NATIONAL MALARIA ERADICATION PROGRAMME INCLUDING KALA-AZAR CONTROL PROGRAMME

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Title: NATIONAL MALARIA ERADICATION PROGRAMME
INCLUDING KALA-AZAR CONTROL PROGRAMME
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Agenda Item No. XIV

w- NATIONAL MALARIA ERADICATION PROGRAMME

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INCLUDING KALA-AZAR CONTROL PROGRAMME

i A MALARIA

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For controlling the malaria disease a nation-wide Malaria Control

Programme was launched as early as 1953 and enthused by the excellent
results achieved, the Government launched a National Malaria Eradication

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Programme in 1958 with an objective of eradicating the disease After

initial spectacular success in controlling the disease and bringing down

its incidence in the community from 75 million during pre-eradication to

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0.1 million by 1965, the programme received setback due to various con
straints of financial, logistics, administrative and technical nature.

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and launcing a Modified plan of operation (MPO) in 1977 to tackle the
The objectives of the M.P.O. were(i) effective control of

malaria to bring reduction in malaria morbidity, Hi) prevent deaths due to
malaria and (Hi) retention of the achievements gamed.

The mam

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strategies adopted are ;
Eady case detection and prompt treatment.
i)
Vector control by house spraying in rural areas with Annual

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Parasite incidence per thousand population 2 & above with

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resulted in the resurgence of the malaria disease during early seventies

situation.

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appropriate insecticides and by recurrent anti larval measures

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Health education and community participation.

With the

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in urban areas.
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implementation of the revised approaches as above, the

brought down from 6.47 million cases in 1976
incidence of malaria was i
■ 19&4 and since then total malaria cases are
to !?. /<9 million cases

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contained around two million annually.

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The epidemiological data for the year 1976, and 1984 onwards are as
follows
YEAR

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MALARIA CASES

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DEATHS

(IN MILLION)

. (IN MILLION)

J

1976

6.47

0.76

59

1984

2.18

0.65 M

247

1985

1.86

0.54

213

1986

1.79

0.64

323

1987

1.66

0.62

188

1988

1.85

0.68

209

1989

2.05

0.76

268

1990

2.02

0. 75

353

1991

2.11

0.92

421

1992

2. 13

0.88

422

1993

2.20

0.85

354

1994

2.23

0.8$

1167

0.22

457

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1995(up to June, 95)

0.58

p

•8

. P.F.CASES

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(out of these 197

suspected unconfirmed)

From these data it is evident that with the implementation of MPO
the malaria situation has been contained around two million cases since

1984 inspite of various constraints of financial, logistics, administrative,

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operational and technical nature and added to it, onslaught of natural

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factors promoting the malariogenic conditions in certain areas specially

hilly and forested-tracks in the North Eastern region as well as centra!
peninsula.

The P. falciparum incidence could also be contained around

0.8 million cases per annum.In the major states malaria epidemiological

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profile during recent years is as follows:

MALARIA EPIDEMIOLOGICAL HIGHLIGHTS - MAJOR STATES 1993 TO 1995
________ WP TO JUNE)
SI.
No.

STATE

MALARIA EPID. PROFILE-PERCENT TO TOTAL COUNTRY

1993

1994

CASE

PF

DEATH CASE

PF

14.6

32.0

PF

33.7

12.4

28.8

6.6

DEATH
16.5 36.8
7.0

2. Gujarat
3. Maharashtra ■

13.8

9.0

7,0

1 1.0

1.2

9.4

4,3

1 1.4

8.0

4.3

12.5

7.9
9.7

0.8

4.

12.8

8.6

Madhya Pradesh

12.8

17.6

3.4

12.7

15.0

2.4

9.5

5.

12.7

Rajasthan

.4.8

3.2

5.4

10.3

10.6

39.0

12.0

6.

6.3

6.5

Assam

5.4

9.4

13.5

6.7

10.7

5.8

14.4

19.5

7.

65.0

Karnataka

8.9

5.7

9.2

3.6

0.2

8.8

1.1

0.4

8.

West Bengal

4.0

0.7

3.0

1.5

4.4

2.0

1.1

9.1

9. Uttar Pradesh

5.1

0.6

4.3

0.2

8.3

12.1

0.7
15.1

1.3

1 i I AilNE States

1.

Orissa

V

10.5

31.0

10.9

43.0

16.7 | 22.2

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1995
DEATH CASE

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76.0

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18

TARGETS AND ACHIEVEMENTS

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Under the physical targets annual blood slide examination rate
ABER is taken which indicates efficacy of surveillance which have been
fixed to a minimum to 10% of population under technical target for spray

the area having more than 2 annual parasite incidence(API)

population m 3 sucessive years, is

targeted to be protected with

appropriated insecticides.
A. FOR THE COUNTRY AS A WHOLE

PARAMETERS

YEAR

0 A.p.l.
1990
(Annual Parasite 1993
Incidence)
1994

8

TARGET
(API)

per 1000

ACHIEVEMENTS

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1.9
NOT FIXED
NOT FIXED

2.57
2.64
2.58

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2000 A.D. <^8

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I) ABER
(Annual
Blood
Examination
Rate)

YEAR

TARGET

10% OF THE

1990

ACHIEVEMENTS
% Of target
93.8

populaNon
-DO—
-DO-

1993
1994

iii) POPULATION
PROTECTED WITH
RESIDUAL INSECTI
CIDE

1993
1994

159.49 MILL.
162.67 MILL.

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9/.8

87.3
66.75
58.52

Mt

1995
(PROJECTED) 158.34 MILL.

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B. ACHIEVEMENTS BY THE STATES

The States which have achieved physical targetsiagainst 1O%‘ ABER) during last year are Andhra Pradesh (13. 13), Arunacha! Pradesh

(35.07), Gujarat (16.10),Haryana (11.95), Himachal Pradesh (13.83),
Karnataka (12.71), Maharashtra (13.91), Meghalaya (11.20), Mizoram
(28.87), Punjab (11.76), Rajasthan (11.32), Sikkim (12.61), Andaman &

^Nicobar Island (51.08), Chandigarh (14.66) Dadara & Nagar Haveli
(29.98), Daman & Diu(21.03), Delhi (1 1.31) and Pondicherry (26.04).

The States which could not achieve physical target of ABER are

Bihar (0.65), Assam(9.91), Kerala(3.59), Goa (8.55), West Bengal (3.35),
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Jammu & Kashamir (8.79), Madhya Pradesh (9.84), Manipur(8.52),

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Naga/and(5.07), Orissa (8.55), Tamil Nadu (8.63), Tripura(8.21), Uttar

Pradesh( 5.52) and Lakshadeep(5.20).

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The percentage achievements of States

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against the technical

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target for spray operation during 1994 are as indicated in the bracket
against each State, Assam (81.49), Jammu and Kashmir (69.2), Madhya

Pradesh(70.31),

Maharashtra(69.41),

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' Meghalaya(85.06),
■

Mizoram(86.25), Tripura(97.O7), A&NIsland (12 1. 74),Chandigarh(250),

Daman& Diu(125), Andhra Pradesh(50.82), Arunacha! Pradesh(53.97),

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BihfftSS. 08), Gujarati50.29), HimachalPradesh(52.8), Karnataka(45.26),

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Manipur(50), Punjabl53.9),

Haryana(32.04) Goa(IO.O) and Tamil

Nadu (4.9 5)

fair.’ ,

MALARIA IN URBAN AREAS

Urban Malaria Scheme (UMS) was launched in 1971 with the

St

objective to control malaria by reducing the vector population in the

urban areas through recurrent anti larval measures and detection and

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forty thousand and more

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population and reporting 2 and more API are to be covered. The scheme

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wa.' sanctioned for 181 towns distributed in 18 states and two UTs. It
ha* so far been implementf^in 131 towns. During 1993 about 2.3 lakh

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During 1994, 54 towns showed a decrease in malaria cases by 51 % as

compared to the corresponding period of 1993.
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BUDGETARY ALLOCATION TO NMEP

NMEP is centrally sponsored category - // scheme based on 50:50
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malaria cases have been reported from these towns and 60 towns (46%)

showed a decrease in the number of malaria cases as compared to 1992.

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treatment of cases through the existing health services.

In this scheme all the towns having

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sharing between the States and Centre, except in case of seven North
Eastern States of Assam, Arunacha! Pradesh, Manipur, Meghalaya,
Mizoram, Nagaland and Tripura where it has been made 100% centrally

sponsored with effect from December, 1994. The centra! assistance

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provided during the last three years and budget provision for 1995-96

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(including Kata-azar) are as

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YEAR

1992- 93
1993- 94
1994- 95

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CENTRAL ASSISTANCEfRs.lN LAKHS)

..

9800.14
11054.28
11000.00
13900.00

1995- 96(8.E)

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SPECIAL ACTION TAKEN

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To intensify malaria control activities in the seven North Eastern

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States of Assam, Arunacha! Pradesh, Manipur, Mizoram, Nagaland and

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Tripura, 100% centra! assistance with effect from 1st Dec.94 has been

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provided.'

5

%

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UN ’

For tribal areas of seven states of Andhra Pradesh, Bihar, Gujarat,

Maharashtra,

Madhya

Pradesh,

Rajasthan,

and

Orissa

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external

assistancefWorld Bank) for intensification of malaria control activities is
$

contemplated.

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Honorable PM reviewed the programme on the 5th Dec'94 and

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disease.A icordingiy in Dec. 1994 an Expert Committee was appointed

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gave directions to identify worst affected areas through an expert
and

take

specific

measures

to

curb

resurgence

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and submitted its report on 2 7 January 1995. The main recommendation
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were a) identifying the high risk and hard core areas on the basis of

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malaria mortality, doubling of slide positivity rate during the last 3 year

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provided it is 5%, predominance of Pf,drug resistance and vulnerability

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of the areas etc, b) Accelerating control measures in 29 identified cities
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and towns where urban malaria scheme is already being taken, c) More

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DDC and FTD to make drug available in every

village,d)

Special

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attention to projects and e) Emphasis on Training.

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The recommendations have been communicated to the States who
are implementing.

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specific control measures adopting variables like topography, average

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rainfall, vector prevalence , average annual parasite incidence, epidemic

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Prioritization of areas through malariogenic stratification for

potential and vulnerability.

v)

Intensification of information, education and communication

system to increase awareness in malaria control programme, from'1st

May to 7th May, 1995 'MALARIA WEEK' was observed throughout the
country for this approach.

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The State Govts, have been requested to ensure availability of

drugs in every village and in areas with inadequacy of surveillance,

community

volunteers

may

be

involved

as

Drugs

Distribution

Centres/Fever Treatment Depots.

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As a special support the Central Government have sanctioned

100 vehicles; one each to highly affected and needy districts in the

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country and 1660 microscopes to strengthen lab. services in the State

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. In addition 4000 microscopes are being procured from German aid for
the same purpose.

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the chairmanship of the Chief Secretary at State level and under the

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District collector at the district level to review the control measures and

viii)

State have been requested to establish High Power Board under

ensure inter and intra - departmental coordination and community

participation for malaria control.

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DIFFICULTIES IN TUE IMPLEMENTATION OF THE PROGRAMME

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1.

Shortage of staff and large number of vacancies at various levels
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as well as frequent transfer of Programme Officers at the State Hqrs f
. Zonal level and District level hamper the programme implementation very

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adversely.

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2.

Spray schedules are not being strictly followed by States due to

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. administrative and financial constraints. In some cases population needing

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insecticidal protection is not fully covered.
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3. The various developmental projects and construction activities increase

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the malariogenic condition and do not have provision in the projeft for

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vector control permitting thereby disease transmission.

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4. Besides financial & logistics constraints, the inadequacy of road

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supervision & monitoring.

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5. In absence of legislative measures in the form of mode! bye-laws, the

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worthy vehicles adversely affect the programme activities and their

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vector control activities in the urban areas do not get desired level of
support frim the community & sanitary deptt.

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6. Transmigration of labour population from one area to another without

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screening for malaria, increase the transmission potential specially spread
of resistant strain.

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Inadequate emphasis to training & refresher courses of technical

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people adversely affects the smooth implementation of programme

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activities.

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KALA-AZAR
Kaia-azar is a serious public health problem m Bihar and West

BengaLAfter its resurgence in Bihar in the early seventies the disease
spread from the four districts to adjoining areas. About 31 districts of
Bihar and 9 districts of West Bengal are now affected by Kala-azar.

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About 75 million population is living in the endemic areas for Kala-azar.

Epidemiological situation

year

Deaths

1991

61670

838

1992

77102

1419

1993

45459

710

1994(prov.)

25531

382

7595

71

1995(Upto May )

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Cases

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Its

77)6 increasing trend of the disease is evident from the fact that

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the total number of cases which were 17806 with 72 deaths in 1986

rose to a total of 77102 cases with 1419 deaths in 1992. However,

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this trend has been arrested in 1993 with a total number of 45459 cases
with 710 deaths, which has further declined significantly during 1994 as

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total 25531 cases and 381 deaths have been reported .
■

In view of the growing problem planned control measures were
■

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initiated to contain Kala-azar. Until 1990-91 the assistance for the Kala-

azar control was being provided by the Government of India out of the

National Malaria Eradication Programme budget provision .

However,

specific funds to the tune of Rs 4.06 crores were made available during

1990-91 for control of Kala-azar. Since then the Government of India
has considerably enhanced the inputs to Rs 15.38 crores in 1990-91 ,

74

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During 1992-93 Rs' 20.00 crores were provided against annual plan

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outlay of Rs 15.00 crores . For 1993-94 Rs 18.64 crores were provided
as material assistance.During

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1994-95 Rs 5.77 crores worth materials

have been utilised by the States against the provision made of Rs. 20.00

i

crores. For 1995-96 a provision of Rs. 20.00 crores has been made.

STRA TEGY FOR CONTROL
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The strategy for Kala-Azar control broaoly includes 3 major
activities :

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annually.

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by undertaking indoor residua! insecticidal spray twice

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Interruption of transmission for reducing vector population

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Early diagnosis and complete treatment of Kala-azar cases.

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Health education for community awareness .

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In view of the financial constraints. Government of India provides
the total cost on medicine and insecticides for Kala-azar in Bihar.

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To

ensure optimum utilisation of available resources district action plan are

prepared under which exclusive infrastructure is deployed for the Kalaazar activities.

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Material and equipment with strict supervision is

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provided.
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Monitoring and concurrent and consecutive evaluation are

regularly carried out.

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REGIONAL OFFICE FOR
SOUTH-EAST ASIA

WORLD HEALTH
ORGANIZATION

INTERCOUNTRY CONSULTATIVE MEETING OF
NATIONAL MALARIA CONTROL PROGRAMME
MANAGERS, NEW DELHI, 20 24 MARCH, 1995

COUNTRY REPORT

INDIA

Dr R.S. Sharma
Director
National Malaria Eradication Programme
22 Sham Nath Marg
Delhi-110054

SEA/MAL/Mect/1

21 February 1995

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COUNTRY- REPORT ON INTER-COUNTRY CONSULTATIVE MEETXNQ OF NATIONAL
MALARIA control programme managers. NEW DELHI, 20-24, MARCH, 1995
1. Basic information :

The following are the 10 top diseases in
report of occurrence of deaths:-

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

I ndi a

based

on

Asthma & Bronchitis
Heart Disease
Pneumonia
Tuberculosis (T.B)
Prematurity
Cancer
Anaemia
Paralysis
Injuries resulting from vehicular accidents
Acute abdomen.

Source: Health information of India - 1992.

2. Objectives of the programme:
a -Prevention of deaths due malaria.
b —Reduction of morbidity due to malaria .
c -Maintenance of achievements gained so far.
REVISED OBJECTIVES:

a-Prevention of deaths due to Malaria
b-Reduction of morbidity due to Malaria
c-Maintenance of achievements gained so far.
d-Early containment of epidemics

0 -J

7^00 t)

3. Stratification of malarious areas

Criteria of stratification used

a) .

