitted to man by

certain species of infected female Anopheline certain species of infected female Anopheline

mosquito.mosquito.

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HISTORYHISTORY

Malaria is one of the oldest recorded Malaria is one of the oldest recorded disease in the world.disease in the world.

1880;1880; Laveran a French Army Surgeon Laveran a French Army Surgeon discovered the malaria parasite in discovered the malaria parasite in Algiers, North Africa.Algiers, North Africa.

1897;1897; Ronald Ross, who discovered the Ronald Ross, who discovered the transmission of malaria by Anopheline transmission of malaria by Anopheline mosquitoes.mosquitoes.

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TYPES OF MALARIATYPES OF MALARIA

1.1. Tribal Malaria:Tribal Malaria:

2.2. Rural Malaria:Rural Malaria:

3.3. Urban Malaria:Urban Malaria:

4.4. Malaria in Project Areas:Malaria in Project Areas:

5.5. Border Malaria:Border Malaria:

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AGENT FACTORSAGENT FACTORS

a). a). AGENT:AGENT:

““Malaria in man is caused by four Malaria in man is caused by four

distinct species of the malaria Parasite:”distinct species of the malaria Parasite:”

* P. Vivax, * P. Vivax,

* P. Falciparum* P. Falciparum

* P. Malariae* P. Malariae

* P. Ovale.* P. Ovale.

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LIFE HISTORYLIFE HISTORY::

i). Asexual Cycle:i). Asexual Cycle:

* * Hepatic PhaseHepatic Phase

* Erythrocytic Phase* Erythrocytic Phase

ii). Sexual Cycle:ii). Sexual Cycle:

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MalariaMalaria

b). b). RESERVOIR OF INFECTION:RESERVOIR OF INFECTION:

c). c). PERIOD OF COMMUNICABILITY:PERIOD OF COMMUNICABILITY:

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HOST FACTORSHOST FACTORS

AgeAge

SexSex

RaceRace

PregnancyPregnancy

Socioeconomic Socioeconomic

DevelopmentDevelopment

• HousingHousing

• Population MobilityPopulation Mobility

• OccupationOccupation

• Human HabitHuman Habit

• ImmunityImmunity

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MODE OF TRANSMISSIONMODE OF TRANSMISSION

a)a) Vector TransmissionVector Transmission

b)b) Direct TransmissionDirect Transmission

c)c) Congenital MalariaCongenital Malaria

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INCUBATION PERIODINCUBATION PERIOD

This is the length of time between the infective This is the length of time between the infective

mosquito bite and the first appearance of clinical mosquito bite and the first appearance of clinical

signs of which fever is most common. This period is signs of which fever is most common. This period is

usually not less than 10 days.usually not less than 10 days.

Extrinsic incubation periodExtrinsic incubation period=organism is present in =organism is present in

the vector+excrete to infect ie eligible to infect the vector+excrete to infect ie eligible to infect

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CLINICAL FEATURESCLINICAL FEATURES

a)a) Cold StageCold Stage

b)b) Hot StageHot Stage

c)c) Sweating StageSweating Stage

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DIAGNOSIS (malaria)DIAGNOSIS (malaria)

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MEASUREMENT OF MALARIAMEASUREMENT OF MALARIA

PRE-ERADICATION ERA:PRE-ERADICATION ERA:

In the pre-eradication era, the magnitude of In the pre-eradication era, the magnitude of the malaria problem in a country used to be the malaria problem in a country used to be determined mostly from the reports of the determined mostly from the reports of the clinically diagnosed malaria cases.clinically diagnosed malaria cases.

The classical malariometric measures are The classical malariometric measures are spleen rate, average enlarged spleen, spleen rate, average enlarged spleen, parasite rate etc. in a control programe, the parasite rate etc. in a control programe, the case detection machinery is weak. case detection machinery is weak. Therefore, the classical malariometric Therefore, the classical malariometric measure may provide the needed measure may provide the needed information, i.e. the trend of the disease.information, i.e. the trend of the disease.

Continued:Continued:

2020

a). a). SPLEEN RATE:SPLEEN RATE:

It is defined as the percentage of children It is defined as the percentage of children

between 2 & 10 yrs of age showing between 2 & 10 yrs of age showing

enlargements of spleen. Adults are excluded enlargements of spleen. Adults are excluded

from spleen surveys because causes other from spleen surveys because causes other

than malaria frequently operate in causing than malaria frequently operate in causing

splenic enlargement in them. The spleen splenic enlargement in them. The spleen

rate is widely used for measuring the rate is widely used for measuring the

endemicity of malaria in a communityendemicity of malaria in a community..Continued:Continued:

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b). b). AVERAGE ENLARGED SPLEENAVERAGE ENLARGED SPLEEN::

This is a further refinement of spleen rate, This is a further refinement of spleen rate,

denoting the average size of the enlarged denoting the average size of the enlarged

spleen. It is useful malariometric index.spleen. It is useful malariometric index.

c). c). PARASITE RATE:PARASITE RATE:

It is defined as the percentage of children It is defined as the percentage of children

between the ages 2 & 10yrs showing between the ages 2 & 10yrs showing

malaria parasites in their blood films.malaria parasites in their blood films.

