Malaria Epidemiology, Surveillance and Prevention

Guided by Dr. S. B. Bansal Dr. Amit Gharia Group 22 Sunil Chawrasia Sushila Chouhan Susheel Soni Shoubhik Banerjee Surrendra Singh Sunil Desai

INTRODUCTION
A protozoal disease. Caused by infection of parasite of genus plasmodium

Transmitted to man by certain species of infected

Anopheles Mosquito Typical attack- cold stage hot stage sweating stage Clinical Feature depends on -sp. Of parasite -pt. state of immunity -intensity of infection -presence of concomitant condition

YEAR

CASES (million)

Deaths

2005
2006

1.82
1.76

963
1703

2007 (up to November)

1.29

996

BURDEN OF MALARIA IN INDIA

STATES/UTs N.E State Jharkhand Chhattisgarh POPULATION % MALARIA % Pf % 3.79 2.60 2.16 12.55 11.36 6.59 18.31 6.23 10.29 Death % 55.08 0.27 0.13

Orissa
TOTAL

3.61
12.16

22.52
53.02

43.34
78.60

17.01
72.49

PREVALENT MAJOR EPIDEMOLOGICAL TYPES OF MALARIA

Tribal malaria Rural malaria

Urban malaria
Malaria in projected areas Border malaria

TRIBAL MALARIA
In tribal areas of Andhra Pradesh, Madhya

Pradesh, Chhattisgarh, Gujarat, Maharashtra, Bihar, Jharkhand, Rajasthan & North eastern states Contributes to about 50% cases of P.falciparum High risk to infants, young children ,pregnant women Factor responsible:-Limited health infrastructure Lack of drugs at village level

RURAL MALARIA
Irrigated areas of arid and semiarid areas of Haryana, Punjab, West U.P, parts of M.P & Rajasthan, plains of Orissa, Andhra Pradesh, Tamil Nadu Malaria is moderate to low endemicity An.culicifacies is the main vector P.vivax is predominant during lean period & P.falciparum during periodic exacerbation In this areas health infrastructure is moderately developed

URBAN MALARIA
In major cities:-Delhi ,Mumbai ,Chennai, Kolkata,

Hyderabad, Bangalore , Ahmadabad, Bhopal, Jaipur, Lucknow, Chandigarh, Kanpur. An.stephansi is main vector P.vivax is predominant &P.falciparum in focal transmission

MALARIA IN PROJECTED AREAS

Areas where construction & development activities are

taken up and temporary aggregation of labourers take place. This bring different strains of malaria parasite in the non immune population. More than one vector is usually involved

BORDER MALARIA
These are high malaria transmission belts along the

international and national border. Problem in regard to malaria control due to mixing of population and poor administrative control.

EPIDEMIOLOGICAL DETERMINANTS
1.
2. 3.

AGENT FACTOR HOST FACTOR ENVIROMENTAL FACTOR a. Climate b. Vector

Agent 2. Reservoir of infection 3. Period of communicability

1.

AGENT
4 species of plasmodium
P.vivax :-70% cases in India P.falciparum :-25-30% cases P.malariae :-< 1% cases P.ovale :- very rare (Tumkur & Hassan district in Karnataka

LIFE CYCLE OF AGENT

2 developmental cycles
1. Human cycle (asexual phase) 2. Mosquito cycle (sexual phase)

-Definitive host :- Mosquito -Intermediate host :- Man

ASEXUAL CYCLE /ENDOGENOUS/SCHIZOGNY

Infective stage to man :--sporozoite 4 phases;1. 2. 3. 4.

