Vector Borne Diseases Control Program

Vector Borne Diseases Control Program
DR. KANUPRIYA CHATURVEDI Series of National Health Programs lectures

Vector Borne Diseases Control Programme
Launched in 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 In India, the Directorate of National Anti Malaria Program (NAMP) is the national nodal agency for prevention and control of major vector borne diseases. In pursuance of the concept of convergence , Government of India approved a National Vector Borne Disease Control Program by merging he NAMP, National filaria control Program and kala azar control Program . Japanese B encephalitis and Dengue /DHF were also included in the Program. 4/20/2017 Dr. KANUPRIYA CHATURVEDI

Strategies for National Vector Control Program
The basic approach for vector borne diseases control involves a strategy directed against the parasite and vector and to enlist the involvement of community in practicing various preventive measures 4/20/2017 Dr. KANUPRIYA CHATURVEDI

Dr. KANUPRIYA CHATURVEDI
Strategies contd. Disease management Insecticide resistance Involvement of NGOs /private sector/community Quality assurance on laboratory diagnosis Long lasting insecticide treated nets 4/20/2017 Dr. KANUPRIYA CHATURVEDI

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 4/20/2017 Dr. KANUPRIYA CHATURVEDI

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. National Malaria control Program was launched in India in April It was based on indoor residual spraying twice a year in endemic areas where spleen rates were over 10%. The NMCP was in operation for 5 years. The results of the program were highly successful in that the incidence of malaria declined sharply from 75 million cases in 1953 to 2 million cases in Government encouraged by the success changed the strategy from control to eradication NMEP).in According to International standards the program was divided into Preparatory, attack, consolidation and maintenance phases. In the beginning NMEP was highly successful but soon setback appeared in the form of focal outbreaks . The resurgence had grown to epidemic proportions. The annual incidence of malaria escalated from 50,000 cases in 1961to a 6.4 million cases in 1976. Considering the resurgence Government of India, the program was modified and a “ Modified Plan of Operation was evolved In 1977. 4/20/2017 Dr. KANUPRIYA CHATURVEDI

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. 4/20/2017 Dr. KANUPRIYA CHATURVEDI

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 4/20/2017 Dr. KANUPRIYA CHATURVEDI

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. 4/20/2017 Dr. KANUPRIYA CHATURVEDI

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. 4/20/2017 Dr. KANUPRIYA CHATURVEDI

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. 4/20/2017 Dr. KANUPRIYA CHATURVEDI

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 4/20/2017 Dr. KANUPRIYA CHATURVEDI

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 4/20/2017 Dr. KANUPRIYA CHATURVEDI

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. 4/20/2017 Dr. KANUPRIYA CHATURVEDI

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 4/20/2017 Dr. KANUPRIYA CHATURVEDI

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. 4/20/2017 Dr. KANUPRIYA CHATURVEDI

‘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 4/20/2017 Dr. KANUPRIYA CHATURVEDI

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 The principal activities are regular insecticidal spraying and entomological assessment. The supportive activities are active and passive surveillance, presumptive and radical treatment. Under the MPO guidelines these areas are given 2 rounds of DDT, 3 rounds of malathion or 2 rounds of pyrethroids, the choice of insecticide depends on resistance developed by vector. Insecticidal spraying is guided by the periodic assessment of entomological assessment who study the behavior of vector mosquitoes. Various approaches are under study . These include source reduction, biological control , environmental improvement, health education and community participation. 4/20/2017 Dr. KANUPRIYA CHATURVEDI

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. In these areas the principal activities are active and passive surveillance, and presumptive and radical treatment The supportive activities are case follow -up, epidemiological investigation, and focal spraying where ever indicated. Surveillance in malaria essentially aimed at case finding and case confirmation. The efficacy of surveillance is determined by early identification of cases and prompt institution of radical treatment. The MPO strategy employs both active and passive surveillance mechanisms. Active surveillance is carried out by multipurpose health workers who visit every house in their respective areas at fortnightly intervals . They enquire whether any one is suffering or has suffered from fever during the previous fortnight. In the event of a positive response a worker prepares a blood smear of suspected case making a thin and thick film on the same slide. The worker also gives a single dose presumptive chemotherapy to the case and makes the necessary entries in the stencil of the house card. He takes the blood smear to the Primary Health Centre (PHC) laboratory for microscopic examination, and in the event of positive report, he contacts the confirmed case and puts him on a course of radical chemotherapy. 4/20/2017 Dr. KANUPRIYA CHATURVEDI

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 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 4/20/2017 Dr. KANUPRIYA CHATURVEDI

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) 4/20/2017 Dr. KANUPRIYA CHATURVEDI

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 of malaria should be promptly investigated and measures to contain the outbreak should be instituted. 4/20/2017 Dr. KANUPRIYA CHATURVEDI

