National Anti Malaria Programme | Medical Science Optional Notes for UPSC PDF Download

Programme in India

Major malaria control activities and programme in India

1953

'National Malaria Control Program' (NMCP) 1953 Objectives: 

Aim to reduce malaria transmission to a point where it no longer constitutes a significant public health issue and maintain malaria transmission at a low level.

Strategies:

• Administer anti-malarial treatment for institutional cases.
• Conduct residual insecticide spraying using DDT in human dwellings and cattle sheds.

1958

The number of cases decreased from 75 million in 1953 to 2 million in 1958, prompting the initiation of a new program called the 'National Malaria Eradication Program' (NMEP).

NMEP Objectives: Strive to terminate malaria transmission by eliminating entire vectors and eradicating reservoirs of infections.

Strategies:

• Implement two rounds of DDT spray in all areas.
• Conduct active and passive surveillance.
• Administer presumptive and radical treatment.

1977

As a result of the National Malaria Eradication Program (NMEP), cases decreased to 0.1 million; however, a resurgence was observed due to technical, operational, and administrative failures. The attempt at eradication was abandoned, and a new program was introduced.

The new initiative, the Modified Plan of Operation (MPO), has the following objectives: Elimination of deaths, reduction of morbidity from malaria, and the preservation of gains achieved by minimizing malaria transmission.

MPO Strategies:

• Stratify rural areas based on API and implement varied vector control measures.
• Conduct active and passive surveillance.
• Administer presumptive and radical treatment.

1995

Owing to the persistent resurgence, an expert committee scrutinized epidemiological parameters related to malaria transmission in the country.

In the Malaria Action Program (MAP) of 1995:

• Areas were categorized into high-risk and low-risk zones based on specific epidemiological criteria.
• Prioritized spraying operations and implemented varied treatments in high-risk areas.
• Identified problematic regions included hard-core (tribal) areas, epidemic-prone areas, project areas, areas resistant to triple insecticides, and urban areas.

1997

Between 1984 and 1998, an annual report of 2-3 million cases was documented. Regions exhibiting unfavorable epidemiological parameters were chosen for the implementation of the 'Enhanced Malaria Control Project' (EMCP) in 1997.

EMCP Objectives:

• To prevent deaths and reduce morbidity associated with malaria, consolidating the gains achieved thus far.

Strategies:

• Emphasis on early case detection and prompt treatment, vector control using appropriate insecticides, health education, and fostering community participation.

1999

In 1999, the national program underwent a name change to the National Anti-Malarial Programme.

The program has two primary objectives:

1. Preventing deaths and morbidity attributed to malaria.
2. Sustaining ongoing socioeconomic development.

Specific Objectives include:

• Reducing Annual Parasite Incidence (API) to 1.3 or less during the 11th Five Year Plan.
• Achieving at least a 50 percent reduction in malaria-related mortality by 2010, aligning with the National Health Policy (2002).
• Halting and reversing the incidence of malaria by 2015, in accordance with the Millennium Development Goals.

Strategies employed encompass:

• Surveillance and Case Management
• Case detection (passive and active)
• Early diagnosis and complete treatment
• Sentinel surveillance
• Integrated Vector Management (IVM)
• Community Participation
• Behavior Change Communication (BCC)
• Monitoring and Evaluation of the program

Stratification of the problem under the Modified Plan of Operation involves categorizing malarious areas based on Annual Parasite Incidence (API) as:

• Areas with API < 2
• Areas with API ≥ 2

This approach aids in defining the population at risk and judiciously allocating resources. Selective application of transmission control measures in these strata includes:

Intervention in areas with API ≥ 2:

• Residual insecticide spray with 2 rounds of DDT or 3 rounds of BHC/Malathion
• Surveillance/treatment of cases
• Entomological assessment

Intervention in areas with API < 2:

• Focal spray around houses with Falciparum
• Surveillance/treatment of cases
• Epidemiological investigation
• Follow-up

2002

In 2002, the malaria control program and other Vector Borne Diseases, including Kala-azar, Dengue, Lymphatic Filariasis, Japanese Encephalitis, and Chikungunya, were integrated into the National Vector Borne Disease Control Programme (NVBDCP).