Pre-erythrocytic phase Erythrocytic phase Gamatogony Exo-erythocyic phase

PRE-ERYTHROCYTIC PHASE
Sporozoite infect liver cell forms hepatic schizonts

merozoite
In P.falciparum-1 sporozoite-40,000 merozoite Others -1 sporozoite -2,000-15,000 merozoite

Merozoite

specific receptors of RBC

Ring tropozoite

schizonts

Cycle is repeated again and again. Duration of erythrocytic cycle P .malariae- 72.hours others- 48 hours

immature schizonts

mature tropozoite

-In all species of malaria some of erythrocytic forms do not divide but forms male & female gamatocyte. -This are sexual form of parasite. -They are infective form to mosquito. Ring tropozoite microgamatocyte macrogamatocyte infective to mosquito

Infective form gametocyte stage Microgametocyte exflagellation Macrogametocyte

4-8 microgamete

macrogamete zygote ookinete oocyst

sporozoite -Time period from gametocyte to sporozoite formation 10-20 days(Extrinsic incubation period)

Resemble Pre-erythrocytic cycle.

Some sporozoite does not undergo multiplication but

enter a stage of resting (dormant) phase. These resting parasite are called HYPNOZOITE. After a period they get activated and release merozoite. Cause relapse of fever. Not found in P .falciparum , so no relapse in falciparum malaria.

RESERVIOR OF INFECTION

Animal reservoir ;- chimpanzees in tropical Africa Human reservoir ;- one who harbours the sexual form of parasite

1. 2. 3. 4.

Condition for reservoir Person must harbour both sex of gametocyte in blood. Gametocyte must be mature Gametocyte must be viable Gametocyte must be present in sufficient density to infect mosquito at least ;-12 /cu.mm of blood

PERIOD OF COMMUNICABILTY
Malaria is communicable as long as mature viable

gametocyte exist in circulating blood in sufficient density to infect mosquito.

RELAPSE
In P.vivax & P.ovale infection the parasite may survive

for long periods in dormant exo-erythrocytic stage as hypnozoites in liver cells.

Reactivation of hypnozoites leads to initiation of fresh

erythrocytic cycle and new attack of fever.

Usually from 24 weeks to 5 years after the primary

attack . P vivax & ovale - 2-3 years

RECRUDESCENCE
After a number of paroxyms the primary attack subsides due to partial immunity. The parasite however is not eliminated but persist in some erythrocyte though the level of parasitaemia is below the threshold level. Erythrocytic schizogony continues in body at low level and gradually the number of parasite build up to cross threshold level This causes new attack after a period of latency. Occurs in P.falciparum & P.malariae

HOST FACTORS
1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

Age Sex Race Pregnancy Socio-economic development Housing Population mobility Occupation Human habits Immunity

1.

AGE Affects all age group New born infants have considerable resistance to infection with falciparum due to high concentration of foetal Hb during few months of life

2.

SEX Male > Female Males are more exposed to out door activity Females in India are better clothed

3. RACE Sickle cell trait ;- mild illness with falciparum Duffy negative ;-resistant to vivax infection

4. PREGNANCY Increase the risk of malaria May cause intrauterine death of foetus Cause premature labour or abortion

5. POPULATION MOBILITY Labours connected with engineering ,irrigation ,agricultural & other project and migration of nomads may import malaria parasite in their blood & reintroduce malaria in areas where malaria have been controlled or eliminated.
6.OCCUPATION Malaria is predominantly a rural disease and is closely related to agriculture practices

7. SOCIO ECONOMIC DEVELOPMENT A disease of low socio economic areas Malaria disappeared from developed country as a result of socio economic development. 8. HOUSING The ill ventilated and ill-lighted houses provide ideal in door resting place for mosquito So, proper housing is major control measure

9. HUMAN HABITS
Sleeping outside doors. Nomadism. Refusal to accept spraying of housing. Replastering of walls after spraying . Not using measures of personal protection. All the above factors increase the risk of malaria.

10. IMMUNITY

Immunity is accquired after repeated exposure for several years. In endemic areas a state of collective immunity is established slowly. So, infants and travellers from non-endemic areas are main suffers. Immune mother transfer IgG antibody that infants for 3-5 months. Active immunity is species specific. Immunity usually declines after leaving endemic areas. Both humoral &cellular factors play a role in protection

ENVIRONMENTAL FACTORS
It is divided into parts:-

a. Climate b. Vector A. Climate :- This include 1. Season 2. Temperature 3. Humidity 4. Rainfall 5. Altitude 6. Man made malaria

CLIMATE
The factors are

1. Season:- Malaria is a seasonal disease. -In most parts of India the maximum prevalence is from July to November. 2. Temperature:-The optimum temperature for development of malaria parasite in the insect vector is between 20-30 deg.C. - If the temp. higher than 30 deg.C are lethal to the parasite.
- The parasite ceases to undergo development in the mosquito if the mean temperature is below 16 deg.C.

