Vector Borne Diseases Control Program

1. Vector Borne Diseases Control Program

2. Major vector borne diseases- • Malaria • Filaria • Kala-azar • Japanese Encephalitis • Dengue / Dengue Hemorrhagic fevers • Chikungunya

3. Vector Borne Diseases Control Programme • Launched in 2003-04 by merging NAMP,NFCP & Kala Azar Control programmes .Japanese B Encephalitis and Dengue/DHF have also been included in this Program • Directorate of NAMP is the nodal agency for prevention and control of major Vector Borne Diseases

4. Strategies for NationalVector Control Program The basic approach for vector borne diseases control involves a strategy directed against the parasite and vector and to enlist the involvement of community in practicing various preventive measures

5. Strategies contd. • Disease management • Insecticide resistance • Involvement of NGOs /private sector/community • Quality assurance on laboratory diagnosis • Long lasting insecticide treated nets

6. Contd. • Improve quality and efficiency of services at primary, secondary and tertiary levels • Environmental management • Monitoring and evaluation • Collaboration with National Malaria Institute of malaria research and medical colleges • Inter-sectoral collaboration

7. National Anti Malaria Programme • Started in 1953 as NMCP with Two rounds of residual insecticidal (DDT) spray as the mainstay of the program. • Dramatic reduction of malaria mortality and morbidity lead to National Malaria Eradication Programme with malaria eradication as a goal in 1958. • Reverses to the programme and resurgence of malaria due to Technical, Operational and Administrative causes necessitated changing it to ‘Modified Plan of Operation’ in1977.

8. Magnitude of the problem • Provisional data for the year 2004 reveals the largest numbers of cases in the country were reported by Orissa, followed by Gujarat, Chhattisgarh, West Bengal, Jharkhand, Karnataka, Uttar Pradesh and Rajasthan and the largest numbers of deaths were reported by Orissa, followed by West Bengal, Mizoram, Jharkhand, Meghalaya, Karnataka, Tripura and Assam. • 1.87 million cases of malaria (including 0.86million P.falciparum cases) and 1006 deaths were reported from the country in 2003.

9. Vectors of malaria • Anopheles culicifacies is the main vector of malaria • 1. Feeding habits • It is a zoophilic species • When high densities build up relatively large numbers feed on men • 2. Resting habits • Rests during daytime in human dwellings and cattle sheds

10. Contd. • 3. Breeding places • Breeds in rainwater pools and puddles, borrow pits, river bed pools, irrigation channels, seepages, rice fields, wells, pond margins, sluggish streams with sandy margins. • Extensive breeding is generally encountered following monsoon rains.

11. Contd. • 4.Biting time • Biting time of each vector species is determined by its generic character, but can be readily influenced by environmental conditions. • Most of the vectors, including Anopheles culicifacies, start biting soon after dusk. Therefore, biting starts much earlier in winter than in summer but the peak time varies from species to species.

12. Malaria control strategies • 1. Early case Detection and Prompt Treatment (EDPT) is the main strategy of malaria control – radical treatment is necessary for all the cases of malaria to prevent transmission of malaria • Chloroquine is the main anti-malaria drug for uncomplicated malaria. • Drug Distribution Centers (DDCs) and Fever Treatment Depots (FTDs) have been established in the rural areas for providing easy access to anti-malarial drugs to the community. • Alternative drugs for chloroquine resistant malaria are recommended as per the drug policy of malaria.

13. Contd. 2. Vector Control  • (i) Chemical Control • Use of Indoor Residual Spray (IRS) with insecticides recommended under the programnme • Use of chemical larvicides like Abate in potable water • Aerosol space spray during day time • Malathion fogging during outbreaks

14. Contd. • (ii) Biological Control • Use of larvivorous fish in ornamental tanks, fountains etc. • Use of biocides. • ( iii) Personal Prophylactic Measures that individuals/communities can take up • Use of mosquito repellent creams, liquids, coils, mats etc. • Screening of the houses with wire mesh • Use of bed nets treated with insecticide • Wearing clothes that cover maximum surface area of the body

15. Control strategies contd. 4. Community Participation • Sensitizing and involving the community for detection of Anopheles breeding places and their elimination • NGO schemes involving them in programme strategies • Collaboration with private sector.

