Malaria: Bringing Down The Burden

In Odisha

Dr. MM Pradhan

Dy. Director,

NVBDCP, Odisha

MMV Stakeholders’ Meeting, Delhi (India), 8th Nov, 2012

Odisha at a glance Area: 156,000 sq kms (4% of

India’s land area)

Popln: 42 million (3% of India)

Rural : 82% , Urban : 18%

Tribal - 22% + sch. caste -16%

( St & SC = 36%) Out of 75 Primitive Tribal Groups in

India ,13 are in Odisha.

There are 30 district with 314 blocks

and >51,000 villages

Favourable geo-ecotypes: Perennial streams in forest areas

-Forest area are also rich in minerals with mining activities and high

migratory population

Average temperature : 15 0 to 35 0С (extreme: 50С to 48 0С)

Rain fall : 1452 mm with high humidity (>60%)}

14

15

12

15

11

11

15

28

21

14

19

23

15

13

12

23

14

19

25

22

19

16

31

38

2 4

7

2

9 8

15 15

4

10

16

8

0

5

10

15

20

25

30

35

40

0

10000

20000

30000

40000

50000

60000

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

2009 - Death 2010 - Death

2011 - Death 2009 - Cases

Transmission seasonality

Transmission is perennial with one peak in forested districts (mostly tribal dominated)

0

500

1000

1500

2000

2500

3000

3500

4000

4500

5000

Jan Feb Mar Apr May June July Aug Sep Oct Nov Dec

Malaria cases 1765 1864 2193 2691 2542 3760 4154 4826 4363 3190 2865 2338

Pf cases 1678 1771 2077 2549 2410 3583 3935 4543 4143 2975 2644 2203

Death 1 2 7 3 5 7 3 2 3 3 3 0

No

of

case

s

Kandhamal ( Pf > 90%) Forest covers 34.2%

Year Total

Tested +ve PF Death ABER SPR Pf% API

2002 4570466 473223 393523 465 12.21 10.35 83.16 12.64

2007 4945551 371879 323150 221 12.22 7.52 86.90 9.19

2008 5029677 375430 329631 239 12.23 7.46 87.80 9.13

2009 5015489 380904 336047 198 12.00 7.59 88.22 9.12

2010 5240458 395651 350428 247 12.30 7.55 88.57 9.29

2011 4657978 298423 272971 100 11.13 6.41 91.47 7.13

2010 – upto Sept.

3743258 277915 244744 162 7.42 88.06

2011 – upto Sept.

3452288 232911 213029 66 6.75 91.46

2012 – upto Sept.

3457988 187176 173137 46 5.41 92.50

Malaria cases decreased by 20% & deaths by 30% (2011 vs 2012 by September)

Malaria Epidemiological Situation, 2002-12

2011

2010

2009

2008

2007Status of Malaria API of Odisha from 2007-2011

Year 0-2 2-5 5-10 >10

2007 7 3 6 14

2008 7 5 5 13

2009 10 3 4 14

2010 10 4 4 12

2011 12 5 3 10

The

re is

a d

ecr

eas

e in

AP

I

Year wise distribution of Districts with API

Malaria control strategy: As per the National program with

state specific appropriation

A. Primary:

1. Early diagnosis (Microscopy & RDT) and completer treatment with effective & appropriate Antimalaria drugs

2. Integrated vector control : LLIN , IRS, source reduction

B. Supportive: Monitoring & evaluation, capacity building IEC & BCC – PPP & Social mobilisation advocacy, Operational research

30 Districts with 32 Dist Hospital

314 Blocks (125K pop per block)

Primary Health Center (20-30K pop) 4-5 PHCs per block

Sub-center (5K pop) (4-5 SCs per PHC)

51,000 villages (0.5-1K pop per village) (8-10 villages per SC)

Structure of health services in Odisha

Malaria

surveillance,

Diagnosis &

treatment available

free of cost at each

Health facility

11

99

00

0

70

00

00

19

02

668

0

25

43

56

0

0

10

13

50

12

17

00

27

74

000

17

50

725

68

34

00

0

0

50

00

00

0

0

65

00

00

83

91

1

67

43

24

62

28

75

15

00

0

15

00

0

62

20

198

247

100

9.12

9.29

7.13

0

50

100

150

200

250

300

0

500000

1000000

1500000

2000000

2500000

3000000

2009-10 2010-11 2011-12

LLIN

ITN

MO-Mashari

RDT

RDT(Bi-valent)procure byState

RDT(Mono-valent) procureby Sate

ACT

ASHA Capacitybuilding

API

Death

Inputs & interventions for malaria control from 2009 onwards.

