Research & Analysis - HMRI

25th April 2011 World Malaria day A Day to Act

Research & Analysis - HMRI 2

World Malaria Day 2011

World Malaria Day was established in May 2007 by the 60th
session of the World Health Assembly, the decision-making body of the World Health Organization.
The day was established to provide "education and understanding of malaria" and spread information on "year long intensified implementation of national malaria-control strategies, including community-based activities for malaria prevention and treatment in endemic areas."

Prior to the establishment of World Malaria Day, Africa Malaria Day was held on April 25. Africa Malaria Day began in 2001, one year after the historic Abuja Declaration was signed by 44 African malariaendemic countries at the African Summit on Malaria.
Research & Analysis - HMRI 3

World Malaria Day Themes

World Malaria day A Day to Act 25 April is a day to commemorate global efforts to control malaria. The theme of the fourth World Malaria Day Achieving Progress and Impact - heralds the international community's renewed efforts make progress towards zero malaria deaths by 2015.

World Malaria Day Themes

2008: Malaria - a disease without borders 2009: Counting malaria out 2010: Counting malaria out 2011: Achieving progress and impact
Research & Analysis - HMRI 4

History of Malaria:
The word malaria comes from 18th century Italian mala meaning "bad" and aria meaning "air". Most likely, the term was first used by Dr. Francisco Torti, Italy, when people thought the disease was caused by foul air in marshy areas. It was not until 1880 that scientists discovered that malaria was a parasitic disease which is transmitted by the anopheles mosquito. The mosquito infects the host with a one-cell parasite called plasmodium. Not long after they found out that Malaria is transmitted from human-to-human through the bite of the female mosquito, which needs blood for her eggs. According to Med lexicons medical dictionary, Malaria is "A disease caused by the presence of the sporozoan Plasmodium in human or other vertebrate erythrocytes, usually transmitted to humans by the bite of an infected female mosquito of the genus Anopheles that previously sucked blood from a person with malaria Approximately 40% of the total global population is at risk of Malaria infection. During the 20th century the disease was effectively eliminated in the majority of non-tropical countries. Today Malaria causes over 350 million human acute illnesses, as well as at least one million deaths annually. The anopheles mosquito exists in most tropical and many sub-tropical countries of Latin America and the Caribbean, Africa, Oceania, and Asia. According to WHO (World Health Organization), the majority of Malaria deaths occur among children in sub-Saharan Africa, killing an African child every 30 seconds. Not only is Malaria associated with poverty, it is also a cause of poverty and an important obstacle to economic development.
Research & Analysis - HMRI 5

Types of Malaria:
Plasmodium vivax (P. vivax) :- milder form of the disease, generally not fatal. However, infected people still need treatment because their untreated progress can also cause a host of health problems. This type has the widest geographic distribution globally. About 60% of infections in India are due to P. vivax. This parasite has a liver stage and can remain in the body for years without causing sickness. If the patient is not treated, the liver stage may re-activate and cause relapses malaria attacks - after months, or even years without symptoms. Plasmodium malaria (P. malaria) :- milder form of the disease, generally not fatal. However, the infected human still needs treatment because no treatment can also lead to a host of health problems. This type of parasite has been known to stay in the blood of some people for several decades. Plasmodium ovale (P. ovale) :- milder form of the disease, generally not fatal. However, the infected human still needs to be treated because it may progress and cause a host of health problems. This parasite has a liver stage and can remain in the body for years without causing sickness. If the patient is not treated, the liver stage may re-activate and cause relapses - malaria attacks - after months, or even years without symptoms. Plasmodium falciparum (P. faliparum) :- the most serious form of the disease. It is most common in Africa, especially sub-Saharan Africa. Current data indicates that cases are now being reported in areas of the world where this type was thought to have been eradicated. Plasmodium knowlesi (P. knowlesi) - causes malaria in macaques but can also infect humans
Research & Analysis - HMRI 6

Life cycle of Malaria:

Research & Analysis - HMRI

Control Strategy for Malaria

Research & Analysis - HMRI

How does a human become infected with Malaria?

