Early Detection & Prompt Treatment (EDPT)

Identification Of High Risk Area
During the year 1995, the state experienced major malaria outbreaks especially in tribal districts of the state more prominently in Thane, Dhule, Nasik, Yeotmal, Chandrapur & Gadchiroli. Every year High Risk PHCs & Sub Centers are being identified as per guidelines given by Government of India (GOI). following are the epidemiological parameters for identification of High risk area.

Recorded deaths due to malaria with Plasmodium falciparum (Pf) infection during transmission season with evidence of local infection in an endemic area in any of the last 3 years.

Doubling of slide positivity rate (SPR) during last three years provided the SPR of 2nd & 3rd year reaches 4% or more.

SPR does not show doubling trend but the average SPR of the last 3 years is 5% or more.

P. falciparum proportion is 30% or more provided SPR is 3% or more during any of the last three years.

Focus of Chloroquine resistant P. falciparum area.

Tropical aggregation of labour in Project area.

New Settlement in endemic / respective & vulnerable area.

Surveillance

Active Surveillance: Blood smear collection of fever cases through regular house to house visits of multipurpose workers.

Passive Surveillance: Blood smears collection of fever cases coming at Primary Health Centers, rural & cottage hospitals, District Hospitals, & all govt. medical institutions etc.

Contact Mass Nomad (CMN) : Contact : Blood smears collection irrespective of fever of all family members of malaria positive case.

Mass : Blood smears collection irrespective of fever of all families around malaria positive case.

Nomad : Blood smears collection irrespective of fever of all persons of nomadic tribes.

Age group wise Presumptive treatment with Chloroquine is given to all fever cases at during active, passive, CMN collection .

Blood smears collected are examined in field & district level laboratories. On examination, one day radical treatment is given to Plasmodium falciparum (pf) cases detected and 5 days radical treatment to Plasmodium Vivax (Pv) cases detected as per the age group given below.

N.B.: No radical treatment of Primaquine tablets is given to infants and Pregnant women..

Distribution of Anti Malarials ( Chloroquine tablets)

1. Through Drug Distribution Centers (DDCs) :

About 66000 Drug Distribution Centers are established in Grampanchayats, Aanganwadi and Primary Schools at village level Chloroquine 150 mg. tablets are being distributed to fever cases coming to them without obtaining Blood Smears through these Depot holders.

2. Through Fever Treatment Depots (FTDs) :

1500 Fever treatment Depots are established only in tribal districts of the State. Chloroquine 150 mg. tablets are being distributed to fever cases coming to them with obtaining Blood Smears through these Depot holders.

3. Through Malaria Clinics :

Malaria Clinics are established in the State in hospitals & Primary Health Centers where Laboratory Technicians are posted. At present, 1028 Malaria Clinics are functioning in the State at various level.

At these clinics, blood smears are collected from fever cases coming for treatment. Presumptive treatment is administered after collection of Blood smears. These Blood Smears are examined immediately on priority.

Prompt Radical treatment as per age group & species is given on the same day to malaria cases detected after examination

Vector Control measures :

Indoor Residual Spraying Since 1999, State has stopped the use of DDT due to development of resistance in vector species. Synthetic Pyrethroid has been introduced for IRS since 1995-96 in Maharashtra State.

Indoor Residual Spraying (IRS) is being carried out in identified High Risk villages i.e. in Rural area.

Two regular rounds of IRS are being carried out every year during transmission season.

Focal spraying is also being carried out in outbreak areas.

Anti Larval spraying : Weekly spraying of larvicides (Temephos, Fenthion, MLO, BTI etc.) on mosquito breeding places is being carried out in urban areas.

Mosquito Control: Source Reduction

Source reduction involves preventing development of mosquito larvae. The female anopheles mosquito lays eggs in collections of clean water. Each female anopheles mosquito lays millions of eggs in its lifetime of 4-8 weeks. The eggs hatch into larvae which then develop into pupae and adults in a span of 7-10 days. The best method of mosquito control is preventing the development of the eggs into adult mosquitoes. These anti larval measures are not only simple and cost effective, but also environment friendly.