National Filaria Control Program
4/20/2017 Dr. KANUPRIYA CHATURVEDI

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 4/20/2017 Dr. KANUPRIYA CHATURVEDI

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 4/20/2017 Dr. KANUPRIYA CHATURVEDI

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 4/20/2017 Dr. KANUPRIYA CHATURVEDI

National Filaria Control Program
This program was started in 1955 In 1998 the operational component was merged with Urban Malaria Scheme In it was merged with NVBDCP Filariasis has been a major public health problem in India next only to malaria. Indigenous cases have been reported from about 250 districts in 20 states/Union Territories. Bancrftian filariasis caused by Wucheria Bancrofti is transmitted in man by the bite of infected mosquites – culex and mansonia. This infection causes lymphangitis ,lymphadenitis , elephantiasis of genitals, legs and arms and causes tropical eosinophilia due to hypersensitivity. 600 million people are at risk and 60 million are infected in S-E Asia.In India 454 million are at risk and 48 million are infected. 4/20/2017 Dr. KANUPRIYA CHATURVEDI 27

Revised Filaria Control Strategy
The National Health Policy 2002 aims at Elimination of Lymphatic Filariasis by 2015 REVISED STRATEGY Annual Mass Drug Administration with single dose of Diethyl carbamazine(DEC)was taken up as a pilot During 2004 about 400 million population were brought under MDA. This strategy is to be continued for 5 years or more to the population excluding children below two years, pregnant women and seriously ill persons in affected areas to interrupt transmission of disease. 4/20/2017 Dr. KANUPRIYA CHATURVEDI 28

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 4/20/2017 Dr. KANUPRIYA CHATURVEDI

Kala Azar Control Program

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. 4/20/2017 Dr. KANUPRIYA CHATURVEDI

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 in It was merged with NVBDCP in 4/20/2017 Dr. KANUPRIYA CHATURVEDI

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 4/20/2017 Dr. KANUPRIYA CHATURVEDI

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 Serology tests: Variety of tests are available for diagnosis of Kala-azar. The most commonly used tests based on relative sensitivity; specificity and operationally feasibility include Direct Agglutination Test (DAT), rk39 dipstick and ELISA. However all these tests detect IgG antibodies that are relatively long lasting. Aldehyde Test is commonly used but it is a non-specific test. IgM detecting tests are under development and not available for field use. Parasite demonstration in bone marrow/spleen/lymphnode aspiration or in culture medium is the confirmatory diagnosis. However, sensitivity varies with the organ selected for aspiration. Though spleen aspiration has the highest sensitivity and specificity (considered gold standard) but a skilled professional with appropriate precaustions can perform it only at a good hospital facility. 4/20/2017 Dr. KANUPRIYA CHATURVEDI

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 4/20/2017 Dr. KANUPRIYA CHATURVEDI

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 4/20/2017 Dr. KANUPRIYA CHATURVEDI

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 4/20/2017 Dr. KANUPRIYA CHATURVEDI

Control Strategy An organized centrally sponsored Control Programme launched in endemic areas in 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 4/20/2017 Dr. KANUPRIYA CHATURVEDI

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 which led to improved case registration through primary health care system Programme Achievements 4/20/2017 Dr. KANUPRIYA CHATURVEDI

Control of Dengue/DHF 4/20/2017 Dr. KANUPRIYA CHATURVEDI

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 4/20/2017 Dr. KANUPRIYA CHATURVEDI

Dengue/DHF There was a major out break of Dengue /DHF in Delhi in 1996 Since than many focal outbreaks have been reported from different areas of the country mainly from urban areas. This disease has been included in NVBDCP in 4/20/2017 Dr. KANUPRIYA CHATURVEDI 42

Control Strategy Public awareness and community involvement is the key issue in the strategy to control Dengue/DHF All efforts should be made against the breeding of Aedes egypti mosquitoes by source reduction Protection from mosquito bites Early diagnosis and prompt treatment of cases 4/20/2017 Dr. KANUPRIYA CHATURVEDI 43

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 which led to improved case registration through primary health care system 4/20/2017 Dr. KANUPRIYA CHATURVEDI

Japanese encephalitis control

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 4/20/2017 Dr. KANUPRIYA CHATURVEDI

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 4/20/2017 Dr. KANUPRIYA CHATURVEDI

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. 4/20/2017 Dr. KANUPRIYA CHATURVEDI

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 4/20/2017 Dr. KANUPRIYA CHATURVEDI

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) 4/20/2017 Dr. KANUPRIYA CHATURVEDI

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 4/20/2017 Dr. KANUPRIYA CHATURVEDI

Control Strategy 1. Care of the patient to prevent sequaele 2. Development of a safe & Standard vaccine 3. 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 4/20/2017 Dr. KANUPRIYA CHATURVEDI

Vector Borne Diseases Control Program

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