Malaria Control in India an Utpian Dream Prof. Dr. S. Elango, MD, - - PowerPoint PPT Presentation

Malaria Control in India an Utpian Dream

• Prof. Dr. S. Elango, MD, DPH,DIH,

Director of Public Health & PM (Retd) HOD, Dept. of Community Medicine Sri Muthukumaran Medical College Chennai-69

• Recall Malaria history
• Global Burden
• Malaria scenario in India
• Failures and challenges
• New Advances/ Researches
• Conclusions

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How many of you agree that National Malaria Control Programme (NMCP)

has made No Progress Some progress Good Progress  Very Good Progress

in control of Malaria in INDIA………..

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• 1500 years ago little knowledge on the cause or treatment of

malaria.

• During this time malaria spread – in Europe and the New

World

• New idea came that the disease is related with swamps and

marshes.

• Led to the belief that malaria was caused by malignant

vapors (miasmas) – French term Paludisme roughly translates “of the marshes”

• Mal’aria (bad air) was ascribed by Horace Walpole in 1740

The Dark Ages

• Spanish missionaries learned from

Indian tribes of a medicinal bark for treating fevers

• Wife of the Viceroy of Peru, was

cured of her fever.

• The bark was then called Peruvian

bark and the tree named Cinchona.

• Medicine from the bark is now known

as quinine.

• Like artemisin, quinine still remains
• ne of the most effective anti-malarial

drugs available today

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Dis isco cover ery y of Qu Quin inin ine e (Early y 17th Ce Cent nt.) .)

• Charles Louis Alphonse Laveran, a

French army surgeon was the first to notice parasites in the blood of a patient suffering from malaria.

• This occurred on the 6th of

November 1880.

• For his discovery, Laveran was

awarded the Nobel Prize in 1907.

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Dis isco cover ery y of t the M e Malaria ia Parasi site e (1880)

NO NOBEL EL PRIZ IZES

• Four Nobel prizes have been awarded for

work associated with malaria:

• Sir Ronald Ross (1902),
• Charles Louis Alphonse Laveran (1907),
• Julius Wagner-Jauregg (1927),
• Paul Hermann Muller (1948).

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Malaria imposes a staggering worldwide burden

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Level of malaria burden

High None

Death toll Incidence Health impacts

 At least 1 million deaths annually; one child every 30 seconds  350 to 500 million cases worldwide  Debilitating fevers, low birth weights, anemia, epilepsy—and death

Economic impacts

 Reduced current productivity resulting from days and

• ften weeks of missed work, reduced foreign direct

investment and tourism  Constraints on future growth resulting from reduced investments in human capital (missed schooling, higher fertility rates)

Source: World Malaria Report 2005, expert interviews

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Hay, et al. 2004

Di

Distr tributio ibution n of

• f Mal

alar aria ia

(a Tropic ical l Dis isea ease se ?)

Current global estimates of population at at risk by WHO Region

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Approximately 0.95 billion at risk (Source: WHO regional offices, Kicewski, 2007)

Glo lobal al Mal alar aria ia Bu Burde den

• 3.3 billion people (half the world’s population) live in areas at

risk of malaria transmission in 109 countries and territories.

• 35 countries (30 in sub-Saharan Africa and 5 in Asia) account

for 98% of global malaria deaths.

• WHO estimates that in 2008 malaria caused 190 - 311 million

clinical episodes, and 708,000 - 1,003,000 deaths.

• 89% of the malaria deaths worldwide occur in Africa.
• Malaria is the 5th cause of death from infectious diseases

worldwide (after respiratory infections, HIV/AIDS, diarrheal diseases, and tuberculosis).

• Malaria is the 2nd leading cause of death from infectious

diseases in Africa, after HIV/AIDS.

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Glo lobal al Mal

alar aria ia Bu Burden en Cont….

• Feared since the days of the Roman Empire,

malaria remains a major health problem.