Surveillance and Early Diagnosis & Complete Treatment (RDT + ACT) at village level

Out of 41264 ASHAs, >38000 have been trained (92% )

646 AYUSH doctors & around 2000 tribal school teachers have been trained on EDCT

Around 500 Forest (VSS)

Animators have been trained as

FTD to provide EDCT service in

Forest villages in four tribal

districts (Rayagada, Gajapati,

Kandhamal and Koraput)

Sentinel Site Malaria laboratories-2011

380987

25139 (6.59%) 7203

(1.89%) 0

50000

100000

150000

200000

250000

300000

350000

400000

450000

Total In Patient In patient suspectedas malaria

Confirmed Malariacases

No

of

in p

atie

nts

Characteristics of IPD patients at SSL, 2011

1957077

158871 (8.1%)

11175 (.57%)

1000

501000

1001000

1501000

2001000

2501000

Total New OPDCases

Suspected malariaCases

Confirmed Malariacases

Characteristics of OPD cases at SSL, 2011

Seasonality of IPD cases in 2011

74

36

8

85

84

4

12

66

19

94

15

6

42

20

57

73

10

57

5

45

71

14

05

19

49

22

80

15

69

0

500

1000

1500

2000

2500

0

20000

40000

60000

80000

100000

120000

140000Ja

n -

Mar

ch

Ap

r -

Jun

Jul -

Se

p

Oct

- D

ec

Total IPD

Total In patients suspected as malaria

Total Positive

Integrated Vector Control: IRS

Hand Compression Sprayer Pumps (HCSP) have been introduced

IRS – 2 rounds protect high risk

population ( API > 5) - around 8.7

million in 22 districts

Integrated Vector Control : LLIN

State specific LLIN guidelines adopted for LLIN distribution

Total 18.99 Lakhs LLIN distributed in 2009-10 and another 19 Lakh in 2011-12 (total around 38 lakh LLIN) - protect around 90 lakh population,

LLIN distribution was done through GKS (village health sanitation committee),followed by intensified IEC & BCC

API trend after 1st phase LLIN distribution ( around 19 lakh)

11

10

00

65

00

0

68

50

0

94

00

0

40

00

0

90

00

0

30

00

0

10

00

00

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00

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26

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00

0

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00

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00

0

15

00

00

0.00

20.00

40.00

60.00

80.00

100.00

120.00

0

20000

40000

60000

80000

100000

120000

140000

160000

An

gul

Bar

garh

Bo

lan

gir

Dh

en

kan

al

Gaj

apat

i

Gan

jam

Jhar

sugu

da

Kal

ahan

di

Kan

dh

amal

Keo

njh

ar

Ko

rap

ut

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kan

giri

May

urb

han

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Naw

aran

gap

ur

Nu

apad

a

Ray

agad

a

Sam

bal

pu

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Son

epu

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Sun

dar

garh

LLIN Distribution 2009-10

API-10

API-11

Encouraging results after the new interventions:

pf

2037

925

1707

690

336235

positive pf pv•LLIN in 2009 along with

ACT

•Special awareness

campaign- NIDHI RATH

•Nil reported death

0

1000

2000

3000

4000

5000

50

150

250

350

450

550

650

2008 2009 2010 2011

No

. of

Po

siti

ve c

ase

se

K. Nagar Sub. Divisonal Hospital catering

the population of a High Endemic Tribal

block of Dhenkanal district

State initiative Mo Mashari (my mosquito net)

In 2 phases 2.24 Lakh LLINs have been provided to Pregnant mothers in

7 high burden tribal districts to protect pregnant mothers

Besides, pregnant mothers, Tribal school boarders and inmates are

protected by ITN/LLIN - 2.04 Lakh Single size ITN/ LIIN provided to these

vulnerable group.

