NAMP

National Anti Malaria Program

 Topics Discussed

Organisation & Implementation of National Anti Malaria Program in the District

Techniques of blood examinations; Staining & Identification techniques

Spraying techniques & Strategies

Monitoring of the program

Organisation &
Implementation
N A M P is a Cat II centrally sponsored Venture 50 : 50 cost sharing

Central --- Drugs, Insecticides / Larvicides, Technical assistance

State --- Operational costs including staff salary RBM 98

NMCP 53 ---- NMEP 58 ---- UMS 71 ---- MPO 77 ---- MAP 95 ---- EMCP 97 ---- NAMP 99

Integration of the malaria maintenance phase under NMEP with the General Health Services
--- Chadha Committee 63

Along with MPO 77,the MPW Scheme (Kartar Sing Committee) & VHG Scheme 77 took shape

Carry out active & Passive Surveillance ; 1 H.I (Surveillance Inspector) for 4 MPW

The PHC Medical Officers have a key role in the execution of the program

In addition to the District Health Officer, the existing unit officers have been designated
District Malaria Officers – entrusted with the operational & evaluation aspects of the
program

The DMO is assisted by Asst. Malaria Officers

Lab services decentralised; Lab technicians posted at each PHC; come under the DMO
Malaria Trend across the centuries, in India
 Six elements of Roll Back M a l a r i a

1. Evidence-based-decisions using surveillance, appropriate responses and building

community awareness

2. Rapid diagnosis and treatment

3. Multiple prevention. Better multipronged protection using insecticide treated

mosquito nets, environmental management to control mosquitoes and making
pregnancy safer

4. Focussed research to develop new medicines, vaccines and insecticides and to help
epidemiological and operational activities

5. Coordinated action for strengthening existing health services, policies and providing
technical support.

6. Harmonised actions to build a dynamic global movement.

 N A M P Control Strategies
API >2 API<2

Spraying Focal Spraying

Active Surveillance ( active & passive )
Entomological assessment
surv Treatment
Surveillance ( active & passive ) once in
15 days Follow up
Treatment Epidemiological Investigation
Treatment
Presumptive
Tab. Chloroquine 600 mg ( 10 mg/kg ) + Tab. Primaquine 15 mg ( 0.25 mg/kg )

Radical
Vivax
Tab. Chloroquine 600 mg ( 10 mg/kg ) + Tab. Primaquine 15 mg ( 0.25 mg/kg ) on day 1
Tab. Primaquine 15 mg on day 2, 3, 4 and 5

Falciparum
Tab. Chloroquine 600 mg ( 10 mg/kg ) + Tab. Primaquine 45 mg ( 0.25 mg/kg )
 MALARIA INCIDENCE IN RURAL AND URBAN AREAS OF TAMILNADU

Chennai Other UMS

Year State Cases Rural Cases Chennai % Other UMS %
Cases Cases
1990 120029 48478 51272 42.7 20279 16.9

1991 144762 57403 67013 46.3 20346 14.1

1992 151633 52298 72314 47.7 27021 17.8

1993 148057 42908 76749 51.8 28400 19.2

1994 104964 39736 48352 46.1 16876 16.1

1995 92375 40739 41822 45.3 9814 10.6

1996 80586 27249 45930 57.0 7407 9.2

1997 72426 23429 41735 57.6 7262 10.0

1998 63915 16023 40475 63.3 7417 11.6

1999 56366 12141 38165 67.7 6060 10.8

2000 43053 7574 31861 74.0 3618 8.4

2001
31551 5121 23652 75.0 2778 8.8

2002 34523 5490 27205 78.8 1828 5.3

2002 (Jan to
Nov)
31385 5017 24725 78.8 1643 5.2

2003(Jan to
39423 11105 26429 67.0 1889 4.8
Nov)
The control strategies adopted by the TamilNadu Public Health dept :

1) Malaria case detection is being carried out by house to house visit by collection of blood smears from
fever cases and giving treatment for those who are found positive for malaria.

2) Two rounds of residual insecticidal spray during transmission period using synthetic pyrethroid in
malaria endemic areas.

3) Passive surveillance and anti-larval work in urban.

4) Creating awareness among the community for their participation.

5) Whenever imported cases recorded , the same is cross notified by the concerned Medical Officer to the
respective Health Authorities of State for further remedial action at their end.

6) Mass and contact Blood survey are being carried out to prevent the occurrence of secondary cases.

7) Whenever necessary, focal spray is being carried out.

Active surveillance has become a problem all over the country in the recent past. In Tamil Nadu, IEC
activities have made a great impact on surveillance, that more number of cases are being identified under
passive surveillance than Active surveillance.