Continued:Continued:

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d). d). PARASITE DENSITY INDEXPARASITE DENSITY INDEX::

It indicates the average degree of It indicates the average degree of

parsitaemia in a sample of well defined parsitaemia in a sample of well defined

group of the population. Only the positive group of the population. Only the positive

slides are included in the denominator.slides are included in the denominator.

Continued:Continued:

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e). e). INFANT PARASITES:INFANT PARASITES:

It is defined as the percentage of infants below It is defined as the percentage of infants below

the age of one year showing malaria parasites in the age of one year showing malaria parasites in

their blood film. It is regarded as the most their blood film. It is regarded as the most

sensitive index of recent transmission of malaria sensitive index of recent transmission of malaria

in a locality. If the infant parasite rate is zero for 3 in a locality. If the infant parasite rate is zero for 3

consecutive years in a locality, it is regarded as consecutive years in a locality, it is regarded as

absence of malaria transmission even though, the absence of malaria transmission even though, the

Anopheline vectors responsible for previous Anopheline vectors responsible for previous

transmission may remain.transmission may remain.

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f). f). PROPORTIONAL CASE RATE:PROPORTIONAL CASE RATE:

Since the morbidity rate is difficult to determine, Since the morbidity rate is difficult to determine,

except in conditions when the diagnosis and except in conditions when the diagnosis and

reporting to each case is carried to perfection, reporting to each case is carried to perfection,

proportional case rate is used. proportional case rate is used.

It is defined as the number of cases diagnosed as It is defined as the number of cases diagnosed as

clinical malaria for every 100 patients attending clinical malaria for every 100 patients attending

the hospitals and dispensaries. This is a crude the hospitals and dispensaries. This is a crude

index because the cases are not related to their index because the cases are not related to their

time/space distribution.time/space distribution.

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Important parametersImportant parameters

Annual parasites incidence(API)Annual parasites incidence(API) API=confirm cases during year/population under API=confirm cases during year/population under

surveillance*1000surveillance*1000

Annual blood examination Annual blood examination rate(ABER)/populationrate(ABER)/population

Number of slides examined*100Number of slides examined*100

Annual falciparum incidence(API)Annual falciparum incidence(API) Slide positivity rate(SPR)Slide positivity rate(SPR) Slide falciparum rate(SFR)Slide falciparum rate(SFR)

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MODIFIED PLAN OF OPERATIONMODIFIED PLAN OF OPERATION

1.1. ObjectivesObjectives

2.2. Reclassification of endemic areasReclassification of endemic areas

3.3. Areas with API > 2:Areas with API > 2:

a). Sprayinga). Spraying

b). Entomological Assessmentb). Entomological Assessment

c). Surveillancec). Surveillance

d). Treatment of casesd). Treatment of cases

Continued:

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4.4. Areas with API < 2:Areas with API < 2:a). Sprayinga). Sprayingb). Surveillanceb). Surveillancec). Treatmentc). Treatmentd). Follow Upd). Follow Upe). Epidemiological investigatione). Epidemiological investigation

5.5. Drug distribution centers & fever Drug distribution centers & fever treatment depotstreatment depots

6.6. Urban malaria schemeUrban malaria scheme7.7. P. Falciparum containmentP. Falciparum containment8.8. ResearchResearch9.9. Health educationHealth education10.10. Re-organizationRe-organization

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SURVEILLANCESURVEILLANCE

a)a) Active SurveillanceActive Surveillance

b)b) Passive SurveillancePassive Surveillance

c)c) Parameters of malaria surveillanceParameters of malaria surveillance

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APPROACHES & STRATEGIES OF APPROACHES & STRATEGIES OF MALARIA CONTROLMALARIA CONTROL

a.a. Management of malaria casesManagement of malaria cases

b.b. Disease control strategiesDisease control strategies

i). Case Detectioni). Case Detection

ii). Treatmentii). Treatment

* Presumptive treatment* Presumptive treatment

*Radical Treatment*Radical Treatment

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DrugssDrugss Usual amount Usual amount per tablet or per tablet or

capsulecapsule

Adult DoseAdult Dose

Generic NameGeneric Name Common Common trade namestrade names

For prophylaxisFor prophylaxis For treatmentFor treatment

ChloroquineChloroquinebb AralenAralen

AvlochlorAvlochlor

NivaquineNivaquine

ResochinResochin

100 / 150mg 100 / 150mg (base)(base)