3.Humidity: -Direct effect on the life of the mosquito. -It has no effect on the parasite. -A relative humidity of 60% is necessary for mosquitoes to live their normal lifespan. -When the relative humidity is high, mosquitoes are more active & feed more voraciously. -If the humidity is low mosquitoes do not live long.
4.Rainfall:-It provides opportunities for the breeding of mosquitoes and may give rise to epidemics of malaria. -It also increases humidity which is necessary for the survival of mosquitoes.

5.Altitude:High altitudes unfavourable for mosquitoes.

6.Man Made Malaria:These are:-Burrow Pits -Garden Pools -Irrigation Channels -Engineering Projects

VECTOR
Out of 51 species of Anopheles only 9 causes malaria -An. Culicifacies:- rural areas -An. Stephensi:- urban areas -An. Fluvitalis:- Hills & Foot hills areas -An. Minimus:- Hills & Foot hills areas -An. Philippinensis:- Planes of West Bengal & North East India -An. Sundaic:- Eastern costal areas -An. Annularis:- Andman & Nicobar -An. Varuna:- Hills & Foot hills of eastern ghat -An. B balabacensis:- Forest area of North East India

IMPORTANT VECTOR FACTORS 1.Density 2.Life span 3.Breeding habits 4.Resting habits 5.Resistant to insecticide 6.Choice of host 7.Biting time 8.Vectoral capacity

1.Density- Critical density:- density below which the effective transmission not occur. -It is vary from species to species. -High density required- An. culicifacies - Low density required- An. fluviatilis 2.Life SpanIt is the key factor in the transmission of malaria. -The vector mosquitoes must live at least 10-12days after an infective blood meal. -The strategy in malaria eradication is to shorten the life span of mosquitoes to<10 days by insecticides.

3.Breeding habits:It varies from species to species. -Moving water An. Fluvitalis -Brackish water - An.Sundaicus -Wells & overhead tanks-An.stephensi
It is required for conducting anti-larval operation. 4.Resting habits:Endophily-those mosquito resting indoor. Exophily- those mosquito resting outdoor. These forms the basis the of Anti-adult measures.

5.Resistance to insecticides:It is necessary for the choice of insecticide to be used.

6.Choice of host:Some mosquitoes prefer human blood, some animal blood & some show great variation in their feeding habits.

7.Biting time:Majority of Indian mosquitoes bite after evening throughout the night. 8.Vectoral capacity:It refers to the combine effect of :-Density of vector population -Susceptibility to infection -Probability to feed on man -Life span

MODE OF TRANSMISSION
Two typesA)Vectoral B)Non-Vectoral
A. Vectoral Transmission-

Malaria is transmitted by certain infected species of An.mosquitoes.

Important factors for transmission are-Adequate life span -Preference to human host -Tendency to reside around human population -Should be in sufficient density to make transmission chain

-Environmental factors like temp., humidity, rainfall

B) Non-Vectoral Transmission-Blood transfusion -Sharing infected needles -Transplacental or vertical

INCUBATION PERIOD
This is the length of time between the infective mosquito bite and the first appearance of clinical sign of which fever is most common. P.Falciparum-9-14 days P.Vivax- 12-17 days P.Ovale- 16-18 days P.Malariae- 18-40 days

PRE-PATENT INCUBATION PERIOD:It is the time between the inoculation of parasite into human being & appearance of 1st parasite in blood . PROTRACTED INCUBATION PERIOD:In some strains of P.vivax a period of latency is observed when incubation period is prolonged to 8 -10 months

CLINICAL FEATURES
-The primary fever corresponds to the development of parasites in the RBC. -The peaks of fever coincide with the release of merozoites into the blood stream. The typical attacks comprises three stages1.Cold stage- The onset with lassitude, headache, nausea, chilly sensation associated with rigors. -This stage lasts for about an hour.