Criteria under Modified Plan of Operation

Under the National Malaria Eradication Programme
alaxProgramme the
the iu
ma-larious areas of the country are’categorized. into two broad strata
V areas
c T.n+-h
A ot 2
n and
j above ___ ...
_
'
namely
with API
and areas with less than 2 API
for taking intervention measures.

1/
1/1^^

io 0 0

4
1
t'S

i

♦

1A I
h ■-

r4

IJ J

b).

Criteria used under Malariogenic stratification

It was decided t_
to take into consideration i
‘
the
factors which
are epidemiologically
<
_
n
more
relevant
and
for
which
generated on continuous basis through the existing data ican be
delivery
system. Thus the following six variables health care
were
fied:identi1.
2.
3.
4.
5.
6.

Topography
Average annual rainfall
Vectors prevalent in the areas
Average API for the last five years
Epidemic potential
Vulnerability

Some
friable
for e.c
e.g. topography, vectors etc.
---- j3 for
are
different
nature, To simplify methodology
and
nature.
of
• compilation thc^nrT
1119 the
thG ^aiariogcnic impact of diffcrcnprocessing
variables
theyare given weights from 0-10 depending upon
the ir
expected impact.

)

After assigning the weights
cumulative weights are arrived at and to these six variables,
areas are divided into the foi
lowing five strata

Stratum

Cumulative weights

E

0-10

II

10.1

15

III

15.1

20

IV

20.1

25

V

This
wise
budget.

4

More than 25

ls being done
of W.H.O.
Maharashtra,

Population under different stratified areas
^hA^mh/iSe P°Pul.ation
the states of Karnataka, ’ Gujaaharashtra and Rajasthan is given in the following table:-

rat,

Eppujation fin OOP's) in different strata
Sr.
No.

1.
2.
3.
4.

State

Karnataka
Gujarat
Maharashtra
Rajasthan

I

II

33462 *
1496
28225
13175

4142
12213
6672

Stratum
III

IV

V

2462
7457
5336
5704

1448
6588
2322
3196

1368
11798
1151
2742

Total
38740
31481
49427
31489

* Combined figures for strata
I and II
Changes don^_. after K M W G meeting

an Expert
with
. The Expert Committee categorised the
areas
the
into the following groups to arrive at area specific strategies
:
1• Hardcore areas

Areas with difficult terrain and inhabited predominant
ly by tribal population reporting a great proportion of
malaria
morbidity and mortality.
2;
Epidemic prone areas of 1,North-Western
’^
Gangetic plains and semi-arid climatic
-c zones.

plains,

Indo-

3. Project Areas
4 . Triple resistant areas where the local vector is
ant to DDT, BHC and Malathion.

resist-

5.Endemic rural areas
6 • Urban area's

• 11 Revised

strategies based up on malariogeni/c
malariogehtc st
stratification
.be_planned takin9 into consideration
—i the Recommendations
of
this Expert
Committee
«
.
-------- * whose report
is Ibased on the
Recommendations
of RMWG
meeting.
P

c
3

/ /. ( 7 (
.tri a:

/A

7
vV '■
Ml

I

0

Mi

A' -

1

f/L

, 4^

4. Malaria situation :

(a) Malaria information str_ata~wj.se during the last
three years
Country: INDIA

1.

Population ('000)

Year

Country Total

Malarious areas
Moderate
Low
2—20 API.
<2 API

Total

Claime
Free f
Malari

15031

325460

567611

808102

36222

15350

229935

578852

824137

40210

15487

232300

584829

832616

41159

High
>20 API
1991
1992
1992

844324
264347
873775

• 2.
Epidemic Outbreak
Population affected/000)
BSE('OOO)
Reported Clinical cases
Est.Clinical Cases

NO

OUTBREAK

OF

Reported Malaria Deaths

MALARIA

Est-Malaria Deaths

DURING

1991,1992 AND 1993

★ Village as Unit of Area

4

3.

Case finding

Malaria information

High
1991 1992 1993
Reported Clinical Cases
(in '000)
-No. Out patient ('000)
-Proportion of Out
patient (I)

3157 3317 3251

Receptivity
Moderate
1991 1992 1993 ’ 1991

Lov
1992

1993

1991

Total
1992 1993

27C8 2EE91 2E297 «524 46833 45851 75159 79311 77399

1089 1156 1170 9478 10363 10167 15356 16334 16507 25925 27575 27654
34.49 34.91 35.991 34.49 34.90 36.00 )34.49 34.90 36.00 . 34.49 34.90 36.00

I

Reported Clinical
Inpatient
-No. Inpatientf'000)
-Proportion to total
admission (?)
-Malaria Case Fatality
Rate (?)

£

Est Clinical Cases '
(in '009)

415

418

432

1250

1255

1433

351

353

355

2117

2125

2203

F®ported Deaths Due
to Malaria

151

9?

104

224

2=1

205

45

34

34

421

422

344

Est.Deaths cue to
Malaria

151

9?

104

224

2=1

235

45

34

34

421

422

344

Severe Malaria cases

X?>

Treatrent Failure
cases

£

BSE('000)
Positive ('000)
SFR \ ‘
Ff cases
Fit .

3157 3317 3251 2’476
416
41?
432 1359
13.17 12.59 13.29 4.91
30:0*1 2=3905 2:4671 519580
74.35 70.35 55.=3 38.49

28=91 2E297 44524 45833 45651 75159 79011 7'3=9
1355 1403 351 353 355 21 r 2125 2200
4.6= 4.95 0.’9 0.75 0.80 2.E2 2.69 2.84
495815 460561 93747 66525 63915 918488 676245 649347
35.58 34.25 25.83 25.54 22.99 43.38 41.22 38.53

4.

Vector Control

Methods

High
1991 1992 1991

1991

Xoderate
1992 1993

1991

-peculation protected 15031 15350 1548? 1105’69 71420 51262^ 0
under planned spray
operation (000)
I
0
-population protected 0
0
553
5 621 • 225
under ereqenc/
(due to epidemic/
outbreak) spray
operation ('C00)

Biological control ♦ \
-Population Protected
('000)
Source Reduction *
-Population Protected)
('000)
/

1230

1250 1293

Lov
Total
1992 1993 1991 1992 1993
0

0

7

260

120600 66763 66750

685

1-4:5 12823 14152 5:452 59949 61464 7313“

Personal Protection
-Population Protected
('000)
(* 2 Integrated approach is being adopted in urban areas)

12

891

76925

(b) £lPJ,denuQ,l o^jcal analysis
Population iunder malarious areas or the country durino
of the <—
years 1991 to 1993--is; rnore or lessareas
stable. ?—
’ -- aurln9 the
Around 15'million are
residing in highly malarious utg*
s areas; 225 million in moderately
malarious; and around 568 million
country during these years. There in low malarious areas of the
epidemics during these three years. were no reports of malaria
The number of
slight decline duriia"^^1^ reP°rted cases of malaria showed
auring 1993 as compared to 1992
about the number Of
in-patients due to malaria in the Information
not available. Number of
country is
in the year 1993 (344) as reported deaths due to malaria declined
respectively). Informationcompared to 1991 and 1992 (421 and 422
grounds and the number of..ii on deaths due to malaria on clinical
able. The proportion of Pf csevere cases of malaria is not availmg trend during these threecases has assured the gradual declin—“ years (43.38 to 38.60).
Population protected iunder planned insecticidal
tion showed significant*
spray operasignificant’decrease
during these three years. Infor— population using
methods are not
under the National
these are beinrr
naiaria
Eradication
Programme
, but
being encouraged.

4.(c) Brief situation -^alysis._of__drug resistance
-its control
of malaria

and

No. of teams engaged in resistance
testing.
At ]present
--there are thirteen imonitoring teams
testing the
engaged in
”rresponse of Erfalciparum
—I to chloroquine and other
anti-malarials .
No. of tests carried out, results obtained.
During the period 1991-93 drug sensitivity tests havo
carried out
been
..d^odLqilneZ'r^u^s^re^^Lnows:-^6^^
1^
combination and

(1991-93)
DRUG TESTED-CHLOROQUINE (25 MG/KG BD.WT DIVIDED OVER 3
DAYS)
Year No. of cases
No.'S' No.S/RI
No.RI
No.RH
No.RIH
1991
541
102
311
50
34
44
(18.9%) (57.543%) (9.2%)
(6.3%)
(8.2%)
1992
1045
134
646
135
61
69

7

1993

II.

844

(12.82%) (61.82%) (12.92%)

(5.48%)

(6.6%)

63
(7.5%)

82
(9.7%)

56
(6.6%)

580
(68.7%)

63
(7.5%)

DRUG TESTED SULFADOXINE + PYRIMETHAMINE
(1000 mg)
(50 mg)

1991

121

100
(82.64%)

17
(14.05%)

1
(0.82%)

1
(0.82%)

2
(1.65%)

1992

246

62
(25.20%)

179
(72.76%)

2
(0.81%)

2
(0.81%)

1
(0.4p%)

1993

136

36
(100%)

0

0

0

0

ii

*94

0

92
(97.87%)

2
(2.13%)

0

0

* Drug dosage is sulfadoxine 1500
mg + Pyrimethamine 75 mg.

III DRUG TESTED: AMODIAQUINE (2.5 mg/kg 1x1.wt. divided over three
days
1991

14

1992

49

0

27
(55.10%)

10
(71.42%)

0

21
(42.85%)

1
(2.04%)

3
(21.42%)

0

1
(7.14%)
0

Mote: Figure in parenthesis indicate percentage

Area/population
1993).

affected by drug resistance

(1991

through

63 1Primary Health Centers/18,90, 000 populatipn(approximate
PHC population = 30,000), areas reported resistance to alternate
drugs included:
Action/plan to control its spread.

The concerned state governments are advised.

Residual insecticidal spraying of human dwellings
Ensuring good coverage f rooms

8

Gearing-up
malaria
la cases.

the surveillance activities
in order

to

detect

to render prompt/radical treatment

As per the drug policy of NMEP,
no change of
advocated in Rl resistance
resistanm areas.

drug policy is

In rii

a^naa;easOrpnqUrne is bein9 administered
chloroquine,
in place of
upto 25% of the total tested^ases^f^T^o)^
of Rin CaSeS (i.e.
like ^1PJ" Pyri®ethamine combination have been
alternative drugs
per the
<
recommended as
- drug pol1Cy of 1981. These areas are ?n the
Assam, Orissa,/ aharashtra and Uttar Pradesh.
states of
Quinine tablets and injections
ment of complicated c
^ec^ions are rreserved for the treatcases of malaria such
10 mg/kg bd.wt day for
n as cerebral malaria £
r 7-days.
Analytical comments

Since

. .w„.

£_» falciparum
resistance
has been detected 1..
chloroquine
states/UTs. Out of these
PHCs of 65 districts■ in 17 i-1?
100
n 17 states reported Rin level of
ance. Average Rin —
level
resistof resistance is about 3.5%.
Trend nf Llalclaarun, to Chloroquine strains .
increase of Mil level or resistance especially slncishows steady
J 1987.

Recent • '
have also indicated - *
RII and Rm studies
2-3 scattered cases
foci in
glong district
--- ; (Assam) and
against i„rof
sulphadoxine
pyrimethamine combination which is a sooonS%
’?peS;ntP1US
4 (d).

4(D)

VECTORS AND THEIR

line
sis,
331arisP
are secondary vectors of

1Inary whlle the last

,•

^^^^^^throughout'^th^countrv
« -alarl, i„
is responsible 0^
-- j country
except the2 northeastern
p
and Islands. This mosquito
breeds^n^rp^-^*
states
dur-inrr'A
----*
9
r
eat
variety
high densities during
during August September
September < ' yariety
waters with
* known of
rester and zoophilic August
9
September and is
to be indoor

9

Aj—Stephensji
container breeder beside^brled^ng^n^resh iater
country and is
and around the house premises.
collections in
and cattle mostly during earl'v1™ fGGds indiscriminately
J on human
y uring early morning hours and is
endophilic.
A. fluvjatn i c- .■ c
a^a^~^e^dr^referablve^n°riOf Inalaria in hill
and foot hill
grassy margins5 The plain arn,1®9" Water Slow
moving streams with
the hill group l5 :ngr7poph°Kc1S
and zoophilic while
and exophilic.
An^lv'tical Continents

Spraying of insecticides
&
(DDT,which
BHC r*
& MAT) reduce the density
trans^
Vector mosquitoes
the transmission.
-----I
results
The per man density and"
in interrupting
are reduced. The
J man mosquito contact
’‘ ‘
.of containment !< spraying gives <epidemiological
impact- in terms
Index r
F of Annual .Parasite
of mortality due 1
& also elimination
West^Bengtl1&nitSbrpS ikn°Wri tO bG VGCtor of
malaria in Assam and
exposed to sunshine and is
is vector of malaria i
Himalayas and north eastern states.mainly in foot hill region of
Its 1breeding habit is
to A. fluviatili
— —’ similar
---- s. This species is highly
endophilic.
: anthropophilic and

A-dAXys is known malaria vector
country having highly exophilic andin northeastern region of the
This mosquito breed in streams and highly anthropophilic habit.
burrowpits in forested areas.
A. rsundaicus was <
a known vector of malaria in
region of West Bengal
Orissa, deltaic
and- Andman and Nicobar Islands
recent
it is not
not-years,
---- j but during
9 rePorted from Orissa
Bengal and is found in h’ ?
and West
ound in high numbers in Andman .
It is only vector
& Nicobar Islands.
which
--- 1 breeds in brackish water.

A.

vgruna is vector in Jeypore hills (Orissa),
(A.p.y;
Singhbhom hills

’ '
Vishakhapattanam
(Bihar),
Kerala
and
Madhya
breed ^It9! ^a^lety of breeding grounds
Pradesh. it
.
J grounds
includina slow moving
streams. It is known to
be
endophilic
and
to be endoohilic and anthropophi1ic.
A-^Iinularis is widely distributed f
of local importance in Orissa vi throughout
wuy,,UUL ■India,
L
it is vector
(U.P.). This mosquito is 2oophilic,'end5phinc''
• Y^shakhaPattanam aiS
(A.P.) and Jhansi
--J endophagic in
10

habit.
ADULT MOSQUITO y£CIOB_R£SJ STANCE

TQ INSECTICIDES

felatM^S^i^^taJes
and^T1, y^di't
in 8 states

(DDT,BHC

and
million population; Double resistint
involving 141.1
and 2 UTs (233 districts) !nvo?v?L(5^
BHC) in 16 states
[population,
single resistant (DDT) in ig
’million
’
million population
states and 2 UTs
-J involvingf 730.4

- 3 atates a„a

population.
ant in 6 states and 1 UT (27
P
oPuJ-a^i°n • Double resistpopulation, single JeslsSnt In 7 ^atS)’ J^
1"9 79-°
having
having 92.0 million population.
•i’tates- an
d 1 UT (34districts)
—.J

The other species like A. f luyj at i 1 i ecus, AcJLUU.ntus are susoeptTSle to

-SEAEEINO pattern

in

A

ENTOMOLOGICAL SECTOR IN INDIA

Under Modified Plan of Operation, there are 7?
teams
entomological
and f
two Technicians
in the□ country. A Zonal tnai, has t‘‘,XX"
—8J in 17 states
vector bionomics,
vector
density,
problemetic
'
tests etc. in
problemetic areas
areas, ^rXlte^^H Status' 1bio-assay
ogist is
/ the State Entomolreports and
entomological
»»tlocal
--Malaria
Programme at national

aEtntz°s^^.'v"

t„o

InSia/6 RGgi°"al. Offices for Health & ~ ‘
of
Family Welfare
3Vlng °ne Asstt./Dy.Director Entomology,(govt,
Insect coho
Collectors & Lab.Technicians
rector
two
surveillance <and monitoring & vector help the states in vector
measures both in
in rural' and Urban arPAJeSPOnSeS tO intervention
areas.