The female Anopheles mosquito transmits the parasite to a human when it takes a blood meal - it bites the human in order to feed on blood. Only the female Anopheles mosquito can transmit malaria, and it must have been infected through a previous blood meal taken from an infected human. When the mosquito bites an infected person a minute quantity of the malaria (plasmodium) parasite in the blood is taken. Approximately one week later that same infected mosquito takes its next blood meal. The plasmodium parasites mix with the mosquito's saliva and are injected into the host (human being).

Human-to-human transmission of Malaria:As the parasite exists in human red blood cells, malaria can be passed on from one person to the next through organ transplant, shared use of needles/syringes, and blood transfusion. An infected mother may also pass malaria on to her baby during delivery (birth) - this is called 'congenital malaria'. You cannot catch Malaria by just sitting next to an infected person, or breathing in next to them when they cough and sneeze.
Research & Analysis - HMRI 9

Symptoms of Malaria:
In areas where Malaria is endemic people may have immunity or semi-immunity, and therefore have either no symptoms or few symptoms. The severity of the Malaria depends on three things: 1. The type of parasite. 2. Your immunity. 3. Whether you still have your spleen.

Early stage symptoms of Malaria :A high temperature (fever) Chills Headache Sweats Tiredness (fatigue) Nausea Vomiting

Symptoms may occur in cycles; each time they come they might do so at different levels of severity. How long symptoms last may also vary, depending on each cycle. However, at the beginning of the illness, symptoms may not follow this typical pattern.

Research & Analysis - HMRI

10

Other common symptoms:

Dry cough Back Pain Muscle ache Enlarged spleen

Very rare symptoms:

Impairment of brain function Impairment of spinal cord function Seizures (fits) Loss of consciousness People who are infected with the P. falciparum parasite and become ill generally have much more serious symptoms, which may become fatal.

Research & Analysis - HMRI

11

Incubation period of Malaria:

Incubation period refers to how long it takes from initial infection to the appearance of symptoms. This generally depends on the type of parasite: P. falciparum - 9 to 14 days P. vivax - 12 to 18 days P. ovale - 12 to 18 days P. malaria - 18 to 40 days However, incubation periods can vary from as little as 7 days, to several months for P. vivax and P. ovale. If you are taking medication to prevent infection (chemoprophylaxis) the incubation period is usually longer. It is important that a doctor eliminates other possible diseases or conditions which may have similar symptoms to Malaria. These include: Cold, flu, and some other viral infections Rickets (tick bite diseases) Gastroenteritis Hepatitis Typhoid fever Meningitis, and other bacterial infections Non-malarial parasitic infections
Research & Analysis - HMRI

12

Treatments for Malaria:

According to WHO, in endemic areas treatment should start within 24 hours after the first symptoms appear? A person with uncomplicated malaria can be treated as an outpatient, while those with severe malaria need to be hospitalized. In non-endemic areas WHO recommend that patients with uncomplicated or severe malaria should be kept under clinical observation if possible. A person who is infected with P. falciparum and has severe symptoms, but cannot take oral medications, should be given treatment intravenously. In some parts of the world anti-malarial drugs may be presented as suppositories (not USA). Some drugs used for treating malaria are available as continuous intravenous infusions. According to the CDC (Centers for Disease Control and Prevention), the following drugs are commonly used for treating malaria: Artemisia derivatives (not licensed in the USA, common elsewhere) Atovaquone-proguanil (Malarone) Chloroquine Doxycycline Mefloquine (Lariam) Quinine Sulfadoxine-pyrimethamine (Fansidar)

Also, primaquine is effective against hypnozoites (the dormant parasite liver forms) and prevents recurrences (relapses). Primaquine should not be given to expectant mothers, or patients who are deficient in glucose-6-phosphate dehydrogenase G6PD. A screening test excludes G6PD deficiency.
Research & Analysis - HMRI 13