2.Hot stagePatient feels burning hot & casts off his clothes. The skin is hot and dry to touch. Headache is intense but nausea diminishes. This stage lasts for 2-6 hours.

3.Sweating stageFever comes down with profuse sweating. Temp. drops rapidly to normal & skin become cool & moist. This stage lasts for 2-4 hours.

COMPLICATIONS
1.P.Falciparum-Cerebral malaria -Acute renal failure -Liver damage -GIT symptoms
2.P.Vivex, Ovale & Malariae-Anaemia -Splenomegaly -Herpes

WHAT IS SURVEILLANCE ? Surveillance means to watch over with great attention ,authority & often with suspicion. DEFINITION The surveillance can be defined as continuous scrutiny of the factor that determine the occurrence and distribution of disease and other condition of ill health.

OBJECTIVE OF SURVEILLANCE
1.

2. 3.

To provide information regarding new and changing trends in the health status of a population. To provide feedback regarding on going control program. To provide timely warning of health disaster.
The ultimate objective of surveillance is prevention.

WHY NEED SURVEILANCE

The surveillance is needed for :-

1.Effective control and prevention. 2.For collection, analysis, interpretation & distribution of relevant data for action. The main purpose of surveillance is to detect changes in trends and distribution in order to initiate investigative and control measure.

SURVEILLANCE OF MALARIA- IN MPO

The Modified plan of operation (MPO) under the NMEP came into force from 1st April 1977. Surveillance is an integral part of MPO. For better control and stabilise the malaria situation in the country, endemic area are reclassified again according to API. - area with API >2 -area with API <2

Before this classification the area were divided by spleen rate >10 or <10.

SURVEILLANCE IN MALARIA
Surveillance of malaria is aimed at case detection

through laboratory services and providing facilities for proper treatment. Collection and examination of blood smear is a key element in MPO. If all the detected cases are given radical treatment, it will lead to depletion of the human reservoir.

TYPES OF MALARIA SURVEILLANCE

It is of two types Active surveillance Passive surveillance

ACTIVE SURVEILLANCE
Carried by-surveillance workers (or MPW )

Norms -

-For normal area 10,000 population / 2000 houses -1 surv.worker /MPW For 4 surv. Worker/MPW -1surv. Inspecter (health assistant) -For terrain area 8000 population-1 surv. Worker/MPW For 4 surv.workers /MPW -1surv. Inspecter(health assistant)

FORTNIGHTLY DOMICILIARY VISITS

The surv.worker/MPW will visit each house in his area once a fortnight

& enquire whether1.there is a fever case in house . 2.there was a fever case in the house between his previous and present visit.

visit

If the answer to either of these question is yes

-MPW collects a blood film (thick & thin) on same slide & presumptive treatment . -Make entries in house card about his visit.

-Dispatch the blood slides at least twice a week to the unit

laboratory (PHC) for microscopic examination. -He also collects blood slide from the sub-centre and FTD & send to laboratory (PHC)

-Take report from laboratory (at least twice a week). -If report is positive for malaria parasite .

-MPW returns to patient and administer a full course of radical treatment for malaria.

PASSIVE SURVEILLANCE
The search for malaria cases by local agencies such as PHC ,sub-centre ,

hospitals , dispensaries and local medical practioners.

In this patients voluntary report to the health agencies. Those cases that escape by active search (MPW) are caught by these

agencies.

They collect blood smear from all fever cases and also from those with

history of recent fever and give presumptive dose of malaria. laboratory (PHC).

These collected slides are ,collected by MPW and send to unit

In next turn to laboratory the MPW collects report, if the report is

positive ,he goes to patient and give radical treatment.

PARAMETERS FOR MALARIA SURVEILLANCE

By definition surveillance also implys the continuing scrutiny of all aspects of occurrence and spread of disease that are pertinent to effective control .
So ,in these also include the systematic collection of data and evaluation of field investigations etc.