16. Contd. • 5. Environmental Management & Source Reduction Methods • Source reduction i.e. filling of the breeding places • Proper covering of stored water • Channelization of breeding source

17. Contd. 6. Monitoring and Evaluation of the Program • Monthly Computerized Management Information System(CMIS) • Field visits by state by State National Program Officers • Field visits by Malaria Research Centers and other ICMR Institutes • Feedback to states on field observations for correction actions.

18. ‘Modified Plan of Operation’ • Objectives - to prevent deaths due to malaria - to reduce malaria morbidity - to maintain agriculture and Industrial - production through intensive anti malaria measures in such areas -to consolidate the gains achieved so far • Areas were reclassified based on the Annual Parasitic Incidence (API) as those having API > 2 and those having < than 2 for operational purposes

19. Areas having Annual Parasite Index (API) > 2 • Regular 2 rounds of insecticidal spray with DDT/ Malathion / Synthetic Pyrethroids at the dose of 1, 2, 0.5 mg/sq meter respectively. • Entomological assessment for vector behavior and development of insecticidal resistance • Active and passive surveillance is carried outon regular basis every fortnight • Presumptive Treatment to all fever cases and radical treatment to all slide positive cases is given

20. Areas having Annual Parasite Index(API) < 2 • Regular spray is not carried out but ‘focal’ spray is carried out around falciparum cases detected during surveillance • Regular passive surveillance once in a fortnight • Treatment –All positive cases to receive radical treatment • Follow up- All positive cases to be followed up for 1 year at monthly intervals after completion of radical treatment • Epidemiological investigation of all malaria positive cases .This may also include mass blood survey.

21. Urban Malaria Scheme (UMS )was launched in 1971 to over come the increasing incidence of malaria in urban areas where the vector was found to be An. Stephansi. Intensive anti larval measures and drug treatment are the mainstay of UMS • P. falciparum containment Programme was launched in October 1977 with the assistance of SIDA to contain the spread of falciparum malaria This programme is operative in the North Eastern States, and parts of Orissa, Bihar, WB, AP ,MP, Gujrat, Maharashtra and Rajasthan

22. Reorganization - Malaria Units under NMEP were reorganized to conform to the geographical boundaries of the district and the DHO was made responsible for implementation of the programme • Recentralization of Laboratory services- Laboratory Technician with the necessary facilities is now located at each PHC • Establishment of Drug Distribution Points (DDPs) and Fever Treatment Depots (FTDs)

23. Investigation of all Malaria Deaths- All cases suspected to have died due to malaria are to be investigated • Monitoring and control of all epidemics and focal out breaks of malaria – Any increase in the number of fever cases suggestive of malaria should be promptly investigated and measures to contain the outbreak should be instituted.

24. National Filaria Control Program

25. Magnitude of the problem • Filariasis has been a major public health problem in India next only to malaria.  The discovery of microfilariae (mf) in the peripheral blood was made first by Lewisin 1872 in Calcutta (Kolkata). • Indigenous cases have been reported from about 250 districts in 20 states/Union Territories. • The North-Western States/UTs are known to be free from indigenously acquired filarial infection. • Cases of filariasis have been recorded from Andhra Pradesh, Assam, Bihar, Chhattisgarh, Goa, Jharkhand, Karnataka, Gujarat, Kerala, Madhya Pradesh, Maharashtra, Orissa, Tamil Nadu, Uttar Pradesh, West Bengal, Pondicherry, Andaman & Nicobar Islands, Daman & Diu, Dadra & Nagar Haveli and Lakshadweep