Study findings: •91% of pregnant women slept under LLIN last night (n=809). •88% of pregnant women slept under LLIN last night with their child under 2 years (n=809). •But in general / cluster distributed areas (n=2925), 70% of family members slept under LLIN last night

• Use of traditional folk theatre, Jatra

etc.

• Partnership with GKS & CBOs

• Advocacy & Inter-sectoral

coordination

• Involvement of School teacher &

student, Traditional / Faith healers

Innovative IEC &BCC

Nidhi Mausa Adalat

NGO/PPP and Inter Sectoral Co-ordination NGOs engaged under NRHM

are involved in screening of

malaria cases, impregnation of

bed nets, laboratory diagnosis

and community mobilization

and monitoring.

Other departments: Women & Child Development., Forest and Environment, Schedule Caste &

Schedule Tribe, School and Mass Education, Panchayati Raj Institutions, ICMR institutes

LQAS : ME tool in malaria program. Conducted twice a year –at present conducted in 21 districts.

The LQAS findings from 2009 to 2011 on % of people protected either by ITN/LLIN.

Lot Quality Assurance Sampling: LQAS

Sundargarh

Mayurbhanj

Nabarangpur

Kandhamal

Mon Target0%

10%

20%

30%

40%

50%

60%

70%

Nov (2009) Aug (2010) Nov(2010) Aug(2011) Nov (2011)

Sundargarh Mayurbhanj Nabarangpur Kandhamal Mon Target

Operational research

(Dfid support):

• Vector study by VCRC in 10 southern districts- publication awaited

• Mo-Mashari (my mosquito nets) by T & MST (of Dfid) – report released

• LLIN impact study by ICMR institutes – reports awaited

Guidelines and reports:

– LLIN state Guidelines

– Operational manuals

– Annual Activity report – used for advocacy

– Training manuals for doctors, Health workers, ASHA

– FAQs for school students and others

Research & Documentation

Comprehensive case management-

(Pilot): MMV-NIMR - Odisha 3Ts: test, treat & tract

Rationale:

• Case management of malaria, beyond ‘treating the sick’, could reduce the infectious reservoir.

• The size of the infectious reservoir is an important determinant of malaria transmission in low & medium endemic areas

Universal vector control is difficult and expensive

where large populations are at variable risk

Objectives of the Study

Primary • To assess the impact of CCM for uncomplicated malaria on its incidence/

transmission in different transmission settings in the state of Odisha, India

Secondary • Determine the mix of interventions and related costs needed for scale-up

of comprehensive case management

• Develop a community based surveillance model for reporting and timely action

• Better define the burden and epidemiological profile of malaria in the area

• Identify challenges in the radical cure of malaria, particularly P. vivax

• Strengthen the pharmaco-vigilance system to generate community level data on adverse events

Inte

rven

tio

n /

Co

ntr

ol

High transmission (API: 18)

Low vivax (10%)

High case load (ca. 2000 patients p.a) In

terv

enti

on

/ c

on

tro

l Medium transmission (API: 8)

Mixed vivax (30%)

Medium case load (ca. 1000 patients p.a.)

Inte

rven

tio

n /

Co

ntr

ol

Low transmission (API: 3)

High vivax (50%)

Low case load (ca. 300 patients p.a)

Project design

• Operational research project with NVBDCP

• Total study population 800,000

• 3 year study period (October 2012 – 2015)

I want to play at school - help me for no malaria

Thanks

Challenges: •Tribal areas - cultural

and language barrier

•Forest villages

•Inaccessibility and poor

health services

•Inadequate health staff

•Increased mining and

developmental activities

•Urban set ups with

migratory population &

poor health structure for

public health activities

Challenges: More research for newer

interventions

Health system research

-functioning of ASHA

& other health volunteers

-Community based

organizations (GKS)

-Community mechanism

- Role of Traditional

healers in tribal areas

-Role of general

practitioners, chemists,

private and other sectors