5. Malaria control activities

(a)

Surveillance:

The objective <
of surveillance in mpo
MPo is to screen fever
cases, to collect blood
---J
smears
from
such
cases
cases and to detect
malaria positive
-J caz
cases. Under Modified Plan of Operation
10% Of population
is screened in a
at least
-- -j
year (ABER).

11

The <epidemiological
’ ’
isurveillance
*’
activities were on vertical
pattern through iunipurpose
peripheral. t.worker under NMEP till
1977. From 1.4.1977
v(=i , , a
is done through Primary Health
Care system, each MPW surveillance
has been
and
3000
in
allocated
a population of 5000 in
plain area
---of
surveinaS
"LT
35
P^odio
periodicdomicilia^
activities
fortnightly basis. MPWs female?
*D be carried out on
blood
--- J smear from fever cases reported
Jin®tructed to collect
are
- 2* types of surveillance m^S^i
agencies.

Active Surveillance
through the MPWsf3!? th^I^e?? ^h COn^in?ed on fortnightly
cessible the comm^ity i? ^iX? tlnCldrce is hi9h and basis
inaccenters and fever
+ated to set up drug distribution
health authorities.
n” depots WJ-th the help from the local
Passive surveillance

Blood smears <-Tf^COllect’ed froni Patients with f
___
report to the recognised
fever
agencies like
----- j hospitals dispensary

who
etc.

The activities
being undertaken in the
gramme in time and
space are given in above.

pro-

surveiI]ance

Parameter used
ABER (Annual Blood
posed ABER Is 10S ot the population currently mused. Minimum pro-•i a given area in a year.
The
[parasitological
■
load in the <
community is measured in
terms of Annual
P
Incidence (API - No.
----- Parasite
of malaria positive
cases per thousand
- pcpulation per year).

AFX
per year/^hh
^loiparum Incidence per
per thousand population
blood slides posltiv??Pf??Sp?
Proportion of total number of
for Pf infection
infection m
in the population
malaria surveillance.
under
SPR (Slide Positivity Rat_eJ

(ABFR?hl?hParaineter is less dependent on c-~
case detective mechanism
-i is inadequate, this
progress of containcommunity?UEeS and
’na 9ive
on
load in the

12

-SFR (Sljcje Zalcipariup Rate)

This £parameter
--also is rdependable where case
poof both in terms < f
detection is
.
—
-J
Of
the Pf predominance in space and tim;:
-i the area. --- - This parameter indicates

There is prisk. But however
monitoring
positivity for malarial parasite
Slide collection
pirasite'.' a ?
.
i
P
two a detailed investunusual increase in
ical and entomological is undertaken?lncludln9 epidemiologThe r
•
raa?hinery is hampered I
quate 'frame
e.?a.u?
^i
Pr^lnary health care as b.MPW
ise of the inadeother work besides
—; loaded with
be ’ ' ^2;
for;
SeVe"1 ''lll.g.s may not
popul.tionprojects r
.■
covered
S
’
sdrSS'la"^'
UrlMn
S1“"s “■=• are
effectively
not

(b)

Disease Management:

The National Drug Policy for
control of malaria is given
the Annexure-1

in

Early Cl
dlabC°M^r • and
treatment is attained
domiciliary visits
by
.<u gives
yives the
ttielreqnmih-PUrfOSe worker, who detects any
case a
and
fever
of malaria control activities educateS^’’0' lncre’=e the outreach
act
rever“,tieS<FTDS
thU5 P-v^e’dr^'aS
members of the community
: the doorstep of the

The first referral ccenter for r
' 2 patient is
a malaria
primary health
the
7*^ center, and then rcommunity
health center,subdivisional
hospitals,district
hospitals
-J and
medical
etc.There are private institutions
colleges
mostly available in
areas also act as referral units.
urban

Regular monitoring of drugs :
by 13 Pf stud's1”9 teamS Spread throughout
resistance is carriedI out
*3 India, The drug
resistance studies are carried out on
reporting therapeutic failure to the priority basis in areas
commonly used drugs f in
areas of malaria outbreak and areas having
sudden
population.
inflow of

13

(c)

Disease prevention

Criteria for ■introducing or
withdrawing house spraying
Incidencer(APl)ilperdthoisa df °peration . ^e
Annual Parasitic
spraying the area The are3q°PU>^On
the lna^n
parameter for
oith conventionm InXttcL".”
2
or more
are sprayed
susceptibility
status
data
revie«IdVeby°theaexpertse?Te1h,1C?1 di!t’ f°'r 1“st : ■ 3-5 years are
gesting the change of res
Advisory Committee))
for sugIf the area (section?
feticides in a particular .
area.
years and there is cinvincTnn"9
leSS than 2 for 3
consecutive
the area, the insecticidal sprayina^ °f.a good surveillance in
control bio-environmental measures are takeS
f°r vector
Method in determining
determining

the time Qf
spraying

The timing for insecticide j
the transmission
is determined
season in that particular
---- r area or state.
Smallest unit of
spray coverage
The smallest
unit
for spray
center of primary health
center.

coverage

is

DDT
BHC
Malathion

dose

lgr/m2
200mg/m2
2gr/m2

per

'section/sub

The costing
<
•'
calculation (i n Rupees)
per thousand
per cycle is shewn
--- n below.
Name of insecticide

as

population

Per capita
expenditure

per thousand

Rs. 8.7
Rs. 9.1
Rs. 34.4

Rs. 8700
Ns. 9100
Rs. 34400

Other methods Pf vector
control used:Other methods
larv?vf engi"eering, environmental
introducti
--- -on of
sanitation,
larvworous fish and application
larvicides etc.
of chemical

6.

Community participation in malaria control activities
in Malaria

ty i/sSo^^rssri?"

i^n,“k: :rSe^Fr --

-rxers of the icos scheme has
During

the

spraying operation intensive

14

health

education

campaign r—
in
t^aebleve co-operation
rin getting their’housZ
of the c;...
community
present
in
the house
j^sS
Epri,
''
i
"9
1"
the
-- » while
spraying
in
all
the
rooms and co-operate with
In the future it is c '
contemplated to
involved
members, volunteer organisation'"''tribal
^
inY°Ived the ~Panchayat
, tribal the
C_oVel
local leaders be involved in decidina
°Plnent projects and
in deciding the anti
ties
i ‘
activiis
being
L.:_ guide in
cases so ?h«t
and
report
fever incidence
SO that an.unusual increase in
incidence
community involvement will also
deciding the ]methodology

’jr1

ch ““ st

To effectively involve
the.to
conununity
their cultural believes, peeds and priorities are
be
pological/behaviour/social
For this anthroies will
will help in shaping thZXh3^/00^^13^- These studthe methodology to be developed
community participation.
f or
7.

Inter Sectoral co-operation

Inter in^rga^Xav^X^
sectoral <
attempted
31 CO-°Pe^tion has
organised
been
actively involve various Sectors
?ttTInPt ls being not
made to
urban development, municipal drain lke' lrrl9ation water supplyt
of malaria.
municipal drainage etc. for effective
control
Recently held technical
suggested
St thethestate
to JnsGri'actlJe^onhorat^^
“ tt^cenEer
making
of Inter
and
sectors
district
committee
should
allied sectors SO as to actively
control
ZJ?
forn,ed that the
- malaria.
of malaria it is necessary that malaria
ZnZZ’ Ff01" the coritro1
1
control
integrated in the general plannina and -admi control measures be
administration
projects create mosquitogenic conditions.
nistratlon of various
8.

Inter country ®^^"der Activities on
taken up at the moment,
which were reqular?] h •
1not
‘"
being
past, .Recently as per the letters rellii^Lo^X
in the
ties including
Activicountries
' > of
border
afresh, jNew proformae have been
up
a^d
concerned to :Bordering states c
to
tion which will
-- be communicated

sou^s Axcrunication to

° ton^i^ s;sz^oSosr
15

.9.

MANPOWER AND .STAFF
----- TRAINING :
Core group staffing at
- central level and training
The Dte.
NMEP has a iresearch
--leaded by a public of
and ftraining
1
Health Specialist
Dy office assistants.
--- i (Dy,Director)) and division,
supported

Division.

Coordination

of

all training is carried

by

the

R&T

Faculty
and experts in the for 1training is drawn from other
specialists
< - NM
* EP
' other
--..LZ institution such
MRC, NIHFW, Medical Dte.1 of
as NICD,
colleges
Hospitals
ologist.
--J and retired senior malari-

Other integrated/supporting
staffing outfit.

,
For training of Staff below the district
' H
fro1” the state
Programme manager.
Regional
Health and F.w. and also'dte.
--- of NMEP.

faculty
offices

is
of

Training to microscopist is |
Medical Officersind
’provided by ROHFW and PHC
-- j and
Qntl
peripheral
i
periphera
L
welfare training centre.
byi state Health and family

number
years.

Various ftraining r-Kufses held at different
°f different
---- categories- of
-- staff trained

1_
levels and the
in—•- the last 3

A total of 45 training
training courses were conducted d.
last 4 years (1991z1992,1993
&
1 during the
fields like F
Malariologv
various malaria
’
—ia related
and a
r total of
or 1014 candidates drawn
Juratory aspects etc,
trained
from different levels
— .. The details are as under were

16

Training conducted by

S.No.Course

1.

MALARIOLOGY

2.

ENTOMOLOGY

3.

PHC MO's

4.

training

5.

WORSHOP MNGT.OF

malaria

NMEP till date are as under:

Date

Venue

25.2.91 TO 5.4.91
11.11.91 To 20.12.91
24.8.92 To 1.10.92
15.2.93 To 26.3.93
To 24.12.93
05.09.94 To 14.10.94
26.09.94 To 04.11.94
26.12.90 To 15.2.91
2.11.92 To 24.12.92
17.11.93 To 12.1.94
18.11.91 To 21.11.91
27.11.91 To 30.11.91
91
23.12.91 To 26.12.91
14.1.92 To 17.1.92
5.3.92 To 6.2.92
20.10.92 To 23.10.92
3-11.92 To 6.11.93
19.1.93 To 22.1.93
16.11.93 To 19.11.93
28.12.93 To 31.12.93
21.12.93 To 23.12.93
11-1.95 To 14.1.95
26.2.90 To 2.3.90
3.9.90 To 7.9.90
4.2.91 To 8.2.91
7.10.91 To 16.10.91
12.10.92 To 16..10.92
1.11.93 To 5.11.93
9.1.95 To 10.1.95
8.11.91 To 19.11.91
3.1.92 To 4.1.92
28.1.92 To 29.1.92
11.2.92 To 12.2.92
24.9.92 To 25.9.92
11.1.93 To 12.1.93
4.11.93 To 5.11.93
4.11.93 To 5.11.93
20.1.94 To 21.1.94
25.3.94 To 26.3.94
22.8.94 To 23.8.94
6.12.94 To 7.12.94
18.1.95 To 19.1.95

17

No: Participants

NMEP
NMEP
NMEP
NMEP
NMEP
NICD
NMEP

33
25
16
22
17
28
7
(SAARC Countries
NMEP
23
HOSUR
21
HOSUR
22
NAGPUR
22
BHUBANESWAR
23
HALDA
27
AIZAWL
25
JAGDALPUR
19
RAMESWARAM
30
JODHPUR
18
ALLAHBAD
27
AGARTALA
30
OHENKANAL
20
tinsukia
35
byrnihat
25
MEGHALAYA
NMEP
15
NMEP
22
NMEP
17
SHIMLA
23
NMEP
22
NMEP
26
ASSAM
2 8 DMOs
BASTAR
26
SURAT
16
UDAIPUR
27
RMLz DELHI
42
BARODA
20
BHOPAL
17
PANJIM
25
VISHAKAPATNAM
25
WARRANGAL
31
AMRITSAR
26
KAKINADA
22
AIZAWL
24
GUWAHATI
20

©
6.
4

7.
8.

MICROSCOPIST

20.7.92

To

22.7.92

NMEP,DELHI

27.7.92 to 29.7.92

NMEP, DELHI

PFMT ROs

10.2.92 To 19. 2.92

NMEPz DELHI

ORIENTATION TRG.
OF CHEB DHE
STUDENTS.

15.5.94 To 13.5.94

NMEP, DELHI

reorientation OF

Training Requirements ‘
including detailed
future training in the
plan for
light Of global
«
-- malaria control strategy
TRAINING NEEDS:

TOR malaria.

KALA-AZAR AND JAPANESE ENCEPHALITIS:
1.
At State level;
State programme officers
30
Entomologists
19
2.
Zonal lev.el
Zonal Malaria Officers
78
Entomologists/Asstt .Ent.
86
3.
District level
Distt.Malaria Officers
412
Asstt.Malaria Officers
412
4.
PHC level
Medical Officers
Health Inspectors/Asstts. 14609
28538
Laboratory Tech.
14609
Male MPWs
102674
FOR FILARIA AND URBAN MALARIA
SCHEME:
Medical Officers/Bioiogists
Filaria Inspectors
230
Laboratory Technicians
840
Insect Collectors
280
Superior Field Workers
840
Field workers
1680
8400
TRAINERS TRAINING:
1) Central;

Regional Office for Health
and Family Welfare;
Regional Directors
17
Medical
ficers/Epidemiologists
Entomologists
y
17
16

18

12 •

’S

2) Regional Filaria Training and
research centers and K.A. Trainmg Center:
Assistant Directors
Medical Officers
Entomologists

4
4
8

3) State Health and Family Welfare

Principals
Medical Lecturers

training centers:

54
54

In addition to the
’
above
* *
disease epidemiology
to the
and control is required to orientation
be given ton
1•
Engineers concerned with urban
development , water resources
and industrial projects.
2. Officers of
Municipalities, armfed forces, mining.
agriculture etc. and
irrigation.
3. Personnel of
General Health Services and
administrators .
4 . Health Educators

5.

Health Volunteers.

TRAINING SCHEDULE:

COURSE

DURATION

PARTICIPANTS

1)

Maiar iology

6 weeks

2)

District malaria uofficers and
officers of alliedJ organisations

Entomology

8 weeks

State ientomologists
‘
and officers
of allied organisations .

Trainers

5 days

PHC Mo's

4 days

3)

4)

5) Workshop on
management of
complicated
malaria.

2 days

Key trainers of RHFWTC, State
^°9^mme officers and Regional
directors and officers.

PHC medical officers.

Clinicians of hospitals.

19

6) Workshop on
3 days
Bio-environmental
methods of vector
control.

State and central PWD
and irrigation engineers.

COURSE CONTENTS:
The course modules; are d.
of the programme for effective
developed keeping in view' the needs
vo implementation of its strategy,
Apart from lectures cr.
on each topics the participants are
exposed to field conditions
also
for proper comprehension <
bas2HinH of
°f thG Probleins• and means
and
under
to solve them.
cased demonstrations and
Laboratory
I
practicals
are also conducted
strengthen the skills and <
— ——J to
capabilities.
Comments on adequacy and
recommendation for improvement
!.
r\
Physical infrastructure
at the Directorate is inadequate and
has to- be
~a strengthened.

2.
The rTraining
" _L..
Division is required
to be
full compliment
- of manpower.
3The core group of
has to be trained.
10.. Health education

strengthened

with

trainers at National and the State

level

practices in Malaria control programme

The activities are being undertaken through the following:a.
Inter Personal r
through field- worker/multipurpose workersJ during Communication
their
visors/Medical 1Officers during aomiciliary visit and health super
several community meetings.
minute
1
language and
UhJsquickies
qbeeJ1dJspatched
etoPrePared ln various
.been despatched
pose of Bro.d„sting
-- • All. India Radio

regional

pur-

c.
rPamphlets/Book-lets/Hand
outs in English/Hindi
regional language
have been printed both by Dte. of and other
various state health Department and r
NMEP and
are distributed in communi
ties and particularly under
epidemic situation
prone areas.
---- 1 and high malaria

20

11.