Geographical Information system (GIS) is being developed in Tamilnadu for carrying out epidemiological
mapping of the villages and for identifying vulnerable areas and seasonal pattern of disease outbreak.

www.tnhealth.org/dphpm/dbmal
Spraying techniques &
Strategies
 SPRAYING

Rapidly reduce populations of flying insect pests and vectors ( A D U L T S )

Exacting, periodical & continuous efforts vital for the success of operations

Space spray treatments Outdoor

No Residual Effects Hand-carried

Space spray equipment Thermal fog / Cold fog Vehicle-mounted

Aircraft application
Residual Spray Treatments Indoor

Residual Effects

Sound knowledge on the Vector breeding sites, lifespan, feeding habits, seasonal trends
(Ecology) essential for successful, cost-effective anti-adult spraying campaigns

Dose and residual effect are important considerations in determining the number of
spray rounds needed to protect a population during the whole, or only the peak, of the
transmission season.
 SPACE SPRAYS

A space spray – technically a fog (sometimes referred to as an aerosol) –

is a liquid insecticide dispersed into the air in the form of hundreds of millions
of tiny droplets

A very important characteristic of space sprays is the size of the droplets being
Dispersed, since this determines the time that they remain in suspension in the air and
their ability to penetrate into spaces that are not fully open.

Sprays, measured by their volume median diameter (VMD), are divided in accordance
with their droplet size into

Coarse sprays with a VMD over 400 µm

Fine sprays with a VMD between 100 and 400 µm

Mists with a VMD between 50 and 100 µm

Fogs or ultra-low volume (ULV) sprays with a VMD below 50 µm

WHO Classification of Pesticides by Hazard (WHO/UNEP/ILO, 1994)

Class 1a Extremely hazardous

Class 1b Highly hazardous

Class 2 Moderately hazardous

Class 3 Slightly hazardous

UH Unlikely to be hazardous
The technical products listed in Table 1 as recommended for malaria control belong to
class II, with the exception of malathion and pyrimiphos-methyl, which belong to class III.
In fact, all the formulations used, at the dilutions actually applied, belong to class III.
Techniques of blood
examinations
 MICROSCOPIC DIAGNOSIS

Conventional light microscopy is the established method for the laboratory confirmation
of malaria.
Microscopy offers many advantages

It is sensitive. It is informative. It is relatively inexpensive.

It is a general diagnostic technique that can be shared with other disease control
programmes, such as those against tuberculosis or sexually transmitted diseases.

It can provide a permanent record (the smears) of the diagnostic findings and be
subject to quality control.
Microscopy suffers from three main disadvantages

It is labour-intensive and time-consuming, normally requiring at least 60 minutes from

specimen collection to result.

It is exacting and depends absolutely on good techniques, reagents, microscopes and,

most importantly, well trained and well supervised technicians.

There are often long delays in providing the microscopy results to the clinician, so that
decisions on treatment are often taken without the benefit of the results.
Monitoring
 Monitoring and evaluation

Monitoring measures the implementation of the range of strategic activities

Monitoring, which is a continuous on-going activity allows step-by-step

recording of the progress made by health programmes

Evaluation measures the extent to which the objectives are being reached

Evaluation is concerned with impact indicators, which allow periodic

assessment of the way in which strategies and implemented activities reach
the planned objectives.
 Parameters of Malaria Surveillance

Confirmed cases during the Yr

API = X 1000
Population under surveillance
Index of
# of slides examined
ABER = X 100 Operational
Population under surveillance Efficiency

WHO – 1 % of Pop / month ; MPO – 10 % of Pop / Yr

Vector Indices :
Monthly blood examn rates Transmission season Non-transmission season
1. Human Blood Index (July – oct) 2. Sporozoite Rate
Active 2%
3. Mosq density ( # of mosq/man-hour-catch ) 1%
4. Inoculation Rates
Passive as % of new OPD cases 20 % 15 %
5. Man biting Rate ( biting density – bites/day/person )

Annual Falciparum Incidence pf proportion

Slide Positivity Rate

Spleen Rate
Slide Falciparum Rate Measure of Endemicity of Malaria
 Malaria Situation in Coimbatore district ( 1998 – 2002 )

Total Blood Radical

Year Population smears Total pf ABER SPR SFR API Death Rx
examined +ve given

1998 24,92,219 2,42,036 21 5 10.7 0.08 0.002 0.01 - 21

1999 25,14,963 2,42,984 125 54 9.51 0.05 0.02 0.05 - 91

2000 25,20,557 2,48,424 7 1 9.4 0.003 0.004 0.002 - 7

2001 25,44,766 2,43,099 10 - 9.6 0.004 - 0.003 - 10

2002 25,94,943 2,66,647 12 - 10.1 0.004 - 0.005 - 12

Source : District Malaria Officer, Coimbatore

National Surveillance Programme of Communicable Diseases

Communicable disease surveillance is important to develop

strategies for control and prevention of disease.