300mg (base) = tablets 300mg (base) = tablets of 100mg or 2 tablets of of 100mg or 2 tablets of 150mg once a week150mg once a week

OROR

100mg (base) = 1 tablet 100mg (base) = 1 tablet of 100mg daily for six of 100mg daily for six days per weekdays per week

600 mg (base) on 600 mg (base) on the 1the 1stst & 2 & 2ndnd days, days, 300mg (base) on 300mg (base) on the third day the third day (total 10 tablets of (total 10 tablets of 150mg or 15 of 150mg or 15 of 100mg.100mg.

ProguanilProguanil PaludrinePaludrine 100 mg100 mg 200mg = 2 tablets once 200mg = 2 tablets once a daya day

Not applicableNot applicable

Sulfadoxine-Sulfadoxine-pyrimethaminepyrimethamine

FansidarFansidar 500mg + 25mg500mg + 25mg Not applicableNot applicable 1500mg + 75mg 1500mg + 75mg = 3tablets in one = 3tablets in one dosedose

Sulfalene-Sulfalene-pyrimethaminepyrimethamine

MetakelfinMetakelfin 500mg + 25mg500mg + 25mg Not applicableNot applicable 1500mg + 75mg 1500mg + 75mg = 3tablets in one = 3tablets in one dosedose

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MefloquineMefloquine Lariam Lariam MephaquinMephaquin

250 mg250 mg 250mg = 1 250mg = 1 tablet one a tablet one a week, on the week, on the same day each same day each weekweek

1000mg (4tablets) or 1000mg (4tablets) or 15mg/kg of body 15mg/kg of body weight, whichever is weight, whichever is lower in one doselower in one dose

OROR

100mg (4tablets) 100mg (4tablets) initially, followed by initially, followed by 500mg (2tablets) 6-500mg (2tablets) 6-8hrs later.8hrs later.

QuinineQuinine 300mg300mg Not applicableNot applicable 600mg (2tablet) 3 600mg (2tablet) 3 times a day for 7 days times a day for 7 days (total 42 tablets)(total 42 tablets)

DoxycyclineDoxycycline VibramycinVibramycin 100mg100mg 100mg = 1 100mg = 1 capsule once a capsule once a dayday

Not applicableNot applicable

HalofantrineHalofantrineb.fb.f HalfanHalfan 250mg250mg Not applicableNot applicable 500mg (2tablets) in 500mg (2tablets) in one dose + 500mg one dose + 500mg after 6hrs, + 500mg after 6hrs, + 500mg after 6 more hrs, (total after 6 more hrs, (total 6 tablets in 12hrs)6 tablets in 12hrs)

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Drugs resistance malariaDrugs resistance malaria

WHO recommendation.WHO recommendation.

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Situation of Clinical Malaria (Fever) in Situation of Clinical Malaria (Fever) in PakistanPakistanINTRODUCTIONINTRODUCTION

Malaria is one of the most devastating tropical disease in the Malaria is one of the most devastating tropical disease in the world, with nearly 2.1 billion people at risk of infection. It is world, with nearly 2.1 billion people at risk of infection. It is particularly dangerous for young children and for pregnant women particularly dangerous for young children and for pregnant women and their unborn children, although others may be seriously and their unborn children, although others may be seriously affected in some circumstances. About 250 to 300 million cases of affected in some circumstances. About 250 to 300 million cases of malaria occur annually many among young children. New anti-malaria occur annually many among young children. New anti-malarial drugs and more efficient diagnostic techniques are being malarial drugs and more efficient diagnostic techniques are being tested to cope with the problem. Malaria is a curable and tested to cope with the problem. Malaria is a curable and preventable disease, but it still kills many people. The main preventable disease, but it still kills many people. The main reasons for this unsatisfactory situation are:reasons for this unsatisfactory situation are:

Some people do not come for treatment until they are very ill Some people do not come for treatment until they are very ill because: because: • they do not realize they might have malaria (people often think they do not realize they might have malaria (people often think

they have a cold, influenza or other common infection); they have a cold, influenza or other common infection); • they do not realize that malaria is very dangerous; or they do not realize that malaria is very dangerous; or • they live far away from health care facilities. they live far away from health care facilities.

People living far from health services will often go to local People living far from health services will often go to local medicine vendors (sellers) for advice, which is not always medicine vendors (sellers) for advice, which is not always appropriate, or to buy medicines, which are not always effective. appropriate, or to buy medicines, which are not always effective.