Field Research

Findings
Dte. of NMEP are under consideration^or
undertaken i*through
’
and by
as under:implementation
--- 1 which are
PARASITE

1.

Anti Malaria Drug'Trials

tCdChTned gVowin9 resistance
to chloroquine and SulfaPyrernethamine
Mefloquine and Halofantrine
are sensitive Artem^sinine under trial.

VECTOR
2.
Impregnated Bednets
Bio-environmental

methods

4.

New Insecticides trials

5.

Bio-larvicides trials

Feasibility trial indicated
significant impact.
effAci^1?1 Pro jects-Reduced
^osqoitogenic
conditions.
Synthetic• pyrethroids found
effective and safe.
Interim :reports suggest eff—
ectvie in reducing mosquito
density.

12.

Logistics
Approx.
annual
anti-malarial idrugs aretechnical requirement of
as under
SI.No.
Name of
I Insecticide
Quantity

1.
2.
3.
4.
5.
6.
7.
8.
9.

BBT (50%)
BHC
Malathion
Chloroquine (Tab)
Primaquine! 2.5 mg.
Primaquine 7.5 mg.
Amodiaquime
Quinine (~
(Tab)
Sulpha pyremethamine

15964 MT
13487 MT
14436 MT
4050 Lakhs
60 Lakhs
290 Lakhs
100 Lakhs
20 Lakhs
25 Lakhs

insecticides

and

Cost in (Rs.in
Lakhs) (Approx)
9757
2562
4764
1890
7
66
35
16
56

Provision for emergency
amount of Rs. 867 Lakhs to be needs of drugs and
kopt being 5% of the insecticides
above items.
total cost of

21

for
the

■e

13.

Cost—analysis
Years
1991- 92
1992- 93
1993- 94

14.

Insecticides/Larvicides(Rs. in careers)
Drugs
Others

decentralisation

47.85
59.62
75.98

9.86
8.22
11.7

14.67
9.96
3.68

-

National
implemented
system . with the
tralisation process is

Program-e is a

Total
72.38
77.80
91.36

horizontal programs
Primary Health Car
Operation decen

turP In
a decentralisation
i process .development of
so thatand<VeStrengthenin9 of ( '
proper
infrastriZ ’’j
existing i nfrastructu re
so that it would be able
need to be doh
to carry out activities?
Logistic
---at District :1 management and spray
operation
L’
Head Quarter . Spray squ
‘ds
planning
is being donfunction v ertically from
remain
at the
- --- 1 there.
district
an<
Microscopes
ic areas one lab
In high endem*
posted
malaria
work.
PHC Medical Officer is overall
ties
in the PHC
incharge for < ‘ *
Spray activities
antimalarial
jurisdiction
are also supervised by'hi; activiin his
Surveillance activities have U
services carried
integrated with
d out by Multipurpose
general health
DDCs
and FTD are manned by Viliarro
Member and other volunteers
llage Health
nreers from the community.
NEW APPROACHES - ‘

Guide

\Panchayat

.Stratification
of areas based cn va
orogical parameters is
on various cecological and
sation of resources.At going on in phased
-J manner for <effective epidemipresent some new
utiligenic potential are under
related
t malario---- 1 to
consideration parameters
of the
—a Expert Group.
^tensification of i ' ’
antimalarial <activities
• • ■
with additional inputs
in the
,
has
been
tribal areas
-1 commenced with
0 7 N E States w.e.f.ist
100% Central
December 1994.
-- assistance
New approaches for .*
intensification
areas and project areas are
of malaria
under
in urban
—the formulation by control
a Expert Group.
22

’ ©•
. Identification of
various level is under th“S:essACtiVlti8a to be

decentralised

ai

Criteria for de-i
marking Hard r"tea -r PriOrititatioPS-nS:rte„Larea:ti„nthe urhan
is under the
and

project
lor Jestrengthemonitoring
“1"gt°otn2IS<!ij"
pl
“
ied
f
*
formats of reports
’ J. of mis is
trraie.it is also
,lso J
—concluding stage and returns
°f field
-13 with NIC Net.

«s„tatio„1”S0pIom’metJeSli;f0her SUperviSio„
effective
have been
v.n^rs\aLTiSi°" ’M ‘““S «
“tedfte“tIyntCotiOS“dy out of
-- - directly to ’

15.

impleextradistrict-s of

Monitoring and Evaluation

Activities and feed-back
The implementation of the r—
of
monitored with the help of
Programme is being -Territories.
in
°r reports received
regularly
- -J from the States and
In
addition,
Welfare send periodic^an^6 •Regional Offices
Union
periodic
follow-up action is initiatfn31^31 rePorts based for Health and Family
on which
inrtrated with the concerne'd stated"
11 necessary

of Health and Family^elfare ^On’n'1^tec is constituted by the
t= ... necessary
preview
Eval1idl^ltiOn'

Indepth
the nS
per

Ministry
- - and

VariOUS

1O" C™"ttees a^dn?endF^ Assessment Committees
and
also being appointed
depending as

Changes ■gnyisaged
inef£ln changes
like the introduction of
resistant: areas or insecticide synthetic aPyrebeing initiated triple
as
resistance
recommendations. The ^commended
Statpo <- • by the' Technical Advisorv
f are
to sut.it their ActleonSt“-s'and
to Union 1Territories have been o
tee'S
incorporate the-e >-Q
been requested
tneoe recommendations.
16.
External assistance

throids

World! Health
funds for training t Organisation has assisted NMEP bv
meetings, seminars and supply of by
equipments over two
yearly.
To tackle
malaria in the seven= states
‘d t^G problem Of
of tribal1,^.
--- * of Andhra .JF’r.desh, Bihar, gujarat^
rashtraz madhya
‘
^a esh, Orissa and Rajasthan,
gujarat,
Bank is being sorted.
/ assistance
of World
--- » of

23

1

CA
17. Resume of i_
technical and operational problems
to overcome them
and
-J as seen on a national level

The major technical and

ways

operational problems are: -

1.

Vector resistance of insecticides.

2.

Resistance of P-falciparum to
commonly available of drugs,
Lack of Inter sectoral and
co-operation.

3.
4.

be

aeSX”"UnltY particiP’ti»" and health education need

5.

6.
7.

to

Lack of epidemiological skills

at the district and PHCs level.
Large number of peripheral workers
posts are not filled.
Suggested ^g^^§-^MALrQ2<^pv_e_rcome the problems

(J

i.
r
■
Development
of
the epidemiological
stills by training and
of the
< '
development of possible epidemiologcal cell
--- - at a district level.
2. _ Motivate community particination
in anti-malaria activities
by intensifying health education

minist2rialS|oSitte|OandemaviOn tO be achieved '
‘
by forming Intermaking
malaria control integral^and
built part of process.
akln9 malarla
- -- 1 in

■'

/nA^

■>

I

- tl (A
I
2, ■

- |DJ/

pt
««

r'J)

ytA'

AAV

MA
\\(Aa- c {a ‘ i

5i>c.,

aaMvj

i

irn

'vt. -»

4-'‘
f

EXECUTIVE SUMMARY

During the VIII
Five Year Plan period,
N.M.E.P.
activities are proposed to be taken up
based on the broad outlines of the Modified Plan of
Operation with certain changes to gain maximum
output with optimal utilization of resources.

1

in the
In the plan, certain problem areas
country have been accorded priority depending on
First priority is given to tribal
various factors,
the malignant
areas with very high occurrence of
-f a]_ciparum mal aria) .
Next
in
type of malaria (P-fal_ciparum
the order of priority comes high intensity malaria
areas followed
by developmental
rural
& urban
prone
areas’..
ep idemic/ep idemic
and
projects
high
to
protect
in
the
strategy
is
thrust
Another
pre
inf
ancts
,
of
population
viz.
risk groups
areas
,
women
in
all
ch
i
1
dren/pregnant
school/school
in
labour
population
in
urban
areas,
si urn dwel 1 ers
project areas.

a

using
approaches
Different
strategic
spray
,
insect
ic
ide
conventional techniques such as
and
be
taken
up
case detection and treatment will
b10-environmentai
innovative
measures such as
measures(use
of
control,
personal
protection
impregnated mosquito nets) are. contemplated.

■

■

if
i.,

■T

I
I

h
ii

object i ves,
order to achieve these
In
the same
certain policy changes are required and
Fundamental y
i n the pl an document.
are enumerated in
f or
criterion
issues relate to the API
these
1007.
i.e.
insecticidal
spray ,
spray
funnding pattern
50:50
areas and
tribal
central
assistance
in
sharing basis in other areas. decentralisation of
logistics to states.
With
a view to increase the eff ic iency of
of N.M.E.P. to function as a techni cal
the Dte.
body, certain organizationa I restructuring
apex
strengthening is proposed during VIII Pl an period.

Pl an document
VIII
The
si tuat ion
analysis 5 constraints in
of
the programme,
recommendat ions
evaluation and of Central Council of
object i ves,
strateg i es, activi t ies,
and financial impl icat ions.

D3

presents
the
imp I ementation
of
experts’*
Health
F.W.,
inputs needed

I ■■

VIII

FIVE

DOCUMENT

YEAR

POLIC Y-CUM-OPERATIONAL

PLAN

NATIONAL MALARIA ERADICATION PROGRAMME
I

1.

preamble

1.1
Nat i ona I Malar i a Erad i c at i on Pr ogramme (NMEP)
1aunched in 1958 in India, when there was an
was
mi I 1 ion
with
1
estimated n unib er of cases of 75 million
incidence
By 1965, all 11 me I ow
mil 1 ion deaths.
of 0.1 mil 1 ion cases with no deaths was recorded.
Thereaf ter, there was resurgence of malaria ‘during
by
1976,
late sixt ies and early seventies and
cases and 0.85
there were 6.47 million total
malari a
al so
malignant cases of
mi 11 i on
known as P_=.f ^1 c ip arum malaria.
1 .2 Government of India, taking cognisance of the
of
resurgence, has launched a Modified Plan
Operation (MPO) on 1.4.1977.

1.2.1

Objectives of MPO

(i)
(ii)
(iii)

,Prevention oT deaths due to malaria,
Reduction oT morbidity due to malaria.
on—going
socio—economic
Maintaining
developments.

1 .2.2

t!E.'Q Strategy
. . Incidence of cases
Basis
(API
population per
year
Parasitic Incidence) .

per

thousand
Annual

On the basis of API , country was divided into
strata.for antimalaria spray activities.

'll

r
i

two

•Above 2 cases per thousand population in one
(i)
spray
(above 2 API), where indoor residual
year
appropriate insecticide, active and passive
with
antimalaria act i vi t ies through
survei11ance and
as school
commun i ty members as volunteers such
panchayat members forest officials and
teachers,
(Communi ty Heal th Gui de
commun i ty heal th guide
in
1977)
have
been
introduced
Scheme
was
drugs
To make available antimalar i al
undertaken.
to the outreach areas volunteers known as Drug
D i stribut i on Cent res
(DDCs)
and
so nie of
these
volunteers to function as Fever Treatment
Depots
(FTDs),
where blood
smears are collected
and
presumptive treatment i nst i tuted.

(ii)

Areas with 1 ess than 2 cases
D4

per

thousand

a
year
(below
2
API),
populat ion
in
investigation of cases,
focal
Ep idemiolog ical
intensive surveillance through peripheral
spray,
heal th workers known as active surveillance and
health
institutions
like
through governmental
dispensaries ‘ known
as passive
heal th centres,
In’
addition,
entomological
survei11ance .
disease
to study the trend of
observat ions
potential.
Of
Alma-Ata
India being a signatory of
1 .2.3
declaration to achieve the goal—"Heal th for All by
providing
2000 A.D.", has taken up as a policy of
Primary IHealth Care delivery system to cater to
the needs of every citizen for which Multipurpose
NMEP
Heal th Workers Scheme has been introduced.
activity since 1958 has
which* was a vertical
into the..-Mul tipurpose Heal th Workers
integrated
System from’ ‘1977.

1

introduced
the
Government
of
India
1.2.4
in
1 977
in
Community Heal th Volunteers Scheme
services
to
al
1
i
provide
basic
health
order to
rural areas.
the
Government of India having realised
1 .2.5
(
i
.
e
.
P
f
al_ciparum2_
magnitude of malignant malaria
to the extent of 0.85 million cases, especial 1y in
Governments
tribal
and hilly areas, with Swedish
as
assistance provided additional
inputs such
train
ing
expert
manpower,
mobility, material ,
capabilities through the P.falciparum Containment
Programme (PfCP)
since 1977.

2.

!i'

I

ff
•

I

SITUAIION ANALYSIS

2.1.
With MPO strategy, total imalaria cases of
6.47 million andP^-f al_c i parum0 .85 mi 11 ion during
1 976 has been brought down to 2.18 million total
cases and 0.65 million P . f a]_c i parumcases during
The API has been reduced from 1 1 .4 to 3.08
1 984 .
during the corresponding period.
To achieve the goal of "Heal th for Al 1 by 2O00
targets have been set at 5 year
physical
A.D. ii
based on case
to 2OO0 A.D.
intervals from 1 981
incidence per thousand population per year (API) .

JL2.
1981
1985
1988
1990
2000

Achievement

4.60
2.70

4.11
2.57
2.08

1 .90
0.50

Kt

J

D5

(API )

(ANNEXURE 1

2

MAP

API

1976 -1988)

2.3 During the VII Five Year Plan period (1985 to
MPO strategy was continued to be adopted
1989),
and there had been reduction in the API from 3.08
to 2.35.
During this period
period,, the population has
increased from 730.54 mi
million'to
11 ion * to 791.56
/91.56 million.
There has not been marked dent in the total number
1 .8 mil-lion
mil-1 ion cases in 1985 and
of
malaria cases -1.8
1.78 million in 1988 indicating that the positive
proportionately to the
cases, have not changed
The total
and
population
growth.
malignant
growth.
i.parum) have been
malaria cases (F'_.fal^c
P^fi.parum
contained
Plan period
at the same level during the VII
Similarly deaths recorded were 247
(1984-1988).
in 1984 and 209 in 1988.
Arunachal
Pradesh , Bihar,
2.4.
The States of
Pradesh,
Jammu
Kashmir,
Jdimachal
Haryana,
Tripura,
Uttar
Pradesh,
West
Punjab ,
Nagaland ,
Territories
of
Chandigarh
and
Delhi
Union
Bengal ,
a decreasing trend during the first
have shown
four yjg^ars of the VII Plan period, where the MPO
guidelines were followed strictly.
(Annexure 3 & 4 - Incidence of total. (PaLacia cases
and P^falciQarum cases = f?84 = L?88).

2.5

outbreaks

pl an
VII
During the first four years of
in
period,
there have been malaria outbreaks
1985
during
certain parts of the country example
Jalpai guri
4 Primary Health 'Centres
(PHCs)
of
District of
West Bengal ; during 1986 4 PHCs of
Purulia and Cooch Behar districts of West Bengal; 3
town
PHCs of Nalbari district of Assam and Panaji
in Goa and during 1987 focal outbreaks in some PHCs
Madhya Pradesh - Dhar,
of
seven districgs of
Ujjain,
Indore,
Mandal
and
Jabalpur, E^arwan i ,
in
Panaji
town
of
Goa;
during
1988
Rajgarh and al so
in two PHCs of Cachar district of Assam; Vadodara,
Ahmedabad and Bhavnagar districts of Gujarat; in 4
PHCs of Manipur and Ramnad district of
Tamilnadu
and in Panaji town of Goa.
2.6
,.v

Urban Malaria Scheme

Scheme started in 1971 with the objective
2.6.1
of effective control of malaria in urban towns with
measures,
recurrent antilarval
measures,
case
strategy of
and treatment through malaria clinics,
detect ion
By
1988, scheme has been functioning in 128 towns
rotect ing 69 million population in 19 states and

D6

with
DDT,
Die1 dr1 n
and Malathion.
Out of
263
d i str i ct s io 13 States and 1 Un 1on
Terr1tory,
the
pr i nc i pa I
vector A2.cul.ic1 facies is found
•f ound
to be
resistant
to DDT.
I n 218 districts in
10
1 0 States
and 1 Union Territory, this vecdtor is reported
to
be resistant to DDT
and Dieldrin and
in
62
d istricts
in 6 States and 1 Union Territory,
this
vector showed resistance to DDT,
Dieldrin and
Malath ion.
Important
urban
malaria
vector
A^stephensji
is reported to be resistant to DDT
in
34 districts in 7 States and 1 Union Terriroty;
to
DDT and Dieldrin in 7 States and 1 Union Territory,
The
1arval
stages of the vector
are
still
manageabl e with conventional
larvicides in urban
areas.
The
other
vectors
AjiTiQifDySj.
AjiQMl^QQ^nensis,! A_.f l_uvi atal_is and A_.bal_abacensis
are susceptible to conventional insect ic ides.

