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Recent trend in malaria
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Recent trend in malaria. Global Distribution of Malaria Accessed October 17, 2004 CDC. Available at .

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Page 1: Recent trend in malaria. Global Distribution of Malaria Accessed October 17, 2004 CDC. Available at .

Recent trend in malaria

Page 2: Recent trend in malaria. Global Distribution of Malaria Accessed October 17, 2004 CDC. Available at .

Global Distribution of Malaria

        

                                                         

Accessed October 17, 2004

CDC. Available at http://www.cdc.gov/malaria/distribution_epi/distribution.htm.

Page 3: Recent trend in malaria. Global Distribution of Malaria Accessed October 17, 2004 CDC. Available at .

Malaria is a global disease.

40% world pop. lives in malarious areas.

300-500m malaria cases annually.

2– 3m death an average of one person every 12 seconds. Mostly children (<5 yrs).

India contribute 23% of clinical cases of Pf.

1.2 billion PAR P. vivax which is 42% of the global PAR.

Global BurdenGlobal Burden

Contd…

Hay et al., 2010. Lancet. 7(6):e1000290

Page 4: Recent trend in malaria. Global Distribution of Malaria Accessed October 17, 2004 CDC. Available at .

2.4m malaria cases reported from South Asia.

Of which 75% are in India alone.

Five states responsible >60% malaria.

Orissa, CG, MP, Jharkhand & WB.

Malaria infect human at conception till adult.

Patients survive if they timely access to medicines.

Malaria present a diagnostic challenge.

Burden in Asia and IndiaBurden in Asia and India

World Malaria Report 2009. World Health Organization

Page 5: Recent trend in malaria. Global Distribution of Malaria Accessed October 17, 2004 CDC. Available at .

Burden

Dhingra et al., Oct 2010 Lancet

Page 6: Recent trend in malaria. Global Distribution of Malaria Accessed October 17, 2004 CDC. Available at .

MALARIA PROFILE OF INDIAMALARIA PROFILE OF INDIA (1961-2010)(1961-2010)

Page 7: Recent trend in malaria. Global Distribution of Malaria Accessed October 17, 2004 CDC. Available at .

Malaria Cases PF

Deaths

State wise malaria contribution in India

Page 8: Recent trend in malaria. Global Distribution of Malaria Accessed October 17, 2004 CDC. Available at .

DiagnosisDiagnosis

Clinical: Grossly inaccurate

Microscopy: Thick and thin blood smear

Fluorescent Microscopy

Polymerase Chain Reaction (PCR)

Rapid Diagnostic Tests (RDT)

Page 9: Recent trend in malaria. Global Distribution of Malaria Accessed October 17, 2004 CDC. Available at .
Page 10: Recent trend in malaria. Global Distribution of Malaria Accessed October 17, 2004 CDC. Available at .

Blood SmearBlood Smear

! The quantity of blood is very important for the thick smear! The quantity of blood is very important for the thick smear

! Not enough blood may lead to a WRONG NEGATIVE RESULT.! Not enough blood may lead to a WRONG NEGATIVE RESULT.

Too much blood cannot be stained properly and CANNOT BE Too much blood cannot be stained properly and CANNOT BE EXAMINED EXAMINED

Page 11: Recent trend in malaria. Global Distribution of Malaria Accessed October 17, 2004 CDC. Available at .

FLUORESCENCE MICROSCOPY

Fluorescent dyes have an affinity for nuclic acid in the parasite nucleus.

They attach to the nuclei.

Under UV light, the nucleus fluorecence strongly (490nm).

Two fluorochromes used,

Acridine Orange (AO) Benzothio Carboxypurine (BCP)

Green/Yellow fluorescence

Page 12: Recent trend in malaria. Global Distribution of Malaria Accessed October 17, 2004 CDC. Available at .

Quantitative Buffy Coat (QBC)(Becton Dickingson Franklin Lakes N.J.)

QBC combines an AO coated

capillary tube.

Centrifuged Parasite concentrate

below layer of cells.

In the upper layer of RBC

Between layers of Platelets and

WBC.

Parasite can be viewed through

the capillary tube using focal

length objective (Paralens)

Page 13: Recent trend in malaria. Global Distribution of Malaria Accessed October 17, 2004 CDC. Available at .

LimitationsLimitationsQBC, BCP and AO are rapid and easy when parasitaemia >100 parasites/l.

Inability to differentiate between Plasmodium species (AO/BCP)

AO hazardous has special disposal requirements

QBC/BCP more demanding technically than AO

QBC requires a particular centrifuge and its tubes. This increase costs to about US$1.7/sample.

Page 14: Recent trend in malaria. Global Distribution of Malaria Accessed October 17, 2004 CDC. Available at .

PCRPCRNested PCR and reverse transcription PCR enable all four species to be identified.

Lane 2-12 :Samples, Lane 1 & 13: positive & negative control, Lane 14:

100 bp DNA ladder

P.vivax

Lane 1-11 :Samples, Lane 12 & 13: positive & negative control, Lane 14:

100 bp DNA ladder

P.falciparum

Page 15: Recent trend in malaria. Global Distribution of Malaria Accessed October 17, 2004 CDC. Available at .

AdvantagesAdvantages

• Ability to detect low level parasitaemia

• 5 parasites/µl can be detected (100% Sen/Sp.)

• Strain variations, mutations and drug resistance

• Mixed infection

LimitationsLimitations

•Expensive, extensive

technical expertise

•Labour intensive

involved multiple steps

•High cost of the

enzymes and primers

Page 16: Recent trend in malaria. Global Distribution of Malaria Accessed October 17, 2004 CDC. Available at .

Why use RDT?

• Early diagnosis and prompt treatment.

• Rapid, reliable and simple to perform-

• RDTs an alternative to microscopy.