Many people do not know what causes malaria or how it is spread, Many people do not know what causes malaria or how it is spread, so they are not able to protect themselves from the disease. so they are not able to protect themselves from the disease.

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Pakistan launched Malaria eradication campaign with the help of Pakistan launched Malaria eradication campaign with the help of WHO in 1960. But eradication of malaria could not be achieved WHO in 1960. But eradication of malaria could not be achieved because of socio- economic and epidemiological factors and so it because of socio- economic and epidemiological factors and so it poses a potential threat to the health of millions of people. On the poses a potential threat to the health of millions of people. On the advice of WHO, Malaria Eradication Programme was converted into advice of WHO, Malaria Eradication Programme was converted into Malaria Control Programme. The current project is an extension of Malaria Control Programme. The current project is an extension of on- going Malaria Control Programme.on- going Malaria Control Programme.

A patient of any age having axillary or oral temperature of 38?C or A patient of any age having axillary or oral temperature of 38?C or more, rectal temperature of 38.5?C or more, continues or irregular more, rectal temperature of 38.5?C or more, continues or irregular at the start of the illness, but soon it may become irregular with at the start of the illness, but soon it may become irregular with attacks every 2-3 days. The attack begins with sever shivering, attacks every 2-3 days. The attack begins with sever shivering, followed by fever and finally by profuse sweating. followed by fever and finally by profuse sweating.

Malaria is a disease that is caused by the presence of very small Malaria is a disease that is caused by the presence of very small organisms (malaria parasites) in the blood. Malaria parasites are organisms (malaria parasites) in the blood. Malaria parasites are so small that they can only be seen under a microscope. They feed so small that they can only be seen under a microscope. They feed on the blood cells, multiply inside them and destroy them. Malaria on the blood cells, multiply inside them and destroy them. Malaria is detected by clinical symptoms and microscopic examination of is detected by clinical symptoms and microscopic examination of blood slides. blood slides.

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NHMIS NHMIS is actively functioning in almost all the districts of the is actively functioning in almost all the districts of the country. Presently National HMIS is collecting valuable information, country. Presently National HMIS is collecting valuable information, which flows directly from the peripheral health facilities to the which flows directly from the peripheral health facilities to the District Computer Centers, then to the Divisional and the Provincial District Computer Centers, then to the Divisional and the Provincial Computer Centers. Ultimately, the information reaches the National Computer Centers. Ultimately, the information reaches the National HMIS Cell on computer diskettes where it is analyzed through HMIS HMIS Cell on computer diskettes where it is analyzed through HMIS software and also through Statistical Package of Social Sciences software and also through Statistical Package of Social Sciences (SPSS). (SPSS).

This monograph has been compiled from the data received by the This monograph has been compiled from the data received by the National HMIS Cell of the Ministry of Health from the HMIS Cells National HMIS Cell of the Ministry of Health from the HMIS Cells located within the provincial health departments. The National HMIS located within the provincial health departments. The National HMIS Cell has made all efforts in compiling this bulletin to reflect the true Cell has made all efforts in compiling this bulletin to reflect the true picture of malaria burden in Pakistan to its readers. picture of malaria burden in Pakistan to its readers.

The prime purpose of this monograph is to present the analysis of The prime purpose of this monograph is to present the analysis of malaria data received from the provinces during Jan 1998 - July 2000. malaria data received from the provinces during Jan 1998 - July 2000. This report is hoped to generate interest and debate at various levels This report is hoped to generate interest and debate at various levels of health care delivery system as to pinpoint areas with high of health care delivery system as to pinpoint areas with high endemicity of malaria, particularly the falciprum malaria prevalence endemicity of malaria, particularly the falciprum malaria prevalence in the country. in the country.

There is still a need to verify and supplement this HMIS information There is still a need to verify and supplement this HMIS information with other data sources like community based surveys or MIS of with other data sources like community based surveys or MIS of Malaria Program etc. The Cell would however welcome the readers to Malaria Program etc. The Cell would however welcome the readers to point out any omission or errors.point out any omission or errors.

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Malaria VaccineMalaria Vaccineburning issue of todayburning issue of today1)sexual blood stage vaccine1)sexual blood stage vaccine

2)second vaccine is designed to arrest the2)second vaccine is designed to arrest the development of the parasite in the mosquito development of the parasite in the mosquito

3)SP166(cocktail) vaccine for 3)SP166(cocktail) vaccine for p.falciparum(dr .m.Pattaryo)p.falciparum(dr .m.Pattaryo)

4)Transmission blocking vac4)Transmission blocking vaccine.Pfs 25(USA 1995)cine.Pfs 25(USA 1995)

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Thank you Thank you

Very muchVery much