• Globally, approximately 225 million malaria cases

and 781,000 deaths reports each year, mostly in African children (WHO, 2010)

• India contributes about 70% of malaria cases and

50% of mortality in the South East Asian Region of WHO

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• Malaria means “bad air”
• A life-threatening parasitic disease
• 40% of the world’s population is at risk
• 90% of the deaths due to Malaria occur in Sub-Sahara

Africa, mostly among young children.

• Around 400-900 million people are affected
• At least 2.7 million deaths annually.
• It is one of the major public health concerns

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In India dia

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• TREND nearing eradication in 1960s (< 100,000 cases) to resurgence in

the mid-1970s (~6.4 million cases) and stabilizing trend to ~2 million cases in the1990s

• ver 10 crore suspested malaria cases, but only 15.9 lakh could be

confirmed last year (8.3lakh -P. Falciparum, 7.6 lakh-P.Vivax)

• Annual deaths: 30, 014 and 48, 660
• Over 70% of India's population, or 100.41 crore face the risk of malaria

infection.

• Around 31 crore, however, face the "highest risk" of getting infected by

the vector-borne disease.

• Indo-gangestic plains and northern hilly states, northwestern India and

southern Tamil Nadu state have < 10% P. falciparum, and the rest are P. vivax infections; in the forested areas inhabited by ethnic tribes, the situation is reversed, and the P. falciparum proportion is 30–90%, and in the remaining areas, it is between 10% and 30% Source:World Malaria report 2011 WHO

Epidemiological demiological Situat ation ion in India( ia(199 995-20 2010) 0) --

• -Nvbdc

dcp

Year Popu pula lati tion

• n

(in ‘000) Total tal Malari ria a Cases (mil illi lion) n) P.falcip lcipar arum um cases (mil illio ion) Pf % API Deaths s due to mala laria ria 1995 888143 2.93 1.14 38.84 3.29 1151 1996 872906 3.04 1.18 38.86 3.48 1010 1997 884719 2.66 1.01 37.87 3.01 879 1998 910884 2.22 1.03 46.35 2.44 664 1999 948656 2.28 1.14 49.96 2.41 1048 2000 970275 2.03 1.05 51.54 2.09 932 2001 984579 2.09 1.01 48.20 2.12 1005 2002 1013942 1.84 0.90 48.74 1.82 973 2003 1027157 1.87 0.86 45.85 1.82 1006 2004 1040939 1.92 0.89 46.47 1.84 949 2005 1082882 1.82 0.81 44.32 1.68 963 2006 1072713 1.79 0.84 47.08 1.66 1707 2007 1087582 1.51 0.74 49.11 1.39 1311 2008 1119624 1.53 0.77 50.81 1.36 1055 2009 1150113 1.56 0.84 53.72 1.36 1144 2010 1151788 1.49 0.77 52.12 1.3 767

Malaria ia Ca Case ses, s, Pf ca case ses( s(in in mil illio ions ns) & Dea Deaths hs (2000 to 2010)

Source: Nvbdc dcp

Total al Malar aria ia Cases es, , Pf %, , Dea eaths hs & MCDR

Year Total tal Malari aria cases (Mil illi lions) ns) P f % Deaths MCDR % Duration tion 1995 2.93 38.84 1151 0.03 4 Years 1996 3.04 38.86 1010 0.03 1997 2.66 37.87 879 0.03 1998 2.22 46.35 664 0.03 1999 2.28 49.96 1048 0.05 7 Years 2000 2.03 51.54 932 0.05 2001 2.09 48.20 1005 0.05 2002 1.84 48.74 973 0.05 2003 1.87 45.85 1006 0.05 2004 1.92 46.47 949 0.05 2005 1.82 44.32 963 0.05 2006 1.79 47.08 1707 0.09 2 Years 2007 1.51 49.11 1311 0.09 2008 1.53 50.81 1055 0.07 2 Years 2009 1.56 53.72 1144 0.07 2010 1.49 52.12 769 0.05 1 Year

Anal alysis sis and Interpre erpretatio tion n of PF% and MCDR% R%

Year Cases in million

PF%

‘Z’ Significe

MCDR%

‘Z’