Alternative
insecticides - pyrimiphos
methyl ,
cyef1uthrine and deltamethrine have been found to be
superior
to conventional insecticides.- They are
expensive and some of them are toxic.
2.9.

I

1it

2.9.1
have
in India‘7 irrigated areas
i ncreased
from 22.6 million hectares in 1951 to 75 mil 1 ion
hectares by the end of VII Five Year Plan period.
Between
1951
and 1980, 205 major and 916 med ium
schemes were taken up for execution. During
1979
to 1984, 67 major and 156 medium schemes were taken
up.
Water
Water logging
logging has
has been
been observed to
be
responsible for mosquitogenic conditions, There has
been
large scale
1abour
population
movement
d isseminating malaria from endemic areas to nonendemic areas.
Studies in Punjab and Haryana have
shown
that
irrigat ion has 1ed
to
increase
in
malaria
inc idence.
Similarly the construction
work
of
Dams ,
so contributed to
Canals have al
also
malaria .
Special mention can be made of
Hirakund,
Nagarjunasagar,
Si 1eru ,
Sri sai1 am
in
Andhra
Pradesh;
Hasdavebango,
Gandh1nagar
in
Madhya
Pradesh and Sathonoor dam i n Tamilnadu and a 1 arge
number of projects in north-eastern states.
During
the VII Plan period, the latest examp1e
is Upper
Krishna Project in Karnataka.
2.9.2 Industria1

■I

a]_ Projects and Malaria .

maJ ar i a

Large number of industries were set up during
the past 3—4 decades 1 ike Steel and Iron ,
Thermal
Power ,
Textile,
Fertilizer, Coal and Mining,
Oil
Cement,
Locomotives —
about
Ret ineries,
292
approx imatel y
.
The industrial
townships dur i ng
deve'l opmental stage and 1 ater on have recorded high

■f

I
*

D8

t

incidence of malaria due to tropical aggregation of
al so due to bad management of water
1abour and
sewage
disposal
of
creating
supply
and
Some of
the notable
mosquitogenic conditions.
ProJect
Power Project
in
examples are Mirzapur Thermal
PradeshMadhya
Pradesh
border,
Mathura
Oil
Uttar
industrial
complex;
Refinery,
a petro-chemical
Plant,
in
Andhra
Pradesh
and
Visakhapatnam Steel
Kribco Fertiliser's in Surat district of Gujarat .

2.10

during Vii

Eiy§.

EL^q

2.10.1 Financial

Inadequacy of
funds as compared to techn i cal
whereas
requirement. Rs. 470 crores were required
the initial outlay was Rs.361 .5 crores for the 7th
pl an (Rural land Urban).
the
2.10.1 .2. Inability of some States to provide
Utt ar
Gujarat,
hatching'
share
i.e.
Orissa,
Pradesh, Madhya Pradesh, Tripura, Bihar and Assam,
t ime affecting
2.10.1 .3.
Funds not rel eased
in
antfmalaria activities as in Bihar, Man i pur, Uttar
Pradesh and Karnataka.

2.10.1 .4.
Spray operations were primarily affected
non—release of
due to financial constraints and
funds but
at the same time some states did not
1acked
schedules and
fol 1ow
the prescribed
supervision.

2.1 0.2
2.10.2.1 .

Seurat, ional

Surveillance Operations

of priority for the programme
a)
Lack
attention to survei11ance
by
with
inadequate
multipurpose workers.

b) Prescribed fortnightly surveillance
being followed in many of the states.

not

of
c)
Long time lag between collection
slides, examination and providing radical treatment
to the cases.
■l

Inadequacy of Laboratory staff
d)
in
backlog of slides.
resulting

thereby

!
Inadequate supervision at all 1evels due
e)
of mobility f or sur.;erv i sio:-s to cover
to
1 ack
1 arge areas.

I

D9

J
;•

f)
Inter-State migratory population to
developmental
projects contribute to dispersal
malaria cases.

the
of

g)
Some states 1 ike Tripura,
Pond i cherry,
Tamilnadu, have the problem of
i m i grat i on
from
bordering(neighbouring) countries .
2.10.3.

Administrative

2.10.3.1 .

Manpower shortacje

a)
Frequent transfer of State Programme
Of +icers and posting of untrained officers as
in
Andhra Pradesh, Karnataka, Gujarat , Dihar, and West
Bengal .

b)
Vacancy of District Mai aria
as i n B i har and West Bengal .

□ f -f icers

PHC1.-level.
0

3.

i

i

Medical Officer
...
1 87. vacancies
H
MPW Supervisor
. . .
I 27
Muitipurpose workers.. 487
II
Laboratory Technician. I 67
II
Malaria Inspectors ..
87

PROGRAMME EVALUATION

An Expert Committee constituted by the Govt. of
India with national and international experts under
the Chairmanship of Dr. V .N . Rao,
ex-Addl .Director
8oi i*?r'a I i
Ind i a n (' c) u n c: i I o f M
H f? c I i c a I RReesseeaarrcchh h a s
evaluated
In-depth the HPO strategy under NMEP
in
India and submitted report 1n Oct. 1 985 .

An evaluation of
PfCP under NMEP was done
by an Expert Committee under the chairmanship
of
Dr.
Harcharan Singh,
Adviser
(Heal th)
PI anning
Commission
during
J an uar y/Feb nruary ,
1989
and
submitted the report to the Government.

I
<*■

u

3.1 .

yajpr recommendat i. ons ofln-depth Evaluation of
NMEP - Oct . I 985

3.1 .! . t- * £ A o 2 s n i. c s t r a 11 f i c a 11 o n o f
devel opmerit of 3 year s strategy plan
for malaria control .

the country and
of
operations

Directorate of NMEP has acquired a computer
system
during
I 989
and
h as
developed
an
ep i dem i ol og i cal
model
of
ma1 ar i ogenic
strati ficat ion for Karnat aka state with PHC as unit
based
on
the
var i ab I es
I 1 |: e
topography,

DIO

conditions, water bodies,
meteorological
vectors,
parasite 1oad in the community and other factors.
be
strategy for each
stratum will
The control
of
the
after field verification
worked
out
Laboratory model and the implementation is expected
in
the first year of
VIII
Plan period
during
Karnatak a and the stratification of major problem
states 1 s expected to be taken up during the next 5
years.

r'

Training in malariclogy and allied fields
3.1 .2.
receive
highest priority under Directorate
should
NMEP
by
creation
of Training Centres at national
of
Also
high priority for training
and state levels.
and
epidemiological
of
PHC doctors on clinical
aspects of malaria.
The proposal to start a Training Di.vi.sign at NMEP
However, State
EJiC^^bgrate could not materialise.
tra i n ing
Training Centres'have beeni identified and
District
Officers,
programmes
for PHC Meical
physicians,
officers,
to
Medical
and Health
on
case
obstetricians
paediatricians
and
management , trainer's training of Regional Health
developmental
Family Weifare Centres, engineers of
19SS-89 by
projects have been taken up during
decentralisation of the training programme.
and
Zonal
The train ing programme for State,
are
malar
i
a
of
Off
icers
Programme
District
of
Institute
continued to be imparted at National
With
col
1
aboration
Communicable Diseases (NICD) in
NMEP .

Plan of action to enlist active commun.it v
be
ion and heal_th education should
worked out jointly by Central and State Heal th
Education, Directorate of NMEP and ICMP .

3.1.3.
h

Based on the advice o-f Expert Committee on
o-f
of
India,
const i tuted by Govt.
Heal th Education
have been
publ ic ity material
video f i1 ms and
developed by the Directorate of NMEP .

i5
j-

k

3-1 .4

Division
of Pl_anning and
Assessment at NMEP Headquarters
headquarters should be created.

and SState

Assessment at
The existing division of
with
augmented
been
has
Headquarters
NMEP
t h e Management
to develup
st rat i f i cat i on cell
Informat ion System (MIS).
3.1 -SA Division g+
Dgerat lonal. Research and
D^Y^lQpment should be established in NMEP Headquarters

1

D11

*

and Operational Research in NMEP and ICMR to
jointly planned and monitored.

• 1

be

An Expert Committee constituted by the
Govt.
of
India of
national
and
international
experts has identified priority areas and submitted
a report in October 1985.
In the Directorate of
N^EP, a division headed by-a Deputy Director with
12 teams to monitor drug resistance of
malaria
parasite (P-falciparum). is functioning. Studies on
relat ive efficacy
persistant malaria transmission, relative
of. different
dit+erent insecticides, alternative drugs have
been carried out during the VII Plan.

biozenyironmentai
trfafs of
al terhat i ve to
methods
in rur il areas as an alternative
have
been
taken up by
insect
ic
ides
convent ional
Centre
in
different
Research
ICMR/Malaria
geograph ical 1ocat ions.

continued
dependence
on
reduce
3.1 .6. r?- To
environmental
intervention
spray
,
insect ic idal
intrAmeasures to be executed through inter and
coordination
as
an
integral
and
in-built
sectoral
parir of Urban Development, Water Resource Projects,
Rural Development Programme.

I
?i?!
V
!

Erased on bio-environmental studies in Kheda
Project
by the Malaria Research
Centre,
ICMR,
extension to a district involving different sectors
like
fisheries,
Social
Forestry,
IRDP,
NREP,
in
Irrigation, Urban Development has been proposed
in
4 disticts of Uttar Pradesh and Kheda district
Gujarat during VIII Five Year Plan.

As
a first step
in this
direction,
Workshops for Developmental Project Engineers have
been
taken up
in collaboration with
Malaria
Research Centre, ICMR.
3-2
Evaluat ion of P_-f al_c iparum
Containment
ECQHCamme under NMEP with SIDAIs assistance = WHOEebruary.1l?S9=recgmmendat ions

Immediate need to provide effective f i rm
3.2.1
an
componants on regular basis of
add i t i onal
add i t i onal component, should there be withdrawal of
assistance presumably in a phased manner
external
necessary coverage during interim period to
with
ensure maintenance of the gains achieved under
Ff CP .
SIDA ' s agreement
exp i i■'ed by 301h June ,
o4:
1989 to support the operational component of
the
programme .
SIDA, however, is continuing support to

D12

1

A group of Entomologists constituted by the
Directorate
of
NMEF brought
out
operational
guidelines for the entomological teams.
3.2.8.
Strengthening of Division of
Training at the Directorate of NMEF.

Research

and

A Health Committee to be constituted at
3.2.9.
projects
State 1 evel to examine all developmental
from malarial point of view and accord clearance.
Recommendations of Central, Council of
Heafth
Welfare^.

3.3.

: 3.3.] .
■ ■-

I

?

Eicst Conference of Central CouQcif of
Health
Family Welfare = February 1988
Recommendations.

the
a)
It
is necessary
to
implement
Integra-Led Programme for Vector Borne Diseases and
the""Directorate of NMEF in consultation with State
Govts.
should
implement such
an
Integrated
Programme from 1.4.1988.

b)
Taking into account the availability of
Rs . 75 crores al lotted for the Malaria and F i1 aria
Control Programmes and the need for implementing an
integrated programme for vector borne d iseases
it
including Japanese encephal itis and K.ala—azar ,
is recommended that the following strategy may be
adopted .
?

To undertake insecticidal spraying operations
over
2
DDT/BHC/Malathion
areas having API
in
depending on vector susceptibi1i1y.

i

p

0
I.

k

c) To implement the integrated programme f or
of vector borne diseases as a !Catesgry-ll
control
the cost being
QeQtral_l_y sEQnsored Scheme with
in
State Govt .
Govt
.
and
the
sl'i ar ed by the Union
ot
d
i
v
i
s
ion
and
by
proportions
equal
responsibil ity.
Effective action should be taken by the
d)
and
St ate/UT Govts .. t o r e m o v e t h e organisat i onal
the
administrative c o n s t r a i n t s a d v e r s e I y a f f e c t i n g
control programme such as : --

funds at appropriate 11 me to
release of
the
during
the
spraying
fac11 i tate
t r a nsmi s s i on period.

H.

e f t c 11 v e s t e p s 1• o r supply and
taking
spraying
vehicles and
m a i n t e n a n c e o+
G

D14

equipments.
appointment
operat ions .

ol

stat f

t or

spraying

filling up ot vacancies of multi-purpose
workers.
ensuring adequate supervision of spray i ng
operations to'improve quality.

Improvement in Annual
Rate (ABER).

Bl ood

Examinat ion

In areas with Male Multi-purpose workers
vacancies, temporary unipurpose workers
should be engaged to ensure fortnightly
1 ater to
surveillance in all the areas, 1
be regularised after in-service training.

Heal th
Female MPWs, and VHGs
(Village
Guides) should be activated to col 1 ect *.
blood si ides.
School“
Adequate coverage of infants,
going children and pregnant women.

51

f ) Improvements in Lab^services

Hal aria
PHCs with high ABER,
two
microscopists to be appointed.
Add it i onal Lab.technicians should be
where stool, urine and
appointed
sputum examinations are undertaken .

Lab. equipments as per
suppl ied .

norms

to

be

One Sr. Technician for every 10 PHCs
at district level to cross-check and
superve PHC 1aboratories.

3.3.2.

Eecgmmendations of 2nd Conference of
Central Council of H^ltb 8/ Fami1y
Welfare 3
LEE?.

a)

The following ac11on s
the year 1989

to

be

t ak en

cr i ter i a ot API
and
The present
above for coverage by spraying
operat i ons but
should
be given to hard-core
areas
pri ori ty
espec i al 1y
areas, development project
areas where deaths have occurred,
areas
with

DI 5

epidemic potential
and tribal hilly areas where
malaria is persistent. ’ In these areas State Govts,
should
intensify the surveillance activities by
filling up the posts of peripheral workers.
b)

r;

I:

lj

The Council noted the field trials at Kheda
district
and other areas in the country conducted
by Mai aril a Research Centre of ICMR and recommended
be
that
Integrated Vector Control Project may
implemented in a phased manner in one district each
k in
the states of Gujarat, Madhya Pradesh, Uttar
1 Pradesh, Bihar and Orissa, in consultation with MRC
and the Directorate of NMEP.

!

i

h

c) Developmental Projects
Council
recommended that the
State
The
a
high
level
intei
—
developmental
1evel
Govts.should have
ma jor
involving
committee to screen proposals
ensure
and
and developmental projects
irrigat ion
authorities
incorporate
project
that
the
the
project
during
in
components
antimalaria
the
maintenance
stage.
planning construction and in
ant
imalaria
in
The engineers should be' trained
operat i ons.
d)

Urban Malaria Scheme

byeThe Council recommended that stringent
in
al 1
should
be
introduced
and
implemented
1 aws
the cities/towns to provide safeguards against open
storage of water and rectification of
drainage
system in problem areas.

e)

the
of
To revive the Independent Appraisal
and
to
order
to
have
uptodate
analysis
NMEP
in
t
i
mely
correcti
ve
measures
.
facilitate taking up

1
ii

•

Independent Appraisal of NMEF

$

If

ri

f)

’

Inter-state border meetings.

