Malaria Control in India an Utpian Dream

Transcription

1 Malaria Control in India an Utpian Dream Prof. Dr. S. Elango, MD, DPH,DIH, Director of Public Health & PM (Retd) HOD, Dept. of Community Medicine Sri Muthukumaran Medical College Chennai-69

2 Recall Malaria history Global Burden Malaria scenario in India Failures and challenges New Advances/ Researches Conclusions 2

3 How many of you agree that National Malaria Control Programme (NMCP) has made No Progress Some progress Good Progress Very Good Progress in control of Malaria in INDIA.. 3

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5 The Dark Ages 1500 years ago little knowledge on the cause or treatment of malaria. During this time malaria spread in Europe and the New World New idea came that the disease is related with swamps and marshes. Led to the belief that malaria was caused by malignant vapors (miasmas) French term Paludisme roughly translates of the marshes Mal aria (bad air) was ascribed by Horace Walpole in 1740

6 Discovery of Quinine (Early 17th Cent.) Spanish missionaries learned from Indian tribes of a medicinal bark for treating fevers Wife of the Viceroy of Peru, was cured of her fever. The bark was then called Peruvian bark and the tree named Cinchona. Medicine from the bark is now known as quinine. 6 Like artemisin, quinine still remains one of the most effective anti-malarial drugs available today

7 Discovery of the Malaria Parasite (1880) Charles Louis Alphonse Laveran, a French army surgeon was the first to notice parasites in the blood of a patient suffering from malaria. This occurred on the 6th of November For his discovery, Laveran was awarded the Nobel Prize in

8 NOBEL PRIZES Four Nobel prizes have been awarded for work associated with malaria: Sir Ronald Ross (1902), Charles Louis Alphonse Laveran (1907), Julius Wagner-Jauregg (1927), Paul Hermann Muller (1948). 8

9 Malaria imposes a staggering worldwide burden High None Level of malaria burden Death toll Incidence Health impacts Economic impacts Source: World Malaria Report 2005, expert interviews At least 1 million deaths annually; one child every 30 seconds 350 to 500 million cases worldwide Debilitating fevers, low birth weights, anemia, epilepsy and death Reduced current productivity resulting from days and often weeks of missed work, reduced foreign direct investment and tourism Constraints on future growth resulting from reduced investments in human capital (missed schooling, higher fertility rates) 9

10 Distribution of Malaria (a Tropical Disease?) 10 Hay, et al. 2004

11 Current global estimates of population at risk by WHO Region Approximately 0.95 billion at risk (Source: WHO regional offices, Kicewski, 2007) 11

12 Global Malaria Burden 3.3 billion people (half the world s population) live in areas at risk of malaria transmission in 109 countries and territories. 35 countries (30 in sub-saharan Africa and 5 in Asia) account for 98% of global malaria deaths. WHO estimates that in 2008 malaria caused million clinical episodes, and 708,000-1,003,000 deaths. 89% of the malaria deaths worldwide occur in Africa. Malaria is the 5th cause of death from infectious diseases worldwide (after respiratory infections, HIV/AIDS, diarrheal diseases, and tuberculosis). Malaria is the 2nd leading cause of death from infectious diseases in Africa, after HIV/AIDS. 12

13 Global Malaria Burden Cont. Feared since the days of the Roman Empire, malaria remains a major health problem. Globally, approximately 225 million malaria cases and 781,000 deaths reports each year, mostly in African children (WHO, 2010) India contributes about 70% of malaria cases and 50% of mortality in the South East Asian Region of WHO 13

14 Malaria means bad air A life-threatening parasitic disease 40% of the world s population is at risk 90% of the deaths due to Malaria occur in Sub-Sahara Africa, mostly among young children. Around million people are affected At least 2.7 million deaths annually. It is one of the major public health concerns 14

15 India TREND nearing eradication in 1960s (< 100,000 cases) to resurgence in the mid-1970s (~6.4 million cases) and stabilizing trend to ~2 million cases in the1990s over 10 crore suspested malaria cases, but only 15.9 lakh could be confirmed last year (8.3lakh -P. Falciparum, 7.6 lakh-p.vivax) Annual deaths: 30, 014 and 48, 660 Over 70% of India's population, or crore face the risk of malaria infection. Around 31 crore, however, face the "highest risk" of getting infected by the vector-borne disease. Indo-gangestic plains and northern hilly states, northwestern India and southern Tamil Nadu state have < 10% P. falciparum, and the rest are P. vivax infections; in the forested areas inhabited by ethnic tribes, the situation is reversed, and the P. falciparum proportion is 30 90%, and in the remaining areas, it is between 10% and 30% Source:World Malaria report 2011 WHO 15

16 Year Population (in 000) Epidemiological Situation in India( ) --Nvbdcp Total Malaria Cases (million) P.falciparum cases (million) Pf % API Deaths due to malaria

17 Malaria Cases, Pf cases(in millions) & Deaths (2000 to 2010) Source: Nvbdcp

18 Total Malaria Cases, Pf %, Deaths & MCDR Year Total Malaria cases P f % Deaths MCDR % Duration (Millions) Years Years Years Years Year