Preventing malaria:
Avoiding mosquito bites - this can be achieved in various ways: Vector control - this means trying to reduce contacts between people and vectors of disease. A vector is an organism, such as a mosquito, or tick that carries disease-causing microorganisms from one host to another. Controlling mosquitoes can significantly reduce malaria incidence, as well as other mosquito-borne diseases. Getting rid of malaria in a region does not necessarily mean eliminating all the Anopheles mosquitoes that might transmit the disease. Anopheles mosquitoes still exist in North America and Europe - however, the parasite is not longer there. Improvements in people's standard of living, such as the installation of screened windows, air conditioning, together with strategies to reduce vector populations are very effective, and have led to the total elimination of malaria without completely getting rid of the mosquito. ITNs (Insecticide-Treated Bed Nets) ITNs can reduce the incidence of malarial infection, and also mortality, in an endemic area considerably. Untreated nets are significantly less effective because the mosquito can bite the host through the net if the person is standing next to it. Also, even tiny holes in the netting are usually enough for the mosquito to find a way in. Nets that have been treated with insecticide are much more protective. Not only does the insecticide kill the mosquito and other insects, it is also a repellent - fewer mosquitoes are likely to enter the room(s). If ITNs are widely used in an endemic area the mosquito population may drop dramatically, as will their life spans. This further protects those in that area who have no ITNs. Preventing disease - using anti-malarial medications. These drugs do not prevent the parasite from entering your bloodstream, but they stop it from developing in the blood. This type of prevention is also known as 'suppression'.
Research & Analysis - HMRI 14

Classification of Malaria Vaccines :

Stage of Plasmodium Pre-erythnocytic Antigens Irradiated sporozoites, Circum Sporozoite Protein (CSP) or peptides, Liver stage Antigens -1 (LSA-1) Salient features Stage/species specific; antibody blocks infection of liver; large immunizing dose required; can abort an infection

Merozoite and Erythrocytes

Erythrocyte Binding Antigen (EBA-175), Merozoite Surface Antigen 1&2 (MSA-1&2); Ring Infected Specific for species and stage; Cannot abort an Erythrocyte Surface Antigen (RESA); Serine Repeat infection; Prevents invasion of erythrocytes, thus Antigen (SERA); Rhoptry Associated Protein (RAP); reducing severity of infection Histidine Rich Protein (HRP); Apical Membrane Antigen-1 (APM-1) Prevents infection of mosquitoes; antibody to this antigen prevents either fertilization or maturation of gametocytes, zygotes or ookinetes; is of use in endemic areas but not suited for travelers; antibody blocks transmission cycle

Gametocytes & gametes

Pfs 25, 48/45k, Pfs 230

Based on incorporation of antigens from Combined vaccine SPf 66 (based on pre-erythrocytic and asexual blood different stages into one vaccine to produce an (cocktail) stage proteins of Pf) immune response, blocking all stages of the parasite development

Research & Analysis - HMRI

15

Epidemiology:
Malaria afflicts 36% of the world population i.e. 2020 million in 107 countries and territories situated in the tropical and subtropical regions. In the South East Asian Region of WHO, out of about 1.4 billion people living in 11 countries, 1.2 billion (85.7%) are exposed to the risk of malaria and most of whom live in India (Kondrachine 1992). Of the 2.5 million reported cases in the South East Asia, India alone contributes about 70% of the total cases. Currently, 80.5% of the 109 billion population of India lives in malaria risk areas. of this, 4.2%, 32.5% and 43.8% live in areas of high, moderate and low risk to malaria respectively (http://www.searo.who.int/). The Global Malaria Eradication Programme of WHO launched in the 1950s was a huge success in India as the incidence declined from estimated 75 million cases and 8, 00,000 deaths in 1947 to just 49,151 cases. In 1996, due to outbreaks and epidemics 30, 35,588 cases and 2803 deaths were reported. In 2006, the reported number of cases was 16,69,333 (API: 1.57; SPR: 1.63% and Pf:45.3%). WHO estimated 19500 to 20000 deaths per annum in India against reported figures of 209, 268, 353 and 406 deaths respectively from 1988-1991 (NMEP 1992).
Research & Analysis - HMRI 16

National Anti Malaria Programme

Selection of PHC: API >2 for last 3 yrs, P.f . > 30%, If 25% of population of PHC is Tribal. Reported deaths of Malaria.