FW
the Regional Directors of the Heal th
Al 1
will organ i se inter-state meetings - one before the
the
spraying
and another after
transmi ssion
]nternational
If
necessary
with
operat i ons .
cooperation .
For spraying acceptability by the communi ty
g)
intensified health educational a c: t i v i t i e s s h o u 1 d b •"?
com m u nit y a bout
taken
to create awareness in the community
the benefits and also supply diazinon for the bedbug nuisance.

O

D16

• 5

Su r v e i I 1 a n c e

h)

act ive
the
Council
recommended
that
T bi e
visits
by
survei11ance through fortnightly house
the peripheral heal th workers and wal I stencils as
evidenced of the visits should be rigidly enforced
on the
passive
Al so stencil
by. the states .
of
e
s
t
a
t:«
1
i
s
h
m
e
n
t
o
f
m a I a r' i a
3ncIuding
survei11ance
the
i
n
st
i
tut
ioris
mak
i
ng
clinics in all tiie medical
and
supervision
laboratory
f or
institutions
personnel -

A
Nobility

i )

F i ve
counci 1 recommended that during-VIiI
unserviceable
’ i and
Year
Fl an, replacement of old
veh icles in a phased manner out of Govt - of India's
be
consultation with the state govts.
50’Z share

,

The

made .

J>

Contingency Amount

India
o-f
recommended that Govt.
The CounciI
amount
i ncrease the ceiling of contingency
shot?! d
2.50 lakhs for a
1 .00 lakhs to Rs.
from Rs.
7-5
lakhs and above
with a population of
district
anddifficult and* hilly terrain district population
less than 7.5 lakhs and Rs.
L— 0.75 lakhs- for districts
with population below 7.5 lakhs to meet the cost of
of
insecticides,
drugs
etc.
rent,
transport
POL,
maintenance
of
vehicles
,
stationery,
of
spray
equipments
and
laboratory
maintenance
equipments etc .

I

4.

yill EiyE l^AR FLAN

4-1 .

Objectives

Immediate objective is to achieve effect ive
f or
measures
malaria by adopting
control
of
FHC
through
act
iv
it
ies
control
strengthen i ng
be
remains
to
goal
stil
1
system and ult imate
from
the
country.
eradication of malaria

Fol 1 owing
objectives

!

i)
i 1)

(

i

are

Elimination of

the

spec it ic

immed i ate

d e a t h s d u e t o m a I a r' i a -

To r e d u c e m o r' b i d i t y d u e t o m a 1 a r i a especi al 1y
1 ow
i n persistent t r a n smi ssion a rsas having
as
such
—
economic
groups
of
population
soc 3. o
urban si urn areas & 1 ahour
tribal
areas,
wit I "i
projects
devel
opmentai
in
populat ion

D17

6

vulnerab1e
special
emphasis on protection of
pre—school
groups of population e.g. infants,
children, school children, pregnant women.

iii)

the community on
To increase awareness of
ensure wi11 i ng
to
malaria
and
problem of
ant imalaria
cooperat
ion
i
n
commun i ty
act ivit ies .

iv)

To i nvolve i dent i -f i ed non-heal th
malaria campaign.'

sectors

in

' ",
Though the MFO strategy
(1977)
has been
; 4.2.
I accepted as wel1-conceived, the implementation has
i not been satisfactory due to various setbacks as
in 1985
' observed by the,indepth evaluation teams
Based
on
the
experts'op
in
ion
and
Central
and 1989.
1 988
of
Health
and
F.W
recommendations
in
• Council
been
the strategic approaches have
and
1989,
f oCmulated.
4.2.1 .

Concept

infection
reservoir
Reduction of pool
vigorous
antiin the community by
supplemented
by
parasitic
measures
insect ic idal
selective
and
effective
source
reduction
spray
operations,
environmental
measures
through
biolog ical
of
modifications,
use
situation
1 ocal
agents as
per the
educat i on
through
the
intensive heal th
commun i ty
and
enlisting
active
enl ist ihg
efforts to get
co-operation and making
co-operation.
intei—sectoral

i

4.2.2. ABBCgaches
Pr i or i t i sat i on
Based
on
malariogenic areas of the country.

:■

I
r

4.2.2.1 .

Tribal. Areas -

Tribal

Malacie

o-f

Action

Elan .
p opu 1 a11 on
A total of 54 m illi on t r i. b a I
P
o
p
u
i
a
11
o
n
i
s
s
p r e a d over
i . e . "7"/ of country ’ s tota I
Territor
ies
in
21
stat.es
a
n
d
Un
i
on
1 26 d istricts
lOOO
population
incidence
more
than
2
per
with case
in a year (during preceding 3 years - above 2 API )
of
contribute 30"; of total malaria cases and 577;
of
the
type
of
malaria
(
P_.f
alciparuml
ma t i gnant
country.

additional

The SIDA assisted FfCP has provid ed
malignant
inputs for protection against

D18

. !r *

var iety ma I aria most 1y
June , 1 999 .

in

tr 1 ba 1

areas from 1979 to

The Evaluation report of PfCP - Feb.in
inputs
1 989 strong!y recommended <idditional
these areas.

Syrvc-i 1 1 ance

of
malaria
infection
load
Reduct i on
variety
<
P_-f
al_c
iparum)
by
malignant
especial Iy
through
trilbal
malaria
active
surveillance
v&lunteers, one each for 1000 population, alongwith
workers
(MPW,
heal th
fortn ight1y visits by the health
male) .
i

through
heal th
Passive
survei11ance
community
members
d ispensaries,
centres,
functioning as drug distributors and as blood smear
school teachers, forest officials, the
dol l ectdrs
T r iba1
Level op men t
of
Integrated
personnel
Int eg rat ed Child
Anganwadi workers of
Programme,
Level op merit Services (ICDS),

Mass surveys, school surveys before and
active transmission season and treatment of
during
A special Combat Teams for
all parasite positives,
each of one lakh population along with the regular
survei11ance staff .
t

transmission

Interrupt ion
Qf
insecticidal sQraYjL

through

Criteria

I:

i

i!

I

Spraying in areas with incidence of 2 cases
in a year during
above per 1 000 population
An additional round of spray to
preceding 3 years.
these high
in
transmission
interrupt perennial
transmission areas.

Areas where insecticide has no role or has
1 imitations and where p e o p I e 11 a v e a I r* e a d y t li e ha Ij i t
synthet i c pyrethroids will
of using mosquito nets,
free of cost especially to families
be suppl led
with
infants and pre-school children and in other
be
impregnated mosquito nets will
tribal
areas
supp1 ied .

to
of
parasite res i stance
Invest i gat i on
screen ing
drug,vector resistance to i r i s e c 11 c i d e s ,
Combat
he special
of
migratory population by tthe
Teams.
One Zonal Mal a r i a T e a m o f the States to be
shifted to Tribal area .

D19

Development
of
specific
health education
material
to the Tribal population,
holding mass
contact educational programmes to create aweareness
a?id to adopt personal protection measures.
4.2.2.2.Rural ^reas other than Tribal areas with
above 5 per 1000 population in a
case incidence 5
year during preceding 3 years.
of 21

Population
. . T20 million in 122
states and 4 Union Territories.

d istricts

IP Ceduce parasite Load in community

Active fortnightly surveillance through
MPW(Male).
The MPW
(Female)
to collect b 1 ood
smerars in her headquarters.
Passive surveillance agencies through al 1
includi ng
.the
health
institutions
indigenous
systems of medicines.
Monitoring of parasite resistance to the
aht4malarials and vector resistance to conventional
insect ic ides .

PHC 1aboratories intensified
supervision.
One senior 1ab.technician to supervise the work
1 oad of technicians of 10 PHCs.
IQterrLipt transmission

Indoor residual
J

insecticide spray

is

the

main stay -

Health education of the community to create
awareness about
malaria problem to accept spray
operations as a benefit, to seek
treatment f rom
health worker or a health institution.
f

4.2.2.3 .Rural areas other than
tr i ba I
ateas below 5
§ cases per 1.000 P.er
year .( low incidence areas)

Emphasis of passive surveillance agenc i es,
all
health
institutions to study trend and to
institute
prompt
treatment
after
contirm i ng
d iagoos is.
F o r t n i g h 11 y a c t i v sl>rvei 1 1 ance by 111e Ma 1 e
M u 1 t i p u r p o s e w o r k e r i n I i 3. s a r • e a a n c I M P W (f e m a I e)
in
her Headquarters.
Blood smerar collection to only clinically
suspected
cases
and
after
parasitological

D20

confirmation ,
radical
rad ica1 treatment followed by case
investigation to decide indigenous transmission or
importation of cases.
Augmentation of DDCs and FTDs so as to make
the antimalarial available even in remote areas.

the
Focal spray in 50 houses around
to
take
active
Members
The Fanchayat
superv i s i on .

case .
in

methods 1 ike
Introduction
of
biological
environmental
using 1arvivorous fish and taking up
methods to prevent mosquitogenic conditions through
ndn-health
sectors at district
and
community
development block
b1ock
1evel
level
i.e•
i.e.
fisheries,
social
Irrigat
ion
.
forestry, IRDF,
Orientation of non-health sector manpower at
..and
district level
about
bio
bTock
1evel
envi ronmenta I methods through ICMR institutions.

Long i tudi ona I

entomo I og i. c.

studies-

Hea l th educat i on.

4.2.2.4.

U*2ban areas ^.Ucban Med arjia Scheme^.

A1 I t owns o f IJ r b a i •« m a 1 a v i a scheme vj i 1 I
two
al so attend to filariasis control wherever the
co-ex
ist
.
problems

Augmentation of source reduction methods
i nter-sectoral
and bio-environmental methods with
cooperation from F'ubl ic Works, Roads and Buildings,
Water Works and Drainage, Fisheries etc .
- .
All construction
works in 1 ocal body arse*
statutory High Power Board with the Ch i e f Execut ive
-f rom
■for
o-f
works
as
Chairman
for
clearance
or
view and
1 egal
malariogenic potential
point of
imp1 ementation
provi s i on i . e . bye—1aws framing and
to be taken up.

1 evel
SI um areas with poar socio-economic
—
active
surveillance
through
.heal
th
of population
to
be
introduced.
Also
malar
i
a
cl
i
n
i
cs
workers
Insect
icide
lab.facility
for
the
si
urn
areas,
w i th
these
localities are to
be
spray operations in
education especially to this
undertaken Heal th
vulnerable group .

D21

l

I

i

Industries
screening by High Power
Body
Committee
Local
and
bve-lA^
inclLlde
bye-1aws
prov i s i ons
penal
for defaulters.
In-built
component
antimalaria
Tor major industries
in
the
towns to
prevent
mosquitogenic conditions
the
and screening of
labour
population ..and
providing
-.treatment .
prompt

’

i

Heal th
education using
the communication
-media
1 ike Radio,
Television,
Newspapers
to
encourage community to adopt
protection
and
to |prevent intra-domestic personal
and peri-domestic
mosquito breeding.

:j

I

4 .2.2.5.

E'SYgleBment Project Areas

Clearance of major social
L
developmental
projects
]
‘
1 ike
irrigat ion , hydro-electric
by High
Power Board at nat i onal
and state 1evel — Ministry
of
Environment
being
the nodal
agency and
Directorate of NMEP at Central
the
I
evel
and the State
Programme fOff
-- -icer (Malaria)
at "the time of submission of *s the expert members
plans to
-o examine the
ma1 ari ogen i c
potential
and ensure ,
provision
ant imalaria
of
component during the construction
and
maintenance stages’ of the projects.
J
Adequate budget provision for health
and
sanitation and advanced
antimalaria measures in the
project areas.

personnel

Training of health and
non-heal th
of the projects.

sectors

4.2.2.6. ^eid&mi^c/Eg'idemic
ECgne areas

Vigilance by peripheral
health workers
through
fortnightly home visits.
All
fever cases
at the t ime of visit or occurring
in
the
preceeding
3-4 days, blood smear
examination and treatment of
positive cases.
Focal
r
spraying
indication
increasing trend of cases or where
11ireatened ep i demi

of

c.

Eegul ar epidemiological,
c
,
meteorol ogical , populat Ion migrationentomological
—,monitoring by
the district malaria
—. - a organisation.
c_

POLICY ISSUES FOE THE VIII PLAN PEEIOD
5.1 .

E’INANC I al. .

5-1.1.

NMEP IRural & Urban ^laria Scheme.

D22

NMEF will continue as Category—II Centrally
Scheme on 50:50 cost
sharing
basis
Sponsored
non-tribal
Cent
r
e
and
States
toward
s
non
t
r
i
ba
i
rur ai
between
Malaria
Scheme.
areas and the towns under Urban
the p 1 an
bearing
5.1 .2
The present pattern of
Zonal,
State
,
of
regular staff
expenditure on
wi 1 1
Urban
)
level
~ NMEF
(Rural
District
committed
the
d u r ing VIII
F1 an be
henceforth
non—pI an
under
of
the State Govt
1 i ab i1 ity
ex penditure of the state.

Seasonal
spraying
staff
cost
5.1 .3.
shared between the Centre and the State
sharing basis.

be
will
50 :50
on

The regular staff of the Di rect orate o+
5.1 .4.
Fami1y
and
NMEF and Regional Office for Heal th
during
F'l
an
under
Wei fare Govt of--India which i s i
account
Five Year Flan will go toi Non-plan
VLI
during VIII Plan period.
expenditure f or
the
of
Cent pei"' cent
5.1 ^5.
as
posts
of NMEF such
field
fiI 1 ing up of crit ical
technicians,
Malaria
Laboratory
MFW(Maie) ,
Supervisors
level Multipurpose
Inspectors at FHC
of
India.
wil 1 be borne by Govt .

$

insect ic ides,
The cent per cent cost of
5.1 .6
vehicles
and
equipment
,
and
material
drugs,
Malaria
Action
Flan
additional posts under Tribal
will be borne by the Govt. of India.
The entire sanctioned budget towards NMEF
5.1 .7
State
of
after vote to be placed at the disposal
the
of
Secretaries
in
the
beginning
Heal th
of
imp
1
ementat
ion
year to f ac11 itate
f inane i al
schedule
.
activities
as
per
ant imalari a I

5.1.8.
57- of the total outlay under NMEF to
earmarked towards health education component.

I

be

5 . I .?
earmark ec!
industr j. c?

be
ot t(.it-Al outlay must
S :i. m J I ar I y «,
and
d e v e 1 o p Hi e n t a I
p reject s
in all
component.
t o w a r d s a n t :i. m a 1 a r'

5.2 .

AptllNISTRAIIVE

Al 1 tra i ned St ate Frogramme Officers,
M <•?. 1 a r • i a Cl f f i c e r s . D:i strict Mal ar i a Uf f i cers
Zonal
and o n a P H (• 1’1 e d i c a 1 Of fi cers and one FHC Medical
be kept in position for at1 east
□f <• icer should
three years i n the NMEF.

CT

1

'I

. X. . I -

cr
o r»
*.J M X- ■ X- •

Al 1

vacant

i

D23

posts o-F

MFW

(Maie)

MPW

Supervisors,
Malaria
Inspectors,
Laboratory
technicians must be ., filled up during
the first
Pl an as per norm.
year of
VIII Plan
The add it ional
inputs under Tribal
Malaria Action Pl an 1 ike
Malaria Combat Teams,Tribal Malaria Volunteers to
be in position in a phased manner within 3 years.
c

O
. XL . O .