19 Analysis and Interpretation of PF% and MCDR% Z Year Cases in million PF% Z Significe MCDR% BASE END BASE END BASE END BASE END Significa ** P< * P< * P< * P< ** P< * P< ** P< ** P< ** P< * P> * P< ** P< ** P< ** P< * P< ** P< ** P< * P< * P< ** P< ** P< ** P< ** P< * P< ** P< * P< ** P< ** P< * P< * P< ** P< ** P<0.001 * Decrease ** Increase

20 Trends in Malaria Malaria cases in million PF% MCDR/

21 Elements of malaria control strategies Drugs and diagnosis at health centre and community level Infected vector STOP Human Parasite STOP P STOP Universal LLIN coverage/ IRS Universal LLIN coverage Infecting vector 21

22 From eradication to control to renewed efforts for elimination: How can we avoid past mistakes? 2007 onwards: Renewed optimism about elimination failed eradication era : Modest era of prevention and control : Era of Apathy and no resources : Neglected Era 22

23 Malaria on the Global Agenda Roll Back Malaria set up in 1998 Abuja Declaration in 2000 Millennium Development Goals, New York, 2000; Global Fund set up in 2000 RBM Global Malaria Action Plan with 2010 and 2015 target The Malaria Eradication Research Agenda (malera) initiative Malaria Vaccine Initiative 23

24 Issues in Malaria Clinical diagnosis Varied presentation- Carrier, Asymtomatic Drug side effects Drug resistance - chloroq, meflo, arteminsin Insecticide resistance Mixed infection vivax with falciparum Mixed infection with others Multi organ involvement Under reported data 24

25 Failures &Challenges Leadership and management capacity for health services (centre and districts) Human resources recruitment, retention and deployment Capacity of Institutions: knowledge, data, information Integrated Health System Delivery of Minimum Package: stamina, incentives, politics Inter-sectoral coordination Sustaining partnership and trust Malaria and emergencies(other priorities) Global Initiatives: Resurgence: Displace local resources, ownership and sustainability Climatic changes, Urbanization Low health sector resource envelope 25

26 Global drug resistance to malaria the WHO Global Plan for Artemisinin Resistance Containment (GPARC) recommended that all countries ban the marketing of oral artemisinin-based monotherapies, one of the major factors fostering the emergence of drug resistance. Change antimalarial treatment policies when treatment failure is >10% (as assessed through monitoring of therapeutic efficacy at 28 days) Change to a treatment which has an average cure rate 95% as assessed in clinical trials " Prompt and accurate diagnosis of malaria is the key to effective disease management and to the reduction of unnecessary use of antimalarial medicines." 26

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28 Malaria Vaccines Currently no licensed Malaria Vaccines. 20 in Trial. RTS,S/ASO1. RTS,S is Pf Vaccines. Bill and Mellinda gates foundation. Glaxo smith, PATH & MVI. 28

29 "Fighting malaria with engineered symbiotic bacteria from vector mosquitoes * Sibao Wang, Anil K. Ghosh, Nicholas Bongio, Kevin A. Stebbings, David J. Lampe and Marcelo Jacobs-Lorena. demonstrate the use of an engineered symbiotic bacterium to interfere with the development of P. falciparum in the mosquito. These findings provide the foundation for the use of genetically modified symbiotic bacteria as a powerful tool to combat malaria 29

30 Way Forward 1 Sustain financing 2 Overcoming barriers to access and coverage Investing in RD to stay ahead of resistance and develop new tools Re-orient and strengthen national malaria control programs to address current and future scenarios Strengthen advocacy and social mobilization 30

31 We need to act with urgency and resolve to ensure that no one dies from malaria for lack of $5 bed net, $1dollar anti-malarial drug and a 50 cent diagnostic test. Robert Newman, director of WHO's global malaria programme 31

32 Time Magazine 30 June

33 Conclusion One of the oldest known diseases. Malaria has been infecting humans for over 50,000 years. References to malaria have been recorded for nearly 6000 years, starting in China. Used to be common in Europe and North America. First advances in malaria were made in 1880 by a French army doctor named Charles Laveran. Carlos Finlay discovered that mosquitoes transmitted diseases. Ronald Ross discovered that mosquitoes transmitted malaria in First effective medicine was discovered by Pierre Pelletier and Joseph Caventou. This medicine is called quinine, which comes from the bark of cinchona trees in Peru. No effective vaccine: only immunity is a result of multiple infections. 33

34 As we reconsider the e word some definitions. Elimination: Reduction to zero of the incidence of infection caused by a specific agent in a defined geographical area as a result of deliberate efforts; continued measures to prevent reestablishment of transmission are required. Example: poliomyelitis. Eradication: Permanent reduction to zero of the worldwide incidence of infection caused by a specific agent as a result of deliberate efforts; intervention measures are no longer needed. Example: smallpox. Extinction: The specific infectious agent no longer exists in nature or in the laboratory. Example: none. 34

35 In India.. There is a decrease in absolute number of total Malaria from 2.93 million in 1995 to 1.49 million in But There is an increased proportion of Pf Cases from 38.84% in 1995 to 52.12% in The Malaria case specific death rate(mcdr) is increased from 0.039% in 1995 to 0.051% in The statistical analysis reveals that increase of Pf cases is very highly significant (P<0.001) and MCDR is also very highly significant (P<0.001). 35

36 Inference So the inference is the Malaria program in India has No impact on reduction of Pf% cases and MCDR.. But there is some progress. 36

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