• With New Expensive ACT, RDT is must.

Page 17: Recent trend in malaria. Global Distribution of Malaria Accessed October 17, 2004 CDC. Available at .

RDTs Three type of Antigen detection tests common.

Histidine rich Protein 2 (HRP-2).

Plasmodium Lactate dehydrogenase (pLDH) test usually detects falciparum and non falciparum.

Combo test– HRP-2 + pLDH based - First Response– HRP-2 + Aldolase - ICT Combo

Page 18: Recent trend in malaria. Global Distribution of Malaria Accessed October 17, 2004 CDC. Available at .

Diagnosis is based on Detection of HRP-2 Diagnosis is based on Detection of HRP-2 released from infected erythrocytes with released from infected erythrocytes with P. falciparumP. falciparum monoclonal antibodies against monoclonal antibodies against HRP-2 fixed in the test strip that reacts with HRP-2 fixed in the test strip that reacts with heamolyzed blood samples from positive heamolyzed blood samples from positive patients. The antigen/antibody reaction is patients. The antigen/antibody reaction is revealed by the addition of a detector revealed by the addition of a detector reagent. A solid pink line on the strip reagent. A solid pink line on the strip indicates a positive test.indicates a positive test.

PrinciplePrinciple

Page 19: Recent trend in malaria. Global Distribution of Malaria Accessed October 17, 2004 CDC. Available at .
Page 20: Recent trend in malaria. Global Distribution of Malaria Accessed October 17, 2004 CDC. Available at .
Page 21: Recent trend in malaria. Global Distribution of Malaria Accessed October 17, 2004 CDC. Available at .
Page 22: Recent trend in malaria. Global Distribution of Malaria Accessed October 17, 2004 CDC. Available at .

Do not require extensive training or good

infrastructure or electricity.

Simple to perform.

Easy to learn.

Ideal on the spot diagnosis and treatment.

No supervision required.

Simple to carry in the field.

Advantages (RDTs)

Page 23: Recent trend in malaria. Global Distribution of Malaria Accessed October 17, 2004 CDC. Available at .

Limitations (RDTs)

Expensive

Low sensitivities in low parasitaemia

Persistent positivity upto 2 weeks after medication

May not be used for identification of drug resistance

False positives rheumatoid factor/ heterophile

antibody

It can not different between current/ recent

parasitaemia

Can not quantify the parasitaemia

Can not differentiate between sexual and asexual

Page 24: Recent trend in malaria. Global Distribution of Malaria Accessed October 17, 2004 CDC. Available at .

Assisting staff fills consent form Collection of blood sample for RDT

Interpretation of Rapid Diagnostic Test Kit Medical Officer provides medicine

Page 25: Recent trend in malaria. Global Distribution of Malaria Accessed October 17, 2004 CDC. Available at .

Portable Reader

Molecular Diagnostics

GENOMIX reader for Point-of-Care Diagnostics

HandheldReader

A functional Genomics Company

Page 26: Recent trend in malaria. Global Distribution of Malaria Accessed October 17, 2004 CDC. Available at .

Malaria Lamp AssayMalaria Lamp Assay

900 grams weight

Loop Mediated IsothermalAmplication

Page 27: Recent trend in malaria. Global Distribution of Malaria Accessed October 17, 2004 CDC. Available at .

Major Vectors in India

• Anopheles fluviatilis

• Anopheles culicifacies

• Anopheles stephensi

• Anopheles sundaicus

• Anopheles minimus

• Anopheles dirus

Page 28: Recent trend in malaria. Global Distribution of Malaria Accessed October 17, 2004 CDC. Available at .

Monitoring of insecticide resistance of An. culicifacies, malaria vector in district Balaghat, Dindori, Mandla,

Sidhi, Jhabua and Shahdol of MP

Insecticide Mortality

DDT 4% 6.7 – 11.2%

Malathion 5% 77.3 – 83.5%

Deltamethrin 74.4 – 97.0%0.05%

Alphacypermethrin 50.0%

Page 29: Recent trend in malaria. Global Distribution of Malaria Accessed October 17, 2004 CDC. Available at .

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P.falciparum P.vivax

DYNAMICS OF P.vivax & P.falciparum RATIO IN STUDY AREA SHOWING SHIFTING TREND

Singh et al., 2004. Trop Med Int Hlth

Page 30: Recent trend in malaria. Global Distribution of Malaria Accessed October 17, 2004 CDC. Available at .

Aims of National Drug Policy on Malaria (2010)

• Providing complete cure of malaria cases.

• Prevention of progression of uncomplicated malaria to severe malaria.

• Prevention of relapses by administration of radical treatment.

• Interruption of transmission by the use of gametocytocidal drugs.

• Preventing development of drug resistance by early treatment of malaria.

Page 31: Recent trend in malaria. Global Distribution of Malaria Accessed October 17, 2004 CDC. Available at .

Treatment of Malaria

• All fever cases should be tested by microscopy/ RDT

• No presumptive treatment

• P. vivax - CQ (3 days) PQ for 14 days

• P. falciparum - ACT 3 days

- PQ single dose

• Cases not responding to ACT should be treated with oral quinine with Tetracycline/ Doxycycline

http://nvbdcp.gov.in/Doc/drug-policy-2010.pdf

Page 32: Recent trend in malaria. Global Distribution of Malaria Accessed October 17, 2004 CDC. Available at .

National Drug PolicyDuring Pregnancy

• Pregnant women with Pf (uncomplicated)

• 1st Trimester – Quinine

• 2nd & 3rd Trimester – ACT

(Artesunate + Sulphadoxine-Pyrimethamine)

Page 33: Recent trend in malaria. Global Distribution of Malaria Accessed October 17, 2004 CDC. Available at .

Thank you…Thank you…