It helps to forecast epidemics outbreak.

The National Surveillance Programme of Communicable Diseases

was started as a Pilot scheme in 1997.

In Tamil Nadu, a National Surveillance Programme for

Communicable Diseases has been launched in Dharmapuri,
Villupuram, Coimbatore, Madurai and Salem.
 The Zonal Entomological Team

Zonal Entomological Teams attached to all the 72 Zones in the country

Carry out Entomological Surveys & Surveillance

Common Tasks are, to find out

1) Which Anopheline Sps are present

2) Which of them are Vectors of Malaria

3) The biology & behaviour of adult vector mosquitoes’ nesting habits (in/outdoors),
feeding habits, seasonal changes in the numbers biting humans, duration of adult life
and the areas in which they are found

4) Breeding Habits of the Mosquitoes

5) Which Vectors are Susceptible (or) Resistant to Insecticides

 Distribution of Pf % in India, 1986-97

Last Modified : 15 October, 2003

WHO Regional Office for South-East Asia
 Chloroquine Resistance Status Of India,1997

Last Modified : 15 October, 2003

WHO Regional Office for South-East Asia
 Dynamics of P.falciparum in India,1985-99

Last Modified : 15 October, 2003

WHO Regional Office for South-East Asia
 Status of P.falciparum Resistance to Anti Malarial Drugs In India,1986-95

Last Modified : 15 October, 2003

WHO Regional Office for South-East Asia
 Pf Resistance Status of Alternative Anti malarials in India,1997

Last Modified : 15 October, 2003

WHO Regional Office for South-East Asia
 Proposed RBM Core Indicators
I.IMPACT
Crude death rate among target groups.
Malaria death rate (probable and confirmed cases) among target groups.
% of probable and confirmed malaria deaths among patients with severe malaria admitted to a health facility.
Number of cases of severe malaria (probable and confirmed) among target groups.
Number of cases of uncomplicated malaria (probable and confirmed) among target groups.
Annual Parasite Incidence (API) among target groups (by region/according to the epidemiological situation).

II.MALARIA PREVENTION AND DISEASE MANAGEMENT

Prevention
% of countries having introduced pyrethroids for public health use and insecticide-treated materials in the list of
essential drugs and materials.
% of service providers (health personnel, CHW…) trained in techniques of treatment of nets and/or indoor
spraying according to the national policy.
% of households having at least one treated bednet.
% of pregnant women who have taken chemoprophylaxis or intermittent drug treatment, according to the national
drug policy.
% of antenatal clinic staff trained in preventive intermittent antimalarial treatment for pregnant women.
Prevention and control of epidemics
% of countries with epidemic prone areas/situation having a national preparedness plan of action for early
detection and control of epidemics.
% of malaria epidemics detected within two weeks of onset and properly controlled.

Early diagnosis and Prompt Treatment

% of health personnel involved in patient care trained in malaria case management and IMCI.
% of health facilities able to confirm malaria diagnosis according to national policy (micro s c o py, rapid test etc.).
% of patients hospitalised with a diagnosis of severe malaria and receiving correct antimalarial and supportive
treatment according to the national guidelines.
% of patients with uncomplicated malaria getting correct treatment at health facility and community levels
according to national guidelines within 24 hrs of onset of symptoms.
III.HEALTH SECTOR DEVELOPMENT
Health Policy
% of districts with plans of action reflecting national health policy.
% of districts using health information for planning.
% of countries having a policy of universal coverage for all with a basic package including relevant
malaria control activities.
Service Delivery
% of health facilities reporting no disruption of stock of antimalarial drugs, as specified in the
national drug policy, for more than one week during the previous three months.
Community Action
% of countries having national guidelines for malaria prevention and treatment including training of
all the informal health providers and recommendations for home treatment of febrile
illness/suspected malaria, recognition of the most frequent signs of danger for children, prevention
of malaria during pregnancy and use of insecticide treated materials.
% of villages/communities with at least one Community Health Worker trained in management of
fever and recognition of severe febrile illness.
% of mothers/caretakers able to recognise signs and symptoms of danger of a febrile disease in a
child < 5 years.
IV. INTERSECTORAL LINKAGES
% of countries with multisectoral and inter-agencies partnership established.
% of countries having established official linkages, including the elaboration of research agenda of
public health interest, between research institutions and Ministry of Health.
V. SUPPORT/PARTNERSHIP
% of countries with agreed national RBM budget met by donor funding.
% of countries with functional sentinel sites for surveillance efficacy of 1st and 2nd line antimalarial
drugs.
Number of antimalarial drugs which have progressed to the level of phase III trials.
 National Malaria Eradication Programme
Programme Achievements

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PARASITOLOGICAL DIAGNOSIS- SMEAR
PARASITOLOGICAL DIAGNOSIS- SMEAR