Significa BASE END BASE END BASE END BASE END 1995 1996 2.93 3.04 38.84 38.86**

• 2.506

P<0.001 0.0393 0.0332* 54.175 P<0.001 1996 1997 3.04 2.66 38.86 37.87* 24.486 P<0.001 0.0332 0.0330* 8.765 P<0.001 1997 1998 2.66 2.22 37.87 46.35**

• 189.594 P<0.001

0.0330 0.0299* 13.319 P<0.001 1998 1999 2.22 2.28 46.35 49.96**

• 76.409

P<0.001 0.0299 0.0460** -89.202 P<0.001 1999 2000 2.28 2.03 49.96 51.54**

• 31.091

P<0.001 0.0460 0.0459* 0.495 P>0.05 2000 2001 2.03 2.09 51.54 48.20* 66.976 P<0.001 0.0459 0.0481** -10.547 P<0.001 2001 2002 2.09 1.84 48.20 48.74**

• 9.897

P<0.001 0.0481 0.0529** -21.715 P<0.001 2002 2003 1.84 1.87 48.74 45.85* 54.01 P<0.001 0.0529 0.0538**

• 3.857

P<0.001 2003 2004 1.87 1.92 45.85 46.47**

• 11.714

P<0.001 0.0538 0.0494* 19.364 P<0.001 2004 2005 1.92 1.82 46.47 44.32* 42.71 P<0.001 0.0494 0.0529** -15.364 P<0.001 2005 2006 1.82 1.79 44.32 47.08**

• 53.397

P<0.001 0.0529 0.0954** -154.258 P<0.001 2006 2007 1.79 1.51 47.08 49.11**

• 36.229

P<0.001 0.0954 0.0868* 27.00 P<0.001 2007 2008 1.51 1.53 49.11 50.81**

• 29.64

P<0.001 0.0868 0.0690* 57.917 P<0.001 2008 2009 1.53 1.56 50.81 53.72**

• 51.027

P<0.001 0.0690 0.0733** -14.648 P<0.001 2009 2010 1.56 1.49 53.72 52.12* 27.983 P<0.001 0.0733 0.0515* 78.533 P<0.001 1995 2010 2.93 1.49 38.84 52.12**

• 266.779 P<0.001

0.0393 0.0515** -59.498 P<0.001

* Decrease ** Increase

20 40 60 80 100 120 0.5 1 1.5 2 2.5 3 3.5

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Malaria cases in million PF% MCDR/100000

Tr Tren ends ds in in Ma

Malar laria ia

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Elements of malaria control strategies

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Human Infecting vector Infected vector Parasite

Drugs and diagnosis at health centre and community level

Universal LLIN coverage Universal LLIN coverage/ IRS

STOP STO P STOP STOP

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From eradication to control to renewed efforts for elimination: How can we avoid past mistakes?

1950-1969 failed eradication era 1970-1990: Era of Apathy and no resources

1990-2007: Modest era of prevention and control

2007 onwards: Renewed

• ptimism about

elimination

1990-2010: Neglected Era

Mal alar aria a on n the e Gl Global al Agenda enda

• Roll Back Malaria set up in 1998
• Abuja Declaration in 2000
• Millennium Development Goals, New York, 2000;
• Global Fund set up in 2000
• RBM Global Malaria Action Plan with 2010 and 2015

target

• The Malaria Eradication Research Agenda (malERA)

initiative

• Ma

Malar aria ia Vacc ccine ne In Initi tiative tive

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Is Issu sues es in in Malaria laria

• Clinical diagnosis
• Varied presentation- Carrier, Asymtomatic
• Drug side effects
• Drug resistance - chloroq, meflo, arteminsin
• Insecticide resistance
• Mixed infection – vivax with falciparum
• Mixed infection with others
• Multi organ involvement
• Under reported data

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Fai ailu lures es &Chal alle leng nges es

• Leadership and management capacity for health services (centre and

districts)

• Human resources – recruitment, retention and deployment
• Capacity of Institutions: knowledge, data, information
• Integrated Health System Delivery of Minimum Package: stamina, incentives,

politics

• Inter-sectoral coordination
• Sustaining partnership and trust
• Malaria and emergencies(other priorities)
• Global Initiatives: Resurgence: Displace local resources, ownership

and sustainability

• Climatic changes, Urbanization
• Low health sector resource envelope

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Global drug resistance to malaria

 the WHO Global Plan for Artemisinin Resistance Containment (GPARC) recommended that all countries ban the marketing of oral artemisinin-based monotherapies, one of the major factors fostering the emergence of drug resistance.