National Malaria Control Programme-1953 National Malaria Eradication Programme 1958 Modified Plan of Action NMEPor Tribal Malaria Enhanced Malaria Control Project (EMCP) 1977 Malaria Action Plan 1995
action Plan was introduced in 1997 by the National Anti Malaria Programme now named as National Vector Borne Disease Control Programme, NVBDCP) in seven North Eastern states and tribal area of peninsular states of India with World Bank assistance (Dhingra et al., 1997).

National Anti Malaria Programme - 1999 (Enhanced malaria control project -1997 2005 with world bank fund )
Research & Analysis - HMRI 17

Enhanced malaria control project

Enhanced malaria control project 1997 2005 with World bank fund
Strategies to control
Early case detection and treatment Reducing Man mosquito contact by Selective vector control Personal protection measures Use of larvivorous fish

Planning and rapid response to control epidemic Strengthening of institutional & Managerial capabilities

Research & Analysis - HMRI

18

MALARIA SITUATION IN INDIA

Malaria has been a problem in India for centuries. Details of this disease can be found even in the ancient Indian medical literature like the

Charaka Samhita
In the 1930s there was no aspect of life in the country that was not affected by malaria. The economic loss due to the loss of man-days due to malaria was estimated to be at Rs. 10,000 million per year in 1935

The annual incidence of malaria was estimated at around 75 million cases in 1953 with
about 8 lakhs deaths annually the Govt. of India had launched the National Malaria Control Programme in April 1953. The programme proved highly successful and within five years the incidence of malaria

dropped to 2 million.
By 1961 the incidence dropped to a mere 50,000 cases a year.

Research & Analysis - HMRI

19

HMRI Services : MALARIA

Research & Analysis HMRI-104

World Malaria Day 2011

104 Advice Services -Malaria

Malria (7,293)

Total Services (2,40,72,671)

(0.03%)

21

Health Issues Related To Malaria

Distribution of Month wise Calls
400 350 300 250 200 150 100 50 0

Research & Analysis - HMRI

22

Health World Malaria Day 2011 Issues Related To Malaria

Avg . Calls Per Day
14 12 10 8 6 4 2 0 11 10

Gender
14% 86%
Males Females

Social Status
17% 21% 46% 16%
Not Given Other Caste Scheduled Caste Scheduled Tribes

16%

1%

Age Group
<16 AGE 16-25 AGE 26-40 AGE 41-60 AGE >60

District wise Share

MAHABUBNAGAR NALGONDA KURNOOL ANANTAPUR WARANGAL KARIMNAGAR ADILABAD KADAPA RANGAREDDY NIZAMABAD MEDAK GUNTUR PRAKASAM KHAMMAM G.HYDERABAD CHITTOOR VISAKHAPATNAM NELLORE VIZIANAGARAM SRIKAKULAM KRISHNA EAST GODAVARI WEST GODAVARI

3%
7% 7% 6% 6% 6% 6% 5% 5% 5% 5% 5%

14.4%

66%

4% 4% 4% 4% 3% 3% 3% 3% 3% 2% 2% 2%

Research & Analysis HMRI-104

Malaria _ Demographic Profiles (Per 10,000 Calls) World Malaria Day 2011
Calls
10 8
6 9 8 9

Gender
18 14
5 5 5

Social Status
25 15

19

6
4 2 0
1

5 5 5

6 6 4 4 4 5 4 5 4 3 4 4 3 3 4 3 3 3 2 3 3 2 3 2 3 3 3 3 3 3 3

16

Females 54 District 43

Males

Not Given

Other Caste

Scheduled Scheduled Caste Tribes

Age Group
34

WEST GODAVARI SRIKAKULAM VIZIANAGARAM EAST GODAVARI VISAKHAPATNAM KRISHNA KHAMMAM CHITTOOR NELLORE GUNTUR G.HYDERABAD PRAKASAM KADAPA ADILABAD MEDAK NIZAMABAD RANGAREDDY WARANGAL KARIMNAGAR KURNOOL ANANTAPUR NALGONDA MAHABUBNAGAR