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Urban malaria scheme (UMS) is being implemented in selected 15 towns of the State. viz. Mumbai, Nasik, Manmad, Dhule, Jalgaon,Bhusawal, Ahmednagar, Pune, Pandharpur, Solapur, Aurangabad, Parbhani, Beed, Nanded, Akola.

Anti larval measures are the mainstay in malaria control and include the following:

a. Preventing egg laying: The easiest, cheapest and most environment-friendly meathod to control malaria is by preventing the mosquito from laying eggs. This is done by avoiding or eliminating the clean water collections. Most such collections are artificial, temporary and man made.

It is common habit to throw the unutilized utensils, buckets, bottles, tyres, tender coconut shells etc. into the open. During the rains, water gets collected in these containers and provides ample breeding locations for the female anopheles mosquito.

Biological activities:

Buckets	Tender Coconut shells
Open tank	Tyres

In the cities, the other sites for mosquito breeding are the water tanks. Shortage of water supply in large cities makes it necessary to have these tanks in virtually every building. Overhead tanks, sump tanks, storage tanks, ornamental tanks etc. are often left uncovered and this provides scope for mosquito breeding.

There is abundant scope for water collection in and around the construction sites: water stored in tanks; the layer of water on the surface of the cement concrete (used for 'curing' the concrete and left as such for 3 weeks); puddles of water in and around the place of construction - all these provide scope for mosquito breeding. To add to the problem, construction workers tend to harbour the malarial parasite, due to frequent infections owing to their poor standards of living. Thus, construction sites not only provide for mosquito breeding but also supply the parasites. This is the reason why malaria tends to be more common in cities where construction activities are in full swing.

The older houses have tiled roofs that are sloping. This helps easy drainage of water during rains, thus minimising water logging. In the recent years, most new constructions have concrete roofs and terraces that tend to be flat and non-sloping. These roofs/terraces may not have proper drains for water-flow. As a result, water tends to collect on these rooftops during the rains and this provides ample scope for mosquito breeding.

Paddles	Water logged in basement

In addition, there are the natural collections of water like the wells, lakes, ponds, paddy fields, marshlands etc. where mosquito breeding occurs in abundance

Unused wells

Therefore, unless these breeding sites (most of which are man-made and temporary) are taken care of, it is impossible to control mosquito breeding and hence malaria. And it is impossible to achieve this without the participation of the general public. Education of the people is thus very important for any meaningful action. The following measures are called for to minimize mosquito breeding and these measures require only a trifle of human efforts:

Do not throw utensils, vessels, buckets, tyres, bottles, tender coconut shells etc. in the open. They should be either destroyed or buried or at least kept inverted so that water cannot collect in them. All such things should be cleared during the rainy season.

All tanks should be kept tightly closed. A black plastic sheet can be used for the purpose. Also, all tanks should be emptied, cleaned and allowed to dry for at least half an hour, once every week.

Terraces and roofs should ideally have a slope, particularly in places where monsoon tends to be heavy. All such roofs/terraces should have adequate drainage for water. Any collection of water on these surfaces should be cleared at least once a week.

At construction sites, all the care should be taken to avoid collection of water at one place for more than a week. The layer of water on the surface of the concrete, used for concrete curing, should be cleared at least once a week and allowed to dry for half an hour. All other puddles should be cleared regularly. Collections of water in the toilets and closets under construction should also be cleared. All tanks should be kept snugly closed. All labourers should be frequently checked for parasitemia and adequately treated. They should also be provided with mosquito nets.

All unused wells and tanks should be closed or destroyed. Engine oil or kerosene has been used as a larvicidal on these collections. Another method to prevent egg laying on unused wells is by adding EPS polyesterene beads onto the surface of water. These beads are non-toxic, cheap and long lasting. They coat the water surface and prevent the mosquito from laying eggs.

Wells that are being used and ornamental tanks can be treated with biological larvicides that do not harm the quality of drinking water. Also, these wells should be covered with either mosquito-proof nets or with plastic sheets.

How engineers can help in malaria control?

Public Health Engineering has lot to do with malaria control, especially by means of Source Reduction.