One Zonal Team to be shifted to tribal
selected
under Tribal Malaria Action Plan and
area
team
to be shifted to state headquarters
one Zonal
to strengthen the State Malaria Organisation.
Monitoring Teams
Present 1 2 P_-tal_c i^arum
5.2.4.
study
the
parasite
sensitivity
to
antimalarials
to
be
regular
component
of
the
Directorate
of
should
NMEP .
All
the Regional
Directors
5.2.5.
public
health
qualified.
should be

of

ROHFW

5.2.6
created
areas.

be
Mob i1e Epidemic Control Teams must
prone
defined epidemic/epidemic
in
al 1

5.3.

OPERATIONAL

Rural areas (Non-Tribal ) with API 5 and
5.3.1 .
will
during VIII Plan be g i ven protect i on
above
with iinsecticidal
nsect ic idal spray replacing the MPO criteria
of 2 API and above.
In tribal areas, the criteria
insect ic idal
of
above 2 API
wil1
be taken for
spray operations.
be
Rural areas with API less than 5 will
5.3.2.
and
with
augmented
case
detection
provided
The
facilities such as DDCs and FTDs.
treatment
post
be
manned by school
teachers,
FTDs will
panchayat members, village health guides
masters:,
and others.

will
In tribal areas, the State Govts.
5.3.3.
mal
aria
component
of
a
regular
spray
provide
combat team consisting of one medical off icer or
one
and
biologist,
one Laboratory techn ic ian
f or
veh
icle
malaria
inspector with a driver and
of
superv
i
s
ion
investigations ,
cross-checking,
antimalaria measures and containment of disease.
The Tribal Malaria Volunteers will
be
5.3.4.
paid an honorarium of Rs.100/- per month covering a
population
of
1 OOV tribals to take up
the
surveillance, treatment and educational activity.

co-ord inat i on
Tribal areas, special
In
5..3.5.
Agency
and
Development
Tribal
Integrated
with

D24

Child
Development Services will
be
Integrated
sought
to involve in the antimalaria act ivit ies
workers
in
the peripheral workers like Anganwadi
I CDS.
survei11ance
5.3.6.
In all Urban Malaria towns,
mechanism for si urn areas will be taken up .

5.4 .

LOGISTICS

The State Govts during
Insecticides.
5.4.1 .
._.wiJ_l
procure
-allthe
VIII
Five Year
FiLan
Maiath ion
requirement of DDT 503d wdp , BHC 503d wdp 9
and
Diaz inon
253d
including
Malathion Technical
with the technical approval of Directorate of NMEP.
The Directorate of NMEP will procure and supply
The qualitative analysis of
only imported DDT 753d.
with
the
continue to be
insecticides
will
Directorate of NMEP.

Al 1
the
Antima]_ari.al_
drugs .
5.4.2.
Chioroquine,
ant imalarials except Primaquine viz;
Sulphainjections,
tablets and
Amod iaquine
and other symptomat i c
comb inat ion
pyrimethamine
by the
drugs
1 ike Paracetamol will be procured
The
Pl an
period .
State
Govts.
during VIII
imported
procure
onl
y
the
Directorate of NMEP will
Primaquine tablets and supply to the States .
of India
The Govt.
V^t j.c^es .
5.4.3.
will procure the vehicles as per the requirement of
of
mechan i sm
States
and the ex i st i ng
the
the
by states will cease as most of
procurement
be
will
states have difficulty and the cost
shared between states and centre on 50:50 basis.

5.4.4.

Material

Egui£ment_.

microslides,
microscopes,
Sprayers,
pricking needles and stains will be continued to be
procured by the State Govt. on 50:50 sharing basis.

6.

OPERATIONAL PLAN OF MALARIA CONTROL

6.1

Active surveillance

In
tribal areas, in non-tribal
rural
urban
si
urn
areas,
developmental
projects
and
areas,
industries with antimalaria component in existance
and
in epidemic
prone areas fortnightly house
visits by the MPW (Maies)/survei11ance staff
to
collect blood smears. In all the areas, MPW(Female)
will
attend to
blood smear collection
in her
headquarters.

D25

In identified tribal areas with above 2
API, a tribal will be selected to act as a malaria
volunteer for a population of
1,000 each for
carrying out surveillance and treatment.

operat ion,
ICDS is in
operation,
the
Wherever
Anganwadi
worker
wilI
act
as
FTD
.
Where
village
worker will
health guides are provided each for
population
each,
he will act as FTD.
In other areas,
school
teachers,
panchayat members, post
masters,
ITEA
peripheral functionaries, forest offic ials wil1 act
as DDC or FTD - one for 1000 population depending
upon —theii--- l iteracy -l evel
col lection
of
blood
smears and treatment or only drug distribution.

The norms of MF'W (mal e) in pl ain areas,
tribal/hi 1 1 y
coverage o+
5000 population and in
o-f
areas 3000 population will continue.
to
Transport of blood smears-> col 1 ected
executive
The
1aboratory twice a week the
and
col 1ect ion
operat ion for
in
instruct ion
a
twice
of the sl ides by MF'W Supervisor
trasport
To
Wednesday and Saturday will cont inueon
week
(
in remote and
the
time
lag, especially
reduce
malaria volunteer
hilly areas, the tribal
tribal
personally
deposit
the
slides
atleast once
will
|
previous
at the PHC and collect reports of
week 1y
weeks to institute treatment.

The State Governments will1 utilise the
transport of.:
public transport
system including
wel fare agency ? pre paid1 postal
ITDA or any other
(---1aboratory
system for transport of"■ si ides to the 1
back
to
from the periphery and
t-- also to give feed
the peripheral worker In islands like Andaman
Nicobar and
the positive^ cases
remote hilly areas, results of (PjL£al_ciparum)
the
,
<_
especial1y mal ignant variety
be
or revenue to
wireless communication of police
util ised .

Mass surveys, seiected
group
surveys
school children will be
carried
out
in
as
such
before
&
during
peak
transmission
areas
tribal
of
the
by the special mallaria combat team
period
volunteers,
male
Multipurpose
F’HC along with tribal ’—
o-f
the area under the supervision
of
the
Workers
of
off
icer/b
idlog
ist
.
F’HC medical
6-2

Passive surveiLLance

PHCs,
Dispensaries ,
Govt .
Al 1
Dispensaries
Hosp itals,
Di v i sion/D i strict

D26

Subof

,T_

■ tt
r?

indigenous system of medicine will
the passive surveillance agencies.

continue to

be

In developmental projects, dispensaries
hospital,
in tribal areas, the existing health
or
care volunteer agencies like mission hospitals and
be identified to function as
d i spensari es will
passive surveillance agencies.

!

■J

■

in
In addition to active surveillance
urn
si
in
VIII
Plan,
for
10000
urban
urban areas
Flan,
one
surveillance worker and for 4
population
workers one Supervisor
—
for
surveil1ance
fortnightly si urn visits.
apart
from
In
urban
areas,
institutions
,
governmental/municipal
health
1
aboratory
institutions with
heal th
vol notary
as passive
be identified to act
facilities wil 1
agencies.

prone areas,
identified epidemic
In
health institutions with 1aboratory facilities wil1
be identified to act as passive agencies.
6.3

Laboratory Services

The present PHCs with a population of 1 to 1.5 lakh
' ■ ■ j
has
for
population
has one
one Laboratory Technician
malaria and other pathological work and the process
' > under
opening of PHCs for 30,000 population is
of
Laboratory
facility
in
L
way in many of;the states.
incorporated
under
Rural
of
the PHC to be
each
1 eave reserve of
Ten percent
Heal th Division.
cont in Lie
in
Laboratory technicians as per MPO will continue
VIII Plan.

For tribal
areas,
one
Laboratory
isprovided
in
the
VIII
Plan
in the
Technician
for
Combat
Team
for
cross-checking
slides,
Spec ial
surveys, invest igat ions.

120
For the non-tribal rural .areas of
and
population in 60 districts with API 5
mil 1 ion
above 5, one Supervisory Technician for one? mi 11 ion
additional
at district level will
be upopulat i on
and supervise the work
functionary to cross-check
1 evel
of
120 senior
of
the PHCs.
A total
F'l
an .
i
n
the
provision
made
in
the
VIII
technicians is
—
In urban malaria towns, one Laboratory
Technician is provided for one lakh si urn population
to examine the slides collected by the surveillance
is the
worker.
A total of 700 Lab. Technicians
additional input during the VIII Five Year Plan for

D27

a population o-f ~70 mil 1 ion
Scheme.
6.4

u jnder

Urban

Mad ar i a

T peatment

Presumptive treatment with
chioroqu i ne
to be
be g iven to al 1 fever cases suspected
will
heal th
work ers
the peripheral
malaria by al 1
community
heal th
ident if ied
the
includ ing
volunteers .
(•'

and
Rad ical treatment wilh chloroquine
be given to all
the confirmed
primaquine will
of
Multipurpose
cases under supervision
positive
in
case
Multipurpose
Supervisor
is
and
Supervisor
not available by the Multipurpose Worker h imself.
voluntary
All
institutions including identified
chioroquine
health institutions will provided with
and primaquine by the State Governments for radical
treatment .

6.5

■

S^ray Operations

cri teri a,
380
As per MPO 1977 API
f or
be
projected
million population
has to
year
of
in
the
first
insecticide spray operations
preced
i
ng
whereas
if
2
above
2
API
of
;
VIII
Pl an , i
mil
1
ion
265
three years 1986-1988 is considered,
needs spray coverage.
For the VIII
populat ion
3
Pl an ,
areas with maximum API in the preceding
of
be the basis for projection
years,
will
The
population under spray in the fol 1 owing year .
year
f
irst
projected
for
spray
during
populat i on
will be as foilows :
For tribal malaria control i above 2 API
i)
areas — 54 million population.
For non-tribal rural areas above 5 API
ii )
120 Jmil lion population i. e. a total
of 174 million population is projected
for
insecticidal spray coverage with
appropriate insecticide.

For subsequent years in Plan period, maximum API of
preceding
3 years will
be
considered.
The
projection of QQpul_ation has been worked out taking
Sistrjct as a unit,.

will

□ne round addtional insect ic idal
be carried out in tribal areas.

spray

” In
the non-tribal
is
below
5
API,
516
million
population
rural areas
est i mated .

028

be con-fined to a foci
positive malaria

__.l spray will
Focal
around
a confirmed
□•f
5o houses a.
case .

out
carried
Spraying
will
be
spec
ial
with
exclusively
in human dwellings
attention to the coverage of 1 iving rooms.

Control. Activities

7.

S&T
under
VIIIFive Year Plan,
During
are
methods
bio-environmental
Mission Project
I
’ introduced "in "Targer*—areas i «e to be
proposed
rural areas
areas <4 districts of
districtsi as a unit in rural
Shahjahanpur
,
Allahabad,
Pradesh namely
Uttar
I Kheda district in Gujarat
and Haldwani and
Hardwar based
on the experience of ^1
Research
State
in
(ICMR) in Nadiad Taluka.
In ad
,
Centre areas other than tribal areas with AFI
1 ess
rural
1 ike introduction
than 5 , bio—environmental methods
of
social
development
1arvivorous
fish,
of
irrigat
ion
engineering measures for
-Forestry ,
sanitation through
channels, rural water supply and
—proposed
in a phased manner.
different sectors are
i
training to the
MRC
(ICMR)
will give orientation
heal th
1 evel
District
Bl ock
1evel
and
Mai
aria
District
The
sectors'functionerieswill
Team
of Zonal Malaria
Off icer with the help
sectors
different
identify the situations! where
other correct ive
in engineering and
•
take part
measures.
and seiected
ident ified
The districts
be
introduced,
will
where bio-environmental methods perational.
cost of
the cost
cost of
of insecticides and o
utilised ’ for bio
the spray
spray operations will be
insect i c ide
environmental
measures with a reserve
for focal spray in emergent situations.
bio-environmental
methods
In Urban areas,
in
measures
are
al
ready
source reduction
the
and the same will be continued with and
operat i on
like fisheries, roads
involvement of sectors industries as well as Water
btiil dings , Rai1 ways and
Sewage disposal.
supply
• • ’ i of bye-1aws to
Framing and implementation
conditions will be taken up
prevent'i mosqLiitogenic (-----Scheme Towns.
in Urban
L. — Malaria
Five Year
areas during
VIII
In Tribal
insect
icide
in areas where indoor residual
period
sociovulnerable,
1 imitations,
has
spraying

D29

material .

survei11ance workers
In Urban si urn areas,
education
up
heal th
take
and
Inspectors will
activities.
Mal_ar waenicStra£if l^ation .

■f or--- mal -ar iogen ic-Epidemiological
model
like
epidemiological,
stratification with variables
has
topographic and mateorological
entomological,
has
been developed by the Directorate of NMEP and
applied to Karnataka State stratifying PHC
been
their
different
categories
based
on
into
potential .
The model is under field
malariogen ic
simi1 ar
It
is
proposed
to take
verif icat ion.
4
problem
during
the
yerar
1989-90
for
exere ises
country
and
during
the
VIII
Five
Year
states in the
the
States
are
proposed
to
be
taken
Pl an period al 1
As the
process
of
up
in
a phased manner.
,
the
strategic
stratification of States progresses
approaches will
be defined for each, strata for
implementation .
N^Q^aement Information System.
$

ep idemiolog ical
Monthly and
annually
continue
to be
generating
from
F'HCs
will
reports
the
states and
transmitted to the districts,
scheduled
dates.
national level as per
Monthly Entomological Information from the
Malaria
Teams and ROH&FW Govt of India will
Zonal
to
be
transmitted from states to central
continue
1evel.

Eiuring VIII Five Year Flan, it is proposed
the
budget/expenditure information
from the
that
states will be transmitted to the central
level
of
quarterly within one month from the completion
the quarter.

10.

P_-fal_ciparum Monitaring for Chforogufne and
alternate drug sensitivity

Drug resistance phenomena of P^f^Ltiparum
type
has
been
occurring
in
(Malignant)
different parts of the country since? early 1970s.
there are 13
Monitoring
teams
F'resentl y ?
1 3 ad—
-hoc t.
—
along
with
Headquarters
component
on
funct ion ing
The
teams
are
conducting
studies
on
annual
basis
drugs
like
Sul
pha-pyrimethamine
Al ternative
comb inat ion , Amodiaquine, Quinine and Mefloquine to
strain .
detect and prevent spread of the resistant
As
it
has an
Continuous monitorin.g is essential .
A- -

DiS 3/V
D31

N ^5"-

/y

LIBRARY
ANO

A O\-

drug
direct beraring on the national
i mportant
and
the
NMEP
with
regard
to
use
of
first
policy of
second line of treatment of malaria case, Hence, it
the
13
is proposed that in VIII Five Year Plan,
integral
part
of
Monitoring teams should be made an
the NMEP.
11 .

Entomgl_O5ical_ Monitoring

Presently, 72 Zonal Teams are functioning
in different states to obtain
scientific data
periodically for carrying out spray operations and
susceptibil ity.
to know the vector behaviour amd
During VIII Five Year Plan in order to strengthen
the state level malaria organisation and in order
areas
to give thrust to the tribal
areas,,
the states
shal 1 have one at
having more than one zonal team,
shall
iin
n hard-core
the state headquarters and the rest
areas and those who have only one zonal team will
locate it at the state headquarters.
12.

£

Activities.

As per the staff sanctioned presently at
level ,
30
State
Mai ariologists
state
Mai aria
Entomologists at
Zonal level, 78
Zonal
Entomologists/Asstt.Entomologists , 410
Officers, 86
:
Mai aria
Officers and 419 Asstt.
District Malaria
I
NICD
is
are
to
be
trained.
Presently,
Off icers
these
f
or
training
for
6
8
weeks
imparting
Y ear Pl an
During VIII Five
categories of staff.
it isproposed that apart from NICD, State
period ,
Training Centres will be identified for
Reg i onal
training of above categories of staff.