For epidemiological surveillance of malaria the following parameters are used -

IN PRE-ERADICATION ERA
Spleen rate- defined as %of children between 2-10 year of age showing enlarged spleen. -it is a measure of endemicity of malaria in a community. 2. Infant parasite rate-% of infant showing malarial parasite in their blood film. -Most sensitive index of recent transmission of malaria in locality. 3.Parasite rate -% of children between 2-10 years showing malaria parasite in their blood films 4.Average enlarged spleen 5.Proportional case rate
1.

ERADICATION ERA
1.Annual parasite incidence (API) API= confirmed cases during 1 year 1000 population under surveillance -It is based on active & passive surveillance. -It measure malaria incidence in a community 2. Annual blood examination rate (ABER) ABER- No. of slides examined 100 population -It is an index of operational efficiency. 3.Annual falciparum incidence (AFI) 4.Slide positivity rate (SPR) 5.Slide falciparum rate (SFR)

 Reduce vector mosquito population Repel the vector mosquitoes Form a barrier between vector and

potential host (personal protection) Reduce the lifespan of vector mosquitoes Reduce the lifespan of potentially infected vector mosquitoes

 Epidemiological situation and risk factors Appropriate for controlling the specific vector species, given its breeding , flight and resting, behavior Simple to understand and apply Affordable and based on locally available resources (equipment , consumable supplies,

and technical skills) Acceptable and compatible with local customs and practices (postemergency phase) Safe for the user and the environment

VECTOR CONTROL CHALLENGES

Resources and infrastructure Insecticide resistance Inadequate surveillance Mosquito species complexes

ANTI-LARVAL MEASURES o SOURCE REDUCTION

o CHEMICAL CONTROL

BIOLOGICAL CONTROL
ANTI -ADULT MEASURES oRESIDUAL SPRAYS oSPACE SPRAYS oGENETIC CONTROL

PROTECTION AGAINST MOSQUITO

BITES

oMOSQUITO NET
oSCREENING oREPELLENTS

SOURCE REDUCTION :COMPRISES FILLING DITCHES, AREAS, PITS, LOW LYING AREAS, STREAMLINING, CHANNELISING, DESILTING, DEWEEDING, TRIMMING OF DRAINS, WATER DISPOSAL AND SANITATION, EMPTY WATER CONTAINER ONCE IN A WEEK, ETC.

CHEMICAL CONTROL :COMMONLY USED LARVICIDES ARE I. Mineral oils II. Paris green III. Synthetic insecticides Toxicants employed as larvicides Toxicant Doses (g/ha) Abate 56-112 Malathion 224-672 Fenthion 22-112 Chloropyrifos 11-16

Biological Control :Bilogical control of mosquito breeding through biological agents specially larvivorous fish and by larvicides. The best known are:GAMBUSIA AFFINIS LEBISTER RETICULATUS

2.ANTI-ADULT MEASURES
INDOOR RESIDUAL SPRAYING:-

Residual spraying with DDT was a major reason for successes in malaria control of 1950s & 60s Malaria eradicated or nearly eradicated from many parts of the world at that time House spraying remains a valuable tool for malaria control under the right circumstances However, large-scale ongoing application of insecticides in this manner is not sustainable due to financial and operational constraints and development of insecticide resistance

INDOOR RESIDUAL SPRAYING IS APPROPRIATE WHEN...

A high percentage of structures in an operational

area have adequate sprayable surfaces, and can be expected to be well sprayed The majority of the vector population in endophilic, i.e. rests indoors The vector is susceptible to the insecticide in use In a given area, residual spraying can be targeted at selected houses where the risk of transmission is highest, e.g. those near important breeding sites

FACTORS TO CONSIDER IN SELECTION OF RESIDUAL INSECTICIDES

Residual effectiveness Safety (LD50, environmental persistence, bioaccumulation) Vector susceptibility/Management of resistance Impact on disease Excito-repellency Costs Acceptance (odor, visibility)

AEROSOL SPACE SPRAY : Space spraying of Pyrethrum extract(2%) in 50 houses in and around every malaria positive case to kill the infective mosquitoes.
Involve the application of pesticides in the form of fog or

mist using special equipment:ULV SPRAYER THERMAL FOG SPRAYER

GENETIC CONTROL:GENETIC METHODS SUCH AS

STERILE MALE TECHNIQUE

CYTOPLASMIC INCOMPATIBILITY CHROMOSOMAL TRANSLOCATION SEX DISTORTION GENE REPLACEMENT

BEING CHEAPER AND POTENTIALLY MORE EFFICIENT THAN CHEMICAL METHODS .