Under the NVBDCP, new tools for malaria prevention and control were introduced:

• Monovalent RDTs for P. falciparum detection in 2005
• ACT in 2006 (for areas with chloroquine resistance)
• LLINs in 2009 (Long-lasting insecticidal nets - Mosquito nets impregnated with insecticide)
• New drug policy in 2010
• Antigen-detecting bi-valent RDTs for the detection of both P. falciparum and P. vivax in 2013
• New drug policy in 2013
• Introduction of newer insecticides and larvicides in 2014-15

National Drug policy for Malaria (2013)

• Decreasing morbidity through the prompt and comprehensive treatment of suspected/confirmed malaria cases.
• Preventing the progression of uncomplicated malaria into severe malaria to reduce malaria-related mortality.
• Administering radical treatment to prevent relapses.
• Utilizing gametocytocidal drugs to prevent the transmission of malaria.
• Preventing the development of drug resistance through the rational treatment of malaria cases.

Salient features of National Drug Policy for malaria are as under:

1. For the treatment of uncomplicated P. falciparum cases: Administer a complete three-day course of Artemisinin-based Combination Therapy (ACT) along with a single dose of primaquine at 0.75 mg/kg body weight on day 2.
2. In the case of uncomplicated P. vivax cases: Prescribe chloroquine at a dosage of 10 mg/kg body weight on day 1 and day 2, followed by 5 mg/kg body weight on day 3. Additionally, administer primaquine at 0.25 mg/kg body weight for a duration of 14 days.
3. For severe malaria cases (both Pv and Pf): Initiate treatment with injectable artemisinin derivatives, followed by a full course of ACT. Fifteen sentinel sites have been designated for monitoring the therapeutic efficacy of anti-malarials nationwide, including ACT, in collaboration with the National Institute of Malaria Research.

Three studies conducted in the North Eastern States during 2012-13 and 2013-14 revealed delayed parasite clearance with ACT-Artesunate + Sulphadoxine-pyrimethamine. Consequently, ACT-Artemether + Lumefantrine is being used in seven North Eastern States in lieu of ACT-Artemether + Sulphadoxine-pyremethamine. At the remaining 12 centers, both ACT (Artesunate + Sulphadoxine-pyremethamine) in Pf cases and Chloroquine in Pv cases demonstrated effectiveness, with cure rates nearly reaching 100%.

2012-17

Malaria control is currently integrated into health service delivery programs within the framework of the National Rural Health Mission (NRHM). This integration creates opportunities to enhance malaria prevention and treatment services in proximity to the community.
Various methods and channels are being employed to implement these interventions, encompassing entry-level facilities such as Community Health Centers (CHCs), Primary Health Centers (PHCs), and sub-centers. Additionally, community outreach services are conducted using community health workers and volunteers, known as ASHAs, at the village level. Collaborations with non-governmental organizations (NGOs), private-sector providers, as well as district and regional health facilities and hospitals, are utilized to ensure comprehensive coverage.

Objective
To achieveAPI < 1 per 1000 population by the end of 2017.

Goals

1. Screen all fever cases suspected for malaria, utilizing quality microscopy for 60% and rapid diagnostic tests for the remaining 40%.
2. Administer a full course of effective Artemisinin-based Combination Therapy (ACT) and primaquine for all P. falciparum cases, and provide a three-day course of chloroquine and 14 days of primaquine for P. vivax cases.
3. Equip all health institutions at the Primary Health Center (PHC) level and above, particularly in high-risk areas, with microscopy facilities and Rapid Diagnostic Tests (RDT) for emergency use, along with injectable artemisinin derivatives.
4. Enhance the capabilities of all district and sub-district hospitals in malaria-endemic regions according to Indian Public Health Standards (IPHS), providing facilities for the management of severe malaria cases.

Strategies:

• Reform approaches to program planning and management.
• Enhance surveillance and strengthen monitoring and evaluation.
• Expand coverage and promote the proper use of insecticide-treated bed nets.
• Target interventions to specific risk groups.
• Increase the control measures for P. vivax.

2017-22

National strategic plan for malaria elimination in India 2017-2022

Over the last 15 years, India has made significant strides in reducing the prevalence of malaria. The country envisions achieving a malaria-free status by 2027 and complete elimination by 2030. The National Strategic Plan for Malaria Elimination (2017-2022) has been formulated based on the National Framework for Malaria Elimination (NFME) of the National Vector Borne Disease Control Programme (NVBDCP) under the Government of India (GOI) and the World Health Organization's Global Technical Strategy for Malaria Elimination (2016-2030). This strategic plan outlines yearly elimination targets for different regions of the country, taking into account the endemicity of malaria over the next five years.