Prevent water logging – Design the buildings with sloping roofs to aid easy drainage of rain water; provide drains in adequate numbers and sizes in buildings with flat roofs

Prevent entry of insects – Screening of all windows and vents should be made mandatory. It is observed that this simple, common sense measure followed in every construction in the U.S.A. has in a big way helped in control of all insects including mosquitoes and hence malaria.

Engineering skills are also called for in draining and flushing of water collections; deepening or filling of water logged areas; proper maintenance of water levels and intermittent irrigation in dams and canals and in changing salt content of water so as to make it unsuitable for mosquito breeding. Mosquitoes that breed in irrigation water can be controlled through careful water management

Anti Larval spraying : Weekly spraying of larvicides (Temephos, Fenthion, MLO, BTI etc.) on mosquito breeding places is being carried out in urban areas.

Urban malaria scheme (UMS) is being implemented in selected 15 towns of the State. viz. Mumbai, Nasik, Manmad, Dhule, Jalgaon, Bhusawal, Ahmednagar, Pune, Pandharpur, Solapur, Aurangabad, Parbhani, Beed, Nanded, Akola.

Biological activities:

Considering the adverse effect such as development of insecticide resistance in Vector and environmental pollution by chemical insecticide, State has developed Biological method, under which introduction of larvivorus Guppy fish at suitable mosquito breeding places is started since 1997, in phased manner in Maharashtra State. In first phase, Guppy fish hatcheries were established at all Health Institutions.

From 1998 onwards, Guppy fish is released in suitable mosquito breeding places. The number hatcheries established is 8269 and Guppy fish are released in 90512 mosquito breeding places in the State so far.

Use of Biocides : It is being used in Navi Mumbai town regularly which is under Enhanced Malaria Control Project. State has purchased additional biolarvicide for another towns from Non Project area.

Entomological studies

Routine Entomological studies such as assessment of impact of insecticides, larvicides which are in use.
Insecticide resistance studies, vector bionomics, investigations of focal outbreaks and to suggest suitable control measures.
Monitoring of Biological Control measures.

Life cycle of human malaria :

click to view details

Use of Biocides : It is being used in Navi Mumbai town regularly which is under Enhanced Malaria Control Project. State has purchased additional biolarvicide for another towns from Non Project area.

Personal Protection Method :

Use of Medicated Mosquito Nets : Since age long mosquito nets have played a major role in avoiding man mosquito contact. Comparing with Synthetic Pyrethroid Indoor Residual Spraying, use of Medicated Mosquito Nets is cheaper and more acceptable by the community. Considering the benefits of medicated mosquito

Bednet

nets, the State has introduced use of medicated mosquito nets in selected villages on pilot project as per guidelines given by National Anti Malaria Programme. Under personal protection methods the use of Medicated Mosquito nets has been shown good results in bringing down malaria situation in selected villages. Since the year 1996-97, 2.20 lacs Medicated Mosquito nets have been distributed in selected 722 villages so far.

Entomological studies

World Bank assisted Enhanced Malaria Control Project : (EMCP)

The anti malaria activities are being carried out in the State as recommended by the Expert Committee in Malaria Action Plan - 1995.

To intensify malaria control activities, World Bank assisted Enhanced Malaria Control Project started in Oct. 1997 in 7 States; one of them is Maharashtra. 14 tribal districts viz. Raigad, Thane, Ahmednagar, Dhule, Jalgaon, Nasik, Pune, Nanded, Amravati, Yeotmal, Bhandara, Chandrapur, Gadchiroli, Nagpur and Navi Mumbai Corporation area are included in the project.

During 1999, District Dhule & Bhandara are split up in 2 districts Dhule, Nandurbar and Bhandara, Gondia respectively. Accordingly, there are 16 tribal districts under EMCP now.

For effective implementation and monitoring of the project, State Malaria Control Society is established under Chairmanship of the Secretary, Public Health Department.

Project activities under EMCP are as given below :

1. Early Detection & Prompt Treatment. (EDPT)

2. Selective Vector Control.

3. Personal Protection method.

4. Early Detection & Containment of Epidemics.

5. Inter Sectoral Co-ordination.

6. Institutional & Management capacity building.