26. Signs and symptoms of Filariasis • Recurrent fever intermittent or remittent with often double rise • loss of appetite, pallor and weight loss with progressive emaciation • weakness • Splenomegaly – spleen enlarges rapidly to massive enlargement, usually soft and nontender • Liver – enlargement not to the extent of spleen, soft, smooth surface, sharp edge

27. Contd. • Lymphadenopathy – not very common in India • Skin – dry, thin and scaly and hair may be lost. Light colored persons show grayish discoloration of the skin of hands, feet, abdomen and face which gives the Indian name Kala-azar meaning “Black fever” • Anemia – develops rapidly • Anemia with emaciation and gross splenomegaly produces a typical appearance of the patients

28. National Filaria Control Program • This program was started in 1955 • In 1998 the operational component was merged with Urban Malaria Scheme • In 2003 -04 it was merged with NVBDCP • Filariasis has been a major public health problem in India next only to malaria. • Indigenous cases have been reported from about 250 districts in 20 states/Union Territories.

29. Revised Filaria Control Strategy The National Health Policy 2002 aims at Elimination of Lymphatic Filariasis by 2015 REVISED STRATEGY Annual Mass Drug Administration  with single dose of Diethyl carbamazine(DEC)was taken up as a pilot During 2004 about 400 million population were brought under MDA. This strategy is to be continued for 5 years or more to the population excluding children below two years, pregnant women and seriously ill persons in affected areas to interrupt transmission of disease.

30. Contd. • Vector control through anti larval spray at weekly intervals. • Biological control through larvivorous fishes • Environmental engineering through source reduction and water management • Information, education and communication

31. Kala Azar Control Program

32. What is Kala-azar? • Kala-azar is a slow progressing indigenous disease caused by a protozoan parasite of genus Leishmania • In India Leishmania Donavan is the only parasite causing this disease • The parasite primarily infects reticuloendothelial system and may be found in abundance in bone marrow, spleen and liver. • Post Kala-azar Dermal Leishmaniasis (PKDL) is a condition when Leishmania donovani invades skin cells, resides and develops there and manifests as dermal leisions.

33. Kala-Aar spread • Currently Kala-Azar is endemic in 33 Districts of Bihar 3 Districts of Jharkhand 10 Districts of West Bengal & 2 Districts of UP • Started as a Centrally Sponsored Programme in1990-91 • It was merged with NVBDCP in 2003-04

34. Signs & Symptoms of Kala-Azar • Recurrent fever intermittent or remittent with often double rise • loss of appetite, pallor and weight loss with progressive emaciation • Splenomegaly - spleen enlarges rapidly to massive enlargement, usually soft and non tender • Liver - enlargement not to the extent of spleen, soft, smooth surface, sharp edge • Skin - dry, thin and scaly and hair may be lost. Light colored persons show grayish discoloration of the skin of hands, feet, abdomen and face which gives the Indian name Kala-azar meaning "Black fever" • Anemia - develops rapidly

35. Diagnosis • Clinical: • A case of fever of more than 2 weeks duration not responding to antimalarials and antibiotics. Clinical laboratory findings may include anemia, progressive leucopenia thrombocytopenia • hypergammaglobulinemia

36. HIV and Kala-azar co-infection • Visceral leishmaniasis (VL) has emerged as an opportunistic infection in HIV and other immunosuppressed patients • More than 1000 cases of HIV and VL are reported from 25 countries. However, in India yet not a serious problem • VL may be first Opportunistic Infection in asymptomatic HIV-I infected person • Also occurs in advanced stage of AIDS

37. Contd. • Also occurs in advanced stage of AIDS • All co-infected patients are not symptomatic • Diagnosis may be altered because symptoms may be of short duration; fever and spleen may not be marked; Leishmania antibodies may be undetectable. • However peripheral blood smears of buffycoat and blood culture may yield good results • Response to treatment is poor; drug side effects may be more and relapses may be common