17 17 14 13

35 18

12
11

9
9

8
8 6 5 5 5 4 4 4 4 3 3 3 3 2

<16

16-25

26-40

41-60

>60

Observations: Out of 1Lakh Female Calls 7 calls belongs to this problem. Out of 1Lakh ST Calls 7 Calls belongs to this problem Among the calls received from Krishna, More calls belongs to this problem.

Research & Analysis HMRI-104

World Malaria Day 2011

MALARIA REPORT _ IDSP

Research & Analysis HMRI-104

World Malaria Day 2011

HMRI _IDSP Project

IDSP (Integrated Disease Surveillance Program): Classification of Surveillance in IDSP:

Syndrome Surveillance: Diagnosis made on the basis clinical pattern by paramedical personnel and members of community Presumptive Surveillance: Diagnosis is made in typical history and clinical examination by medical officers Confirmed/Lab Surveillance: Clinical diagnosis by medical officer and or positive laboratory identification

All the 23 districts in Andhra Pradesh are reporting the data daily. Till date (31-Mar11), 2688 diagnostic labs were registered under IDSP HMRI. Out of these labs, 42% (1129) were Govt. Labs and 58% (1559) were Pvt. Labs. In Lab Surveillance, 27 Lab tests were under observation.
Research & Analysis - HMRI
26

Summary

World Malaria positive cases were recorded in Andhra Pradesh as per the IDSP Lab Surveillance reports, HMRI. (Period : ~30 months) 3,33,166 Malaria Day 2011
Among them 1,70,941 were recorded as Malaria Plasmodium Falciparum positive cases and 1,62,225 were recorded as Malaria Plasmodium Vivax positive cases. Over 2700 (pvt/govt) labs reporting the positive cases of malaria every day. It is observed that the positive cases were high in the month of August10. Monthly summary of Falciparum and Vivax were given in the following Line graph:
20000
15000
13539 12838 12066 10244
15808 15255 13755 13029 10996 10592 8467 8298 7733 7609 7493 7398

Falciparu m Vivax

18387 17553 13907

14389 12448 11457 10944 9802 9302

49% 51%

10000 5000
0

8283 7842 7668 7135 7037

2700 2200 1700 1200

Oct '08 Nov '08 Dec '08 Jan'09 Feb'09 Mar'09 Apr'09 May'09 Jun'09 Jul'09 Aug'09 Sep'09 Oct'09 Nov'09 Dec'09 Jan'10 Feb'10 Mar'10 Apr'10 May'10 Jun'10 Jul'10 Aug'10 Sept'10 Oct'10 Novem'10 Decem'10 Jan'11 Feb'11 Mar'11

Falciparum

Vivax

Govt.

Pvt.

Total

Labs
700

Research & Analysis Research & Analysis -- HMRI HMRI

2.8

Malaria Positive Cases - per Laboratory per Week

4-Aug-08 to 10-Aug-08

2.3

Max. # of cases per lab per week

2.3

1.8 Q3 1.3

1.4
Median

1.0
0.8 Q1

0.7
0.3
Nov-07 Feb-08 Jun-08 Sep-08 Dec-08 Mar-09 Jul-09

0.4
Oct-09 Jan-10 May-10

10-Jan-10 to 17-Jan-10

Min. # of cases per lab per week

Nov-10 Feb-11 Jun-11

Aug-10

Trend can be observed from the graph (The data is from 24-Mar-08 to 31-Mar-11 From the last week of Jun08, the # of positive cases per lab was started increasing. In Aug 1st week its reached the peak and started declining. The minimum # of positive cases per lab was occurred in 2nd week of Jan10 and the positive cases started increasing.