The Prime Minister of India, along with 17 other leaders, endorsed the Asia Pacific Leaders' Malaria Alliance (APLMA) Malaria Elimination Roadmap during the East Asia Summit in Kuala Lumpur, Malaysia, in November 2015. They collectively committed to the objective of achieving a malaria-free region by 2030.

Definition of Malaria Elimination

"Interrupting local transmission involves reducing the incidence of indigenous cases of specified malaria parasite species to zero in a defined geographical area through intentional efforts. Sustained measures are necessary to prevent the re-establishment of transmission." (WHO 2017, A Framework for Malaria Elimination)

Goal:

• Attain malaria elimination (zero indigenous cases) by 2022 in all districts of the existing category-1 and 2 states/union territories, as well as in districts with Annual Parasite Incidence (API) less than 1 in Category-3 states.
• Transition all remaining districts (with API > 2) to the pre-elimination and elimination phase.
• Uphold the malaria-free status in areas where transmission has been interrupted and prevent the reintroduction of malaria by enhancing surveillance.

Specific objectives of NSP are as follows:

• Achieve universal coverage of case detection and treatment services in endemic districts, ensuring 100% parasitological diagnosis for all suspected malaria cases and complete treatment for all confirmed cases.
• Strengthen the surveillance system for the detection, notification, investigation, classification, and response to all cases and foci in all districts, moving towards malaria elimination.
• Achieve nearly universal coverage of the population at risk of malaria through appropriate vector control interventions.
• Achieve nearly universal coverage through appropriate Behavior Change Communication (BCC) activities, improving knowledge, awareness, and responsive behavior regarding effective preventive and curative interventions for malaria elimination.
• Ensure effective program management and coordination at all levels to deliver a combination of targeted interventions for malaria elimination.

The strategies to accomplish the goal and objectives of the National Strategic Plan (NSP) are categorized into four components, aligned with WHO-recommended principles and pillars adapted to India:

• Diagnosis and Case Management
• Surveillance and Epidemic Response
• Prevention - Integrated Vector Management
• Cross-cutting Interventions - Advocacy, Communication, and Community Mobilization, Program Management and Coordination, Monitoring and Evaluation, Research & Development

Enabling Environment for Malaria Elimination

• "Swachh Bharat" for eradicating mosquitogenic conditions and the forthcoming National Mosquito Control Mission,
• "Digital India" for real-time monitoring, capacity building, and communication.

Treatment Guidelines

• Artemisinin-based combination therapy (ACT-AL) is the primary treatment for uncomplicated P. falciparum malaria in accordance with the revised treatment guidelines implemented nationwide.
• Artesunate/Quinine injection is the preferred treatment for severe malaria, followed by a complete oral dose of ACT.
• Quinine remains the preferred treatment for pregnant mothers during the first trimester, children weighing less than five kilograms, and for cases of treatment failure.
• Chloroquine is the drug of choice for treating uncomplicated P. vivax malaria.
• The treatment approach for severe P. vivax malaria mirrors that of P. falciparum.
• Mixed infections (Pv and Pf) should be handled as P. falciparum cases, treated with ACT, and undergo a 14-day radical treatment as prescribed for P. vivax cases.

Malaria transmission is localized and focal, making the district the operational unit. Therefore, all districts or reporting units have been stratified into four categories based on the reported Annual Parasite Incidence (API) for the year 2015:

World Malaria Day

Celebrated annually on April 25th, World Malaria Day revolves around a specific theme each year. The current theme, "End Malaria for Good," underscores the growing dedication and interest in breaking the transmission cycle of malaria and achieving its complete elimination. This day provides an opportunity to reaffirm the political commitment of countries, encouraging sustained financial support and community ownership through various campaigns at all levels.

Anti-Malaria Month

The Anti-Malaria Month is observed throughout June each year, featuring month-long campaigns aimed at fostering stakeholder participation, including the community. Inter-personal communication (IPC) and context-specific Behavior Change Communication (BCC) will be employed to sensitize the community, school children, and other stakeholders, promoting ownership of the malaria elimination agenda. Messages will be widely disseminated through effective channels, such as community radio where feasible. Special efforts will be made to collaborate with the corporate sector, seeking their support through Corporate Social Responsibility initiatives.

National anti malaria programme-Repeats 

Malaria 

• Mention the changes in strategy of National Malaria Eradication Programme (2002). 
• Write about the Revised National Drug Policy for treatment of malaria. (2014)