38. Treatment of Kala - Azar • Kala-azar Drugs available in India • Sodium Stibogluconate (indigenous manufacture, registered for use & sale) • Pentamidine Isethionate: (imported, registered for use) • Amphotericin B: (indigenous manufacture, registered for use and sale) • Liposomal Amphotericin B: (indigenous manufacture & import, registered for use and sale) • Miltefosine (imported/ registered for use & sale) • Drug Policy under Kala-azar Elimination Programme as per recommendations of Expert Committee (2000

39. Control Strategy • An organized centrally sponsored Control Programme launched in endemic areas in 1990-91 Government of India provided kala-azar medicines, insecticides and technical support and the State governments implemented the programme through primary health care system and district/zonal and State malaria control organizations and provided other costs involved in strategy implementation

40. Strategy contd. • Programme strategy included: - Vector control through insecticidal residual spray (IRS ) with DDT up to 6 feet height from the ground twice annually - Early Diagnosis and Complete treatment -  Information Education Communication - Capacity Building • Programme intensified in 1991-92 which led to improved case registration through primary health care system • Programme Achievements

41. Control of Dengue/DHF

42. WHAT IS DENGUE ? • Dengue is a viral disease • It is transmitted by the infective bite of Aedes Aegypti  • Man develops disease after 5-6 days of being bitten by an infective mosquito • It occurs in two forms: Dengue Fever and Dengue Haemorrhagic Fever(DHF) • Dengue Fever is a severe, flu-like illness • Dengue Haemorrhagic Fever (DHF) is a more severe form of disease, which may cause death • Person suspected of having dengue fever or DHF must see a doctor at once

43. Dengue/DHF There was a major out break of Dengue /DHF in Delhi in 1996 Since than many focal outbreaks have been reported from different areas of the country mainly from urban areas. This disease has been included in NVBDCP in 2003 -04

44. Control Strategy Public awareness and community involvement is the key issue in the strategy to control Dengue/DHF All efforts should be made against the breeding of Aedes egypti mosquitoes by source reduction Protection from mosquito bites Early diagnosis and prompt treatment of cases

45. Strategy contd. • Programme strategy included: •       -    Vector control through Insecticidal residual spray (IRS )with DDT up to 6 feet height from the ground twice annually •      -   Early Diagnosis and Complete treatment •      -   Information Education Communication •      -   Capacity Building • Programme intensified in 1991-92 which led to improved case registration through primary health care system

46. Japanese encephalitis control

47. Japanese encephalitis • Japanese Encephalitis is a viral disease • It is transmitted by infective bites of female mosquitoes mainly belonging to Culex tritaeniorhynchus, Culex vishnui and Culex pseudovishnui group. However, some other mosquito species also play a role in transmission under specific conditions • JE virus is primarily zoonotic in its natural cycle and man is an accidental host. • JE virus is neurotorpic and arbovirus and primarily affects central nervous system

48. Contd. • Japanese Encephalitis is becoming a health problem in a number of States especially in AP, TN, Kerala, Karnataka , WB, Assam, Bihar, & Haryana, • There was no national programme for this disease and the affected states were managing the problem with the technical Assistance from the centre • This disease was included under the NVBDCP in 2003-04

49. How JE is transmitted? • Japanese encephalitis is a vector borne disease. • Several species of mosquitoes are capable of transmitting JE virus. • JE is a zoonotic infection. Natural hosts of JE virus include water birds of Ardeidae family (mainly pond herons and cattle egrets). Pigs play an important role in the natural cycle and serve as an amplifier host since they allow manifold virus multiplication without suffering from disease and maintain prolonged viraemia.

50. Contd. • Due to prolonged viraemia, mosquitoes get opportunity to pick up infection from pigs easily. • Man is a dead end in transmission cycle due to low and short-lived viraemia. Mosquitoes do not get infection from JE patient