 Change antimalarial treatment policies when treatment failure is >10% (as assessed through monitoring of therapeutic efficacy at 28 days)  Change to a treatment which has an average cure rate ≥ 95% as assessed in clinical trials

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"…Prompt and accurate diagnosis of malaria is the key to effective disease management and to the reduction of unnecessary use of antimalarial medicines."

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Malaria Vaccines

• Currently no licensed Malaria Vaccines.
• 20 in Trial.
• RTS,S/ASO1.
• RTS,S is Pf Vaccines.
• Bill and Mellinda gates foundation.
• Glaxo smith, PATH & MVI.

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"Fighting ghting malar aria ia with h engineer neered ed symbiotic iotic bacter teria ia from

• m vector
• r mosquitoes”

* Sibao Wang, Anil K. Ghosh, Nicholas Bongio, Kevin A. Stebbings, David J. Lampe and Marcelo Jacobs-Lorena.

• “ demonstrate the use of an engineered symbiotic

bacterium to interfere with the development of P. falciparum in the mosquito. These findings provide the foundation for the use of genetically modified symbiotic bacteria as a powerful tool to combat malaria”

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Way Forward

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1 2 3 4 5

• Sustain financing
• Overcoming barriers to access and coverage
• Investing in RD to stay ahead of resistance and develop

new tools

• Re-orient and strengthen national malaria control

programs to address current and future scenarios

• Strengthen advocacy and social mobilization

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We need to act with urgency and resolve to ensure that no one dies from malaria for lack of $5 bed net, $1dollar anti-malarial drug and a 50 cent diagnostic test.” Robert Newman, director of WHO's global malaria programme

Time Magazine 30 June 1947

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Concl nclusion usion

 One of the oldest known diseases.  Malaria has been infecting humans for over 50,000 years.  References to malaria have been recorded for nearly 6000 years, starting in China.  Used to be common in Europe and North America.  First advances in malaria were made in 1880 by a French army doctor named Charles Laveran.  Carlos Finlay discovered that mosquitoes transmitted diseases.  Ronald Ross discovered that mosquitoes transmitted malaria in 1898.  First effective medicine was discovered by Pierre Pelletier and Joseph Caventou. This medicine is called quinine, which comes from the bark of cinchona trees in Peru.  No effective vaccine: only immunity is a result of multiple infections.

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As we reconsider the ‘e’ word – some definitions…. Elimination: Reduction to zero of the incidence of infection caused by a specific agent in a defined geographical area as a result of deliberate efforts; continued measures to prevent re- establishment of transmission are

• required. Example: poliomyelitis.

Eradication: Permanent reduction to zero of the worldwide incidence of infection caused by a specific agent as a result of deliberate efforts; intervention measures are no longer needed. Example: smallpox. Extinction: The specific infectious agent no longer exists in nature or in the

• laboratory. Example: none.

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In India ……..

• There is a decrease in absolute number of total

Malaria from 2.93 million in 1995 to 1.49 million in

• 2010. But
• There is an increased proportion of Pf Cases from

38.84% in 1995 to 52.12% in 2010.

• The Malaria case specific death rate(MCDR) is

increased from 0.039% in 1995 to 0.051% in 2010.

• The statistical analysis reveals that increase of Pf

cases is very highly significant (P<0.001) and MCDR is also very highly significant (P<0.001).

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Inference

• So the inference is the Malaria program in

India has

No impact on reduction of Pf% cases and MCDR…….

……. But there is some progress.

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