Friday, 24 April 2015

25 points all doctors must know about malaria

Salient features of Malaria in India

Dr K K Aggarwal and Dr A.C.Dhariwal

1. Malaria is endemic throughout India except in areas located 5000 ft above sea level.

2. It is largely prevalent in 16 states of India including 7 North-Eastern states. These are Odisha, Jharkhand, Chhattisgarh, Madhya Pradesh, Assam, Tripura, Arunachal Pradesh, Manipur, Meghalaya, Mizoram, Nagaland, Andhra Pradesh, Gujarat, Maharashtra, West Bengal and Karnataka.

3. Intensity of transmission varies from area to area. The areas having conducive geo-ecological and climatic conditions, inaccessible terrains, poor infrastructure, lack of health seeking behavior, poor availability of health services and high vector load have high disease burden and high mortality rates.

4. The districts which have predominant tribal population are the most affected due to poor availability of health services & lack of health seeking behavior.

5. Main plasmodium species causing malaria in India are P.vivax and P.falciparum, each responsible for 50% of the cases in the country.

6. Malaria incidence has been brought down from 2 million cases annually during the last decade to around 1 million cases annually during the beginning of current decade   and it has been contained at that level for the last 3 years. Similarly annual deaths due to malaria have also declined during this period.

7. 152 Districts have been identified as high endemic.

8. During the year 2014, there was an increase in total cases and deaths due to Malaria as compared to the year 2013. A total of 11 States/ UTs reported case rise in 2014 as compared to the previous year. The major states which reported increased malaria include- Odisha, Madhya Pradesh, Chhattisgarh, Maharashtra, Andhra Pradesh, Tripura, Meghalaya and Mizoram.

9. Some of the main reasons identified for this upsurge are increased surveillance since the introduction of Bivalent Rapid Diagnostic Test (RDT) in 2013 and focal outbreaks such as in the states of Tripura, Madhya Pradesh, Maharashtra, and Meghalaya.

10. With the ultimate goal of bringing down malaria incidence to the level that it is no more a public health problem, National Vector Borne Disease Control Programme is taking intensive malaria control measures.

11. To achieve effective control of malaria, the programme aims at early case detection through active, passive and sentinel surveillance and prompt & complete treatment of all the detected cases.

12. As per National Drug Policy for Treatment of Malaria- 2013, all fever cases suspected of malaria are to be investigated by microscopy or Rapid Diagnostic Test (RDT) for malaria.

13. Although microscopy is the Gold standard test for malaria but in remote, inaccessible areas, during malaria epidemic, for travelers and military forces bivalent RDTs are being recommended and used to detect malaria.

14. NVBDCP recommends only Antigen-based Bivalent RDTs  (Pf and Pv.) for diagnosis of malaria.

15. As per the National Drug Policy (2013), P.vivax cases are to be treated with chloroquine for three days and Primaquine for 14 days.

16. As per the National Drug Policy (2013), P. falciparum cases are to be treated with Artemisinin Combination Therapy (ACT) i.e Artesunate 3 days + Sulphadoxine-Pyrimethamine 1 day and single dose Primaquine on day 2.

17. However, in NE states all Pf cases are to be treated with ACT-AL (Artemether-Lumefantrine combination) + Primaquine on day 2.

18. All severe cases should be treated with injection Artesunate followed by complete oral ACT course i.e of three days.

19. The referral services are being strengthened for the management of severe cases. The referral mechanism under NHM is being used for referring cases.

20. Special measures are being taken for epidemic preparedness and rapid response, through co-ordination with IDSP.

21. To reduce the risk of Transmission, Integrated Vector Management is being done through Indoor Residual Spraying  (IRS) in selected high risk areas with API>2 (-~80 million pop./annually), Use of Long Lasting Insecticidal Nets (LLINs) and use of larvivorous fish and source reduction.
22. Other important Supporting Interventions of the program include Behaviour Change
Communication/ Information, Education & Communication (BCC/IEC), capacity building and Inter-sectoral collaboration and NGO or Public Private Partnerships.

23. In urban areas > 60% of the population seeks health services from private sector and other public undertaking and organized sectors. Their involvement in the programme is of paramount importance.

24. To ensure timely action, actual disease burden, reporting from all the sectors needs to be captured and monitored.

25. Any confirmed malaria case not responding to treatment within 72hrs. may be suspected for resistance. Such cases should be given alternative anti-malarials and should be reported to the programme for detailed investigation.

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