1. Recent trend in malaria

2. Global Distribution of Malaria
                                                                 
Slide 6. Global Distribution of Malaria
This slide shows the global distribution of malaria.
Malaria is found in places where Anopheles mosquitoes can survive and the malaria parasites can complete their life cycle within the host. Climatic factors such as temperature, humidity, and rainfall are especially important, with the highest transmission rate found in Africa South of the Sahara.
Economic development and public health measures have succeeded in eliminating malaria in many temperate areas, such as western Europe and the United States. Many of these areas have Anopheles mosquitoes that can transmit malaria, and reintroduction of the disease remains a risk.
CDC. Available at Accessed October 17, 2004.
Accessed October 17, 2004
CDC. Available at

3. Global Burden Malaria is a global disease.
40% world pop. lives in malarious areas.
m malaria cases annually.
2– 3m death an average of one person every 12 seconds. Mostly children (<5 yrs).
India contribute 23% of clinical cases of Pf.
1.2 billion PAR P. vivax which is 42% of the global PAR.
Hay et al., Lancet. 7(6):e
Contd…

4. Burden in Asia and India
2.4m malaria cases reported from South Asia.
Of which 75% are in India alone.
Five states responsible >60% malaria.
Orissa, CG, MP, Jharkhand & WB.
Malaria infect human at conception till adult.
Patients survive if they timely access to medicines.
Malaria present a diagnostic challenge.
World Malaria Report World Health Organization

5. Burden
Dhingra et al., Oct 2010 Lancet

6. MALARIA PROFILE OF INDIA
( ) 6

7. State wise malaria contribution in IndiaPF
Malaria Cases
Deaths

8. Diagnosis Clinical: Grossly inaccurate
Microscopy: Thick and thin blood smear
Fluorescent Microscopy
Polymerase Chain Reaction (PCR)
Rapid Diagnostic Tests (RDT)

10. Blood Smear
! The quantity of blood is very important for the thick smear
! Not enough blood may lead to a WRONG NEGATIVE RESULT.
Too much blood cannot be stained properly and CANNOT BE EXAMINED

11. FLUORESCENCE MICROSCOPY
Fluorescent dyes have an affinity for nuclic acid in the parasite nucleus.
They attach to the nuclei.
Under UV light, the nucleus fluorecence strongly (490nm).
Two fluorochromes used,
Acridine Orange (AO) Benzothio Carboxypurine (BCP)
Green/Yellow fluorescence

12. Quantitative Buffy Coat (QBC) (Becton Dickingson Franklin Lakes N.J.)
QBC combines an AO coated capillary tube.
Centrifuged Parasite concentrate below layer of cells.
In the upper layer of RBC
Between layers of Platelets and WBC.
Parasite can be viewed through the capillary tube using focal length objective (Paralens)

13. Limitations
QBC, BCP and AO are rapid and easy when parasitaemia >100 parasites/l.
Inability to differentiate between Plasmodium species (AO/BCP)
AO hazardous has special disposal requirements
QBC/BCP more demanding technically than AO
QBC requires a particular centrifuge and its tubes. This increase costs to about US$1.7/sample.

14. PCR
Nested PCR and reverse transcription PCR enable all four species to be identified.
P.falciparum
P.vivax
Lane 1-11 :Samples, Lane 12 & 13: positive & negative control, Lane 14: 100 bp DNA ladder
Lane 2-12 :Samples, Lane 1 & 13: positive & negative control, Lane 14: 100 bp DNA ladder

15. Limitations Advantages
Expensive, extensive technical expertise
Labour intensive involved multiple steps
High cost of the enzymes and primers
Ability to detect low level parasitaemia
5 parasites/µl can be detected (100% Sen/Sp.)
Strain variations, mutations and drug resistance
Mixed infection

16. Why use RDT? Early diagnosis and prompt treatment.
Rapid, reliable and simple to perform-
RDTs an alternative to microscopy.
With New Expensive ACT, RDT is must.

17. RDTs Three type of Antigen detection tests common.
Histidine rich Protein 2 (HRP-2).
Plasmodium Lactate dehydrogenase (pLDH) test usually detects falciparum and non falciparum.
Combo test
HRP-2 + pLDH based - First Response
HRP-2 + Aldolase ICT Combo

18. Principle
Diagnosis is based on Detection of HRP-2 released from infected erythrocytes with P. falciparum monoclonal antibodies against HRP-2 fixed in the test strip that reacts with heamolyzed blood samples from positive patients. The antigen/antibody reaction is revealed by the addition of a detector reagent. A solid pink line on the strip indicates a positive test.

22. Advantages (RDTs)
Do not require extensive training or good infrastructure or electricity.
Simple to perform.
Easy to learn.
Ideal on the spot diagnosis and treatment.
No supervision required.
Simple to carry in the field.

23. Limitations (RDTs) Expensive Low sensitivities in low parasitaemia
Persistent positivity upto 2 weeks after medication
May not be used for identification of drug resistance
False positives rheumatoid factor/ heterophile antibody
It can not different between current/ recent parasitaemia
Can not quantify the parasitaemia
Can not differentiate between sexual and asexual

24. Assisting staff fills consent form Collection of blood sample for RDT
Interpretation of Rapid Diagnostic Test Kit
Medical Officer provides medicine

25. Molecular Diagnostics
GENOMIX reader for Point-of-Care Diagnostics
Molecular Diagnostics
Portable Reader
Handheld
Reader
A functional Genomics Company

26. Loop Mediated Isothermal
Malaria Lamp Assay
Loop Mediated Isothermal
Amplication
900 grams weight

27. Major Vectors in India Anopheles fluviatilis Anopheles culicifacies
Anopheles stephensi
Anopheles sundaicus
Anopheles minimus
Anopheles dirus

28. Monitoring of insecticide resistance of An
Monitoring of insecticide resistance of An. culicifacies, malaria vector in district Balaghat, Dindori, Mandla, Sidhi, Jhabua and Shahdol of MP
Insecticide Mortality
DDT 4% 6.7 – 11.2%
Malathion 5% 77.3 – 83.5%
Deltamethrin – 97.0%
0.05%
Alphacypermethrin %

29. DYNAMICS OF P.vivax & P.falciparum RATIO IN STUDY AREA SHOWING SHIFTING TREND
Singh et al., Trop Med Int Hlth

30. Aims of National Drug Policy on Malaria (2010)
Providing complete cure of malaria cases.
Prevention of progression of uncomplicated malaria to severe malaria.
Prevention of relapses by administration of radical treatment.
Interruption of transmission by the use of gametocytocidal drugs.
Preventing development of drug resistance by early treatment of malaria.

31. Treatment of Malaria
All fever cases should be tested by microscopy/ RDT
No presumptive treatment
P. vivax - CQ (3 days) PQ for 14 days
P. falciparum - ACT 3 days
- PQ single dose
Cases not responding to ACT should be treated with oral quinine with Tetracycline/ Doxycycline

32. National Drug Policy During Pregnancy
Pregnant women with Pf (uncomplicated)
1st Trimester – Quinine
2nd & 3rd Trimester – ACT
(Artesunate + Sulphadoxine-Pyrimethamine)

33. Thank you…