Many types of potential vaccine for controlling malaria are under are development.

TYPES OF MALARIA VACCINES

1) PRE-ERYTHROCYTIC VACCINES 2) ASEXUAL BLOOD STAGES VACCINES 3)SEXUAL STAGES VACCINES

1. PRE-ERYTHROCYTIC VACCINE They are developed to prevent infection and impact of disease
2. ASEXUAL BLOOD STAGE VACCINE

-Based on antigens derived from the blood stages of P.falciparum present in man
o -Designed to reduce severe and complicated

manifestation of disease o -They could lower morbidity and mortality,a particularly high risk group

3. SEXUAL STAGE /TRANSMISSION BLOCKING VACCINE

oThus Designed to arrest the development of the

parasite in mosquito.
oReduce or eliminate transmission of the disease

Stage of Plasmodium

Antigens

Salient features

Pre-erythnocytic

-Stage/species specific; -antibody blocks infection of Circum Sporozoite Protein (CSP) liver; , Liver stage Antigens -1 (LSA-1) - large immunising dose required; can abort an infection

Merozoite and Erythrocytes

Erythrocyte Binding Antigen, Merozoite Surface Antigen 1&2 (MSA1&2); Ring Infected Erythrocyte Surface Antigen (RESA) Serine Repeat Antigen (SERA) Apical Membrane Antigen-1 (APM-1)

-Specific for species and stage; -Cannot abort an infection; Prevents invasion of erythrocytes, -thus reducing severity of infection

Gametocytes & gametes

Pfs 25,, Pfs 230

-Prevents infection of mosquitoes; -antibody to this antigen prevents either fertilization or maturation of gametocytes,zygotes or ookinetes -antibody blocks transmission cycle

Combined vaccine (cocktail)

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

Recombinant Vaccine: Against P. vivax blood stage infection . Combination of malarial antigens with immune boosting adjuvant and hepatitis B surface antigens have been reported.

Gamete Vaccine: When the antibodies are taken up by the mosquitoes, gametes escaping the RBCs will be neutralized, thus preventing fertilization and reducing transmission. DNA Vaccine: Based on a synthetic gene, made by adding 21 epitopes of 9 different antigens present in P. faciparum. Example - Pf 155/RESA (Ring Infected Erythrocyte Surface Antigen).

 Problems in vaccine production including not being

able to grow the parasite in large quantities. Difficulty of evaluation. Complexity of conducting clinical and field trials. Mutation of the parasites. Multiple antigens, specific to species and stage.

CONCLUSION
-Sporozoite vaccines generated by recombinant DNA technology, combined with potent T-cell epitopes for higher immunogenecity seem to inhibit early liver-stages of the parasite . Blood stage antigens combined with Freund's adjuvant or other immunoboosters may generate effects resembling chloroquine chemoprophylaxis. Merozoite vaccines get longer time to interact with their target than the transiently appearing sporozoites in case of sporozoite vaccines. Gamete vaccines hold promise for future where in antibodies when taken up by the mosquitoes will neutralise the gametes escaping RBCs, thus preventing fertilization. .

Can be motivated at 2 levels 1. Individual /Family level 2.Community level

INDIVIDUAL PROTECTION AGAINST MOSQUITO BITES:By preventive measures such as the use of-

Repllents Protective clothing Bed nets Mosquito coils Screening of house

1. HEALTH EDUCATION -Educate the people to wear full sleave cloths. -Avoid outdoor sleeping. -Do not allow water to collect in the sourroundings eg. In tyres in coconut shells 2.COMMUNITY PARTICIPATION
- There is no standing wastewater around water points or elsewhere in the settlement. - Promotion for insecticidal spray in community.

Thank You