Research & Analysis - HMRI

Malaria positive cases Weekly Totals

4500 PF PV 3500 Malaria 4000

3000

2500

2000

1500

1000

500

0 Week1 Week3 Week1 Week3 Week5 Week2 Week4 Week2 Week4 Week1 Week3 Week1 Week3 Week1 Week3 Week5 Week2 Week4 Week2 Week4 Week2 Week4 Week1 Week3 Week1 Week3 Week1 Week3 Week5 Week2 Week4 Week2 Week4 Week2 Week4 Week1 Week3 Week1 Week3 Week1 Week3 Week1 Week3 Week1 Week3 Week5 Week2 Week4 Week2 Week4 Week2 Week4 Week1 Week3 Week1 Week3 Week1 Week3 Week1 Week3 Week5 Week2 Week4 Week2 Week4 Week2 Week4 Week2 Week4 Week2 Week4 Week2 Week4 Week2 Week4 Week2 Week4 Apr'08May'08Jun'08 Jul'08 Aug'08 Sep'08Oct'08Nov'08 ec'08Jan'09Feb'09 ar'09Apr'09May'09un'09 Jul'09 Aug'09 D M J Sep'09 Oct'09 Nov'09Dec'09Jan'10 Feb'10Mar'10Apr'10 ay'10un'10 Jul'10 Aug'10 M J Sep'10 Oct'10 Nov'10 ec'10 D Jan'11 Feb'11Mar'11

From Apr10 on wards the percentage share of Falciparum positive cases decreased. More than 3,500 malaria positive cases were recorded in the Aug 2010. and in Aug 2009. Again in the year 2009, the weekly positive cases were more than 3500 in the last week of Aug. and 2 nd 3rd and 4th Weeks of Sep and 4th week of Oct. Again in the year 2010, the weekly positive cases were more than 3500 in the Jul10 2 nd week to Sep10 4th week. Highest # of positive cases were recorded in 4th week of Aug10. Research & Analysis HMRI Research & Analysis--HMRI

Malaria Cases Monthly District wise

3500 3000 2500 2000 1500 1000 500 0

Coastal Andhra _ Top

East Godavari Krishna Srikakulam Visakhapatnam

Vizianagaram

800 700 600 500 400 300 200 100 0

Coastal Andhra_ Bottom

Guntur Nellore Prakasam West Godavari

Research & Analysis - HMRI

Malaria Cases Monthly District wise

2000 1800 1600 1400 1200 1000 800 600 400 200 0 Ananthapur Chittoor Kadapa Kurnool

Rayalaseema

Research & Analysis - HMRI

Malaria Cases Monthly District wise

3500 3000 2500 2000 1500 1000 500 0

Telangana _ Top
Adilabad Mahabubnagar Khammam

800 700

Telangana _ Bottom

600
500 400 300 200 100 0

GHMC Karimnagar Medak Nalgonda Nizamabad Ranga Reddy Warangal

Research & Analysis - HMRI

Region wise long term trend Malaria Positive Cases per Laboratory per Week
3.0

Andhra

Rayalaseema

Telangana

2.5

2.0

1.5

1.0

0.5

0.0
Week5 Week2
Week3 Week2 Week3 Week2 Week1 Week4 Week2 Week1 Week4 Week3 Week1 Week4 Week3 Week2 Week5 Week3 Week2 Week1 Week4 Week3 Week2 Week5 Week3 Week2 Week1 Week4 Week1 Week4 Week3 Week2 Week5 Week3 Week2 Week1 Week4 Week3 Week2 Week1 Week4 Week3 Week2 Week5

Oct'08 Nov'08 Dec'08 Jan'09Feb'09 Mar'09 Apr'09 ay'09 M Jun'09Jul'09Aug'09 Sep'09 ct'09 ov'09 O N Dec'09 Jan'10eb'10 F Mar'10 Apr'10 May'10 Jun'10Jul'10Aug'10 Sep'10 ct'10 ov'10 O N Dec'10an'11eb'11 J F Mar'11

Research & Analysis - HMRI

THANK YOU

Research & Analysis Research & Analysis -- HMRI HMRI