Vector Borne Diseases Control Program

DR. KANUPRIYA CHATURVEDI

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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

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Strategies for NationalVector Control Program

The basic approach for vector bornediseases control involves a strategydirected against the parasite and

vectorand to enlist the involvement ofcommunity in practicing variouspreventive measures

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Strategies contd.

Disease management Insecticide resistance Involvement of NGOs /private

sector/community Quality assurance on laboratory

diagnosis Long lasting insecticide treated nets

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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

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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.

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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.

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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

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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.

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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.

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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.

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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

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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

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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.

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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

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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.

 

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‘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

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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

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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.

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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

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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)

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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 ofmalaria should be promptly investigated and measures to contain the outbreak should be instituted.

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National National Filaria Control ProgramFilaria Control Program

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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 Lewis in 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

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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

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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

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National Filaria Control National Filaria Control ProgramProgram

This program was started in 1955This program was started in 1955 In 1998 the operational component wasIn 1998 the operational component was merged with Urban Malaria Schememerged with Urban Malaria Scheme In 2003 -04 it was merged with In 2003 -04 it was merged with NVBDCPNVBDCP Filariasis has been a major public health Filariasis has been a major public health

problem in India next only to malaria.problem in India next only to malaria. Indigenous cases have been reported Indigenous cases have been reported

from about 250 districts in 20 from about 250 districts in 20 states/Union Territories.states/Union Territories.

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Revised Filaria Control StrategyRevised Filaria Control Strategy

The National Health Policy 2002 aims at The National Health Policy 2002 aims at Elimination of Lymphatic Filariasis by 2015Elimination of Lymphatic Filariasis by 2015

REVISED STRATEGYREVISED STRATEGY Annual Mass Drug Administration  with single dose Annual Mass Drug Administration  with single dose

of Diethyl carbamazine(DEC)was taken up as a of Diethyl carbamazine(DEC)was taken up as a pilot pilot

During 2004 about 400 million population were During 2004 about 400 million population were brought under MDA. brought under MDA.

This strategy is to be continued for 5 years or more This strategy is to be continued for 5 years or more to the population excluding children below two to the population excluding children below two years, pregnant women and seriously ill persons in years, pregnant women and seriously ill persons in affected areas to interrupt transmission of disease.affected areas to interrupt transmission of disease.

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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

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Kala Azar Control Program

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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.

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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

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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

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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

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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

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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

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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

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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

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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

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Control of Dengue/DHF

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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

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Dengue/DHFDengue/DHF

There was a major out break of There was a major out break of Dengue /DHF in Delhi in 1996Dengue /DHF in Delhi in 1996

Since than many focal outbreaks have Since than many focal outbreaks have been reported from different areas of been reported from different areas of the country mainly from urban areas.the country mainly from urban areas.

This disease has been included in This disease has been included in NVBDCP in 2003 -04NVBDCP in 2003 -04

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Control StrategyControl Strategy

Public awareness and community Public awareness and community

involvement is the key issue in the involvement is the key issue in the

strategy to control Dengue/DHFstrategy to control Dengue/DHF All efforts should be made against theAll efforts should be made against the

breeding of breeding of Aedes egypti Aedes egypti mosquitoes mosquitoes

by source reductionby source reduction Protection from mosquito bitesProtection from mosquito bites Early diagnosis and prompt treatment of Early diagnosis and prompt treatment of

casescases

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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

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Japanese encephalitis control

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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

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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

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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.

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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

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Sign and Symptoms of JE JE virus infection presents classical symptoms

similar to any other virus causing encephalitis JE virus infection may result in febrile illness of

variable severity associated with neurological symptoms ranging from headache to meningitis or encephalitis. Symptoms can include headache, fever, meningeal signs, stupor, disorientation, coma, tremors, paralysis (generalized), hypertonia, loss of coordination, etc.

Prodromal stage may be abrupt (1-6 hours), acute (6-24 hours) or more commonly subacute (2-5 days)

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Contd. In acute encephalitic stage, symptoms noted in

prodromal phase convulsions, alteration of sensorium, behavioural changes, motor paralysis and involuntary movement supervene and focal neurological deficit is common. Usually lasts for a week but may prolong due to complications.

Amongst patients who survive, some lead to full recovery through steady improvement and some suffer with stabilization of neurological deficit. Convalescent phase is prolonged and vary from a few weeks to several months.

Clinically it is difficult to differentiate between JE and other viral encephalitis

JE virus infection presents classical symptoms similar to any other virus causing encephalitis

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Control Strategy

1. Care of the patient to prevent sequaele2. Development of a safe & Standard vaccine3. Sentinel surveillance including clinical

surveillance of suspected cases.4. Studies to identify high risk cases

5. Epidemiological monitoring of the disease and effective implementation of preventive

and control measures