Officers are
At PHC level , 28860 Medical
re-orientati on
functioning and are to be given
F.W Centres.
training at State Regional Health

of
Para-professional s'of PHCs comprising
1
0091
Assistants
,
Health
Inspectors/Health
28538
Lab .Technicians are to be trained at 1 2 ROH S/. FW
Five Year Pl an
Govt
of
India during the VIII
period.
MPWs, VHGs and CHVs sanctioned are proposed
to be trained at
PHC level during VIII Five Year
Pl an period .

Expert As recommended by the several
Commitees, a Division of Training is to be created
p1anning ,
Directorate of
NMEP
for
in
the
monitoring 5 evaluating the training programmes and
the
preparation as per needs of
al so curriculum

D32

programme during the Mill Five Year Plan Period.
To augment the training facilities at ROH .!<
FW level during VIII Five year plan period, it
is
proposed to have one additional
post
of
Publ ic
Health Specialist of grade-II.

Training of the Personnel under Tribal
Malaria Action Plan,.._
. .
For the specific job requirement in Tribal
the existing antimalaria personnel have to
areas ,
personnel like
be re-oriented and the additional
of
Malaria Volunteers and the personnel
Tribal
Combat Teams need to be given training.
zonal
The orientation of the state
level ,
off
ice
officers
and
officers
of
the
Regional
1 evel
be
done
by
the
Ind
ia
will
for Health ?< FW Govt, of
Directorate of NMEP officers at ROH ?< FW.

g i ve
The State Programme Off icers will
District
Mai
ar i a
training
to the
orientation
In turn , the District
Off icers at the State 1evel.
Med ical
train the PHC
of f icers will
Mai aria
The PHC Medical
off icers at the district level.
train i ng
Off icer, in turn will g ive re-orientat i on
from the
Staff
to the para-medical personnel.
Project
Development
ICDS, Tribal
Departments of
1evels along with
at differet
will
be trained
heal th staff .

1 3.
Research on mal aria involves two aspects
the
one is basic and the other operational aspect,
ICMP
former
being
carried out presently
by
institutions and some of the Medical
Coleges and
operational research by the Directorate of NMEP and
i dent i f i ed
ICMR.
An Expert Committee in 1987 has
regard
to
areas
on
priority
basis
with
entomolog
ical
,
cl in ical ,
epidemiological ,
manageri
al
control measures and
chemotherapeutic ,
under the
Present1y ,
the programme,
aspects of
one
Director,
NMEP , One Deputy
D irectorate of
Sr.Reserarch Officer and 14Reserarch Off icers are
P-if
i.Qarum
attending
the
sanctioned
posts
During VIII
Monitoring to chloroquine resistance.
to undertake the field
Five
Year Flan
period
operational studies, strengthening of the reserarch
and
development division has been proposed.
The
Division will be entrusted with the responsibi 1 ity
of planning of operational research activities and

D33

to co-ordinate research
activities
of
other
of
organisations pertaining to malaria and to see that
the results obtained are incorporated in the control
strategies of the programme.

14.

Logistics

I YEAR OF THE VIII FLAN - INSECTICIDE REQUIREMENT

Population in “Mil lion
Quantity
in "M.Tons"
Insec
ticide

Tribal
Non-Tribal
2
>2
5 S/ >5
API
API
Pop. Qty.
Pop .
Qty .

Pop .

Qty.

DDT

38

5700*

31

3100

516

2580

BHD

10

4480*

73

24528

11380 or
8550(Tech.)
29008

HAL

6

7200*

16

14400

21600

T otal

54

120

Non-Tribal
API <5

Total

516

* For one extra round of spray, quantity included.
Central Insecticides Board, GovtofIndia has
banned DDT in Agriculture and for Public Heal th,
a
cei1ing has been fixed at
10,000 M.tons
M .tons DDT
Techn ical
per annum.
In
VIII Plan,
the ceiling
laid will
not exceed
but with
stratification
ex ere i se ,
phasing down of
insecticide usage
is
aimed .

Synthet i c Pyrethroid
will be procured
f or
impregnation of mosquito nets,
Tech -Maiathion
for
fogging during epidemics and Diazinon to mi t igate
bed-bug
will1
nuisance
wil
be
procured
as
per
requirement .
1 4.2.

Antimalarials

The procurement of chloroquine per annum
would be to the extent of
400 million
tablets,
Amodiaquine 20 Million tablets, Primaquine 7.5 mg .
tablets 40 mil Ion and Quinine sulphate tab 1ets
mi 1 1 ion , Quinine dihydrochloride
injections
0.15
Mi 1 1 i on
ampoules,
Sulpha-pyrimethamine
tablets. 1.5 Million Paracetamol 50 Million tablets.
1 4.3

Larvic ides
In Urban Malaria Scheme, the procurement of

D34

Five Year
1arvicides ’will continue as in the VII
Flan and
the
Pyrethrum
extract
for
space
spray will
and the
also be procured .
In the VIII Plan it is proposed
and
the
the states procure al
all1
larvicides
that
cent
cost
.
will
share the 50
per
centre
1 4 .4 .

Vehicles

----- .
jn the Tribal
Mobility in the ergsramfpe
action pl an during- VI IT-pPan “to-cover ' 54
malaria
mi 1 1 i on
one vehicle for 0.1
populat ion ,
mil ion
of
540
is made.
A total
populat ion provision
India as
is
to
be
procured
by
the
Govt,
of
veh icles
cent per cent central assistance.
Under Urban Malaria Scheme, 53 towns have
'
'
al ready been sanctioned and one vehicle for each
isting 128 towns,
town is proposed and out of the ex
as
will
be
provided
one
vehicle
each
32 towns
on
the
cost
of
which
will
be
shared
replacement,
centre
and
the
states.
50:50 basis between

and
For hard-core (non-tribal above 5 API
tribal
above
2
API
)
malarious
areas
under
mal
ar
i
olis
above 2 API
insecticide coverage, for each district the norm o-f
Jeep, 2 trucks
supply of vehicles is one Jeep,
and one
488
Pick-up
van.
There are 122 districts and
is
The
vehicles would be required.
replacement
50‘Z
i-e. 244 vehicles during the VIII Plan period
is proposed in a phased manner.
1 ess
(API
the remaining rural areas
In
a
with
areas
)
non-tribal
rural
than
5
in
280
over
of
510
million
spread
populat ion
it is proposed to repl ace one veh icle
districts,
be
district
i.e. '280 veh icles will
for each
hard-core
i
n
The cost of the vehicles
provided .
be
shared
districts and in other rural areas wil 1
between centre and the states on 50:50 basis.

15.

Organisational re-structuring

the
in
has
been
no
change
There
the
and
structure at the centre
organ isat ional
Modif
ied
1evels since the implementation of
state
to
bring
Operation.
As it is proposed
Pl an
sonu/changes in the operational strategy of
about
jis imperative that there should
be
N .M .E .P .
existing
organisational
structure.
restructuring of
have 8
Accordingly,
the setup at the Centre will
divisions
at
the
headquarter
as
fully equiped
1 isted below :

1. Division of Accounts & Administration.
2. Division of Planning, Assessment & Evaluation.

D35

Kala-azar.
3. Division of Japanese Encephalitis
Division
of
N.F.C.P.
A-.
Heal th
Train ing
Research,
5. Division of
Educat ion.
C.C.O.
6 . Division of Urban Malaria
7. Division’of Public Health Engineering.
8. Division of Entomology and Chemistry.

Each division will be headed by a Deputy
Director
assisted by Assistant Directors and Dy.
Ass i st an t D i rec tors’additional
The following
posts would
be
Director(FA)
two
needed.
One
Deputy
Director(FA) ,
Dy.
Directors(Med.),
three Asstt. Directors(M),
seven
Eng
.,
Asstt.
Director(Ent.) ,
one Suptd .
Eng.,
one
The additional
Executive Eng. and two overseers.
Rs. 10
expenditure on this account would be approx,
lakhs per year.
and proposed organisational chartes are
at Annexure 6 & 7)
In 21
states where Tribal
Malaria Action
is
to
be
implemented
additional
component
of
Fl an
State
Epidemiologist,
one
Statistical
Assistant
one
and one Stenographer each would be provided.
(Existing

At
the peripheral level in
Tribal
Malaria
Action Plan one combat team for 1 lakh population
would be provided.
The combat team consists of one
Biologist, one Malaria Inspector, one Microscopist,
one Driver.
In order to achieve better ep idemiolog ical
inputs the existing zonal
teams would be reallocated in the states where Tribal Mal aria Action
one team
is
Plan
is taken up.
Where more than
would
be
shifted
to
state
head-quarters
present one
If only one team
is
and others to tribal areas.
present it would be shifted to state headquarters.

16 .

Financial imElicat ions:

E'disting strategy
Regular spray in API 2 and above areas based
the
1976 criterion.
If this is
implemented a
on
population of 384 million will have to be covered
Detai 1s of
every year under NMEP(Rural ).
Details
the
financial implications are given in the Annexure 8.

spray
of
3

the
In case the MPO strategy is appl ied and
criterion
are
to
be
based
on
API
operat i ons
a
years instead of
1976 basis,
preceding

D36

population of 265 millions have to be covered every
Details of the financial
implecations are
year.
in
Annex
Lire
SA.
g i ven

strategy
above in Tribal areas and 5 API
2 API
If
in
rural
areas for insecticidal
spray,
above
covered
is
implemented,
the
population
to
be
this
in
insecticidal
spray would be 54 mi 11 ion
under
rural
areas
.
120
million
in
areas
and
Tribal
f
inaneial
and
insecticides
Detais of quantity of
in
implications for NMEP(Rural & Urban) are given
Annexure 9,10
11.
above that the
It
is obvious ;from the
reduced
will
of
insecticides
consumption
account
of
on
substant ial 1 y resulting in savings
as
as
procurement of
insecticides ,as well
1 ess
thus
in the spray wages.
The savings
reduction
obtained may be utilized for furnding the Tribal
sponsoring
Mai aria Action Plan on a 100’Z Central
of
Tribal
The Financial
implications
basis.
Malaria Action Plan are given at Annexure 12.

D37

4'

.-Ana/exur^i

... INDIA

N.M.E. P.

D KALJ MIK

5TRATh-ICATION OF DISTRICTS ACCORDING
TO AP! 1976

DU a Ma

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A

-I

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'pl)v

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0 b

U € N G A L

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oi
u

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X'

D38

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o

aw DBA

L
L, .

J

J O K ADHMtH

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J
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>

PTRATIE.ICAX.1ON. O.F..D.1STRICTS ACCORDIN;-

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(ill

I

i

N. M. E. P.

r'

TO API 1988

*9

i

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■41 iW'W
'iiiW-^

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a.wr7
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c a j

api

PH

iK;. •

•

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311

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I'h.MJTCH

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D39

Anne x ti re

Statewise Positive Cases o f Malaria 1976 • d- 19:-:d to

SI .
No -

1.3’ 4-

?

5■

67891011
12131415.
16171819.
2021 .
222324.—.cr

; 2627.
28.
293031 •_*x_ ■

3334-

1983

; jName of the state/!

! ’iJ-Ts -/Others

!

1976

1984

216154
Andhra Pradesh
27934
Arunachai Pradesh
148608
Assam
78048
Bihar
2012
|G o a
1214028
Gujarat
736566
Haryana
22110
Himachal Pradesh
37839
J amm u & Kash mi r -—
634517
Karnataka
5029
<erala
878693
Hadhya Pradesh
702155
Maharashtra
1208
Manipur
Heghalaya
7035
11941
M i z o ram
1609
[Magal and
329106
Orissa
440465
Punj ab
412776
Raj as than
113
S i k k am
103921
Tamil Nadu
7171
Tripura
337728
Uttar Pradesh
28917
West Bengal
1510
A & N Islands
10535
Chandigarh
D & N Haveli
Daman & Diu
49330
Delhi
103
L'ak shadweep
325
Pondi cherry
4266
Coalfield
15465
DNK Project

46238
28234
59678
51376
112
253552
147160
27966
- • 18144
32293
4735
145712
91949
1284
15315
15056
5322
283527
216098
101955
27
71320
13126
419708
46340
4054
24292
1640
696
38108
7;
545
493
17988

TOTAL

6467215

1985 :

36814
24896
61978
48960
80
139207
10402
36478
34026
39237
38545
111631
61825
1166
12560
16217
5163
246223
223756
67040
57
71347
8334
373006
46814
3648
37546
2400
256
32556
1
274
559
12451

1986

28836
21810
113135
42463
433
153562
62575
4217 6
41815
581 19
3382
165592
4^7998
• 1773
14687
19116
6317
316139
174012
54618
45
58741
9318
228244
53620
3276
30723
4150
394
26613
2
aS X '-I

548
7746

3

1987

19’88 *

61674
53010
19254
16959
56225
63858
14562
32749
6732
4814
274593 460683
9237
18926
10209
22460
4430
11540
92488
88505
5147
3772
306882
303033
84027
60557
1076
1084
1 1863
10975
20030
15356
3478
5000
266068
237310
33342
86604
87949
65523
23
24
74303
55523
4570
8160
126181 • 134429
39782
46027
3360
327 1
7731
19349
5845
5625
779
384
14292
14112
1
3
309
220
126
283
7045

2184446 1864380 1792167 1663284 1780906

*

1

D40

figij. r e s p r o v i s i on a 1 ■

An n e x u r- e

Statewise-fiqures of P-Falciparum cases
for- the years

1976. d

i n the

1984 to

il

country

1988
i

SINo -

Name of the state/I
U-Ts./Others
’

1.
2' 3.
F 4• 567.
8.
9.
10.
11 12.
13.
1415.
16.
17181920;
21 .
22 23.
24-

Andhra Pradesh
A r- u ri a c h a 1 P ra d e s h
Assam
BiharGoa
Gujarat
^aryana
fjimachal Pradesh
J amm u
K a s h m i r-

-'•.c

-L. _< .

2627.
28 2930 31 323334.

1 ) I cA t cA R cA .

kerala
Madhya Pradesh
Maharashtra
ManipurMeghalaya
fj i z o ram
Nagaland
iJ r i s s a
Fjun j at
Raj as than
Sikk im
Ijamil Nadu
lj r i p u r a
Uttar Pradesh
(Jest Bengal
A
N Islands
dhandigarh
D
N Haveli
Daman
Diu
De 1 h i
Lakshadweep
Pondi cherry
Coalfields ~
DNK Project

‘ TOTAL

1976

- 19054
10024
65177
40955
122
73674
3755

!
6990O
38
155759
39055
530
4804
■4701
’ 961
•“210227
479
24163
6
4087
5123
10798
1085
62
4

I

1984

19124
6142
38174
31621
1
29473
. 18853
792
260
3337
45
77332
16621
804
12403
8129
1721
•226279
40866.
20443

5
466
7748

4724
11581
63675
5761
489
1265
19
37.
646O
6
103
14726

753713

655454

89
C)

1985 :

:

14202
5015
41857
28149

1986

1987

9931
4156
80562
26298

21743
3516
38241
20245
16
76158
289
65.
206
29582
112
142825
23430
353
7997
8048
1563
191759
862
13942

21952
34903
9397
2339
659
324
1843
2063
9630
16906
47
87
54970
90688
13379 Y2957
690
904
9681
11618 ?
8338
10155 :
1377
2022 ■
195800 253011
27316
131 14
12643
13890
7
3
4229
3398
6932
8053‘?
55010
19384 ;
10844
1409/6 7
537 j
677
607
148 •
25
161 a
16
19
239
77
O
O
y
6
79
1 06
9378
6356

545005

638276

■j

D41

• •r-'v. • .■ ■ ’

19382
30O7
.34356
8364
287
158552
838
39
378
26637
112
139379
26950
439
8478
8880
919
170845
625
21671

(j

3588
7245
18496
9403
633
26
270
0
22
0
4
34
5901

5143
3815
9667
5385
782
3
349
32
20
0
1
31

618574

655638

fig u r- e s p r- o v i s i o n a 1

1

1988 *

Annexure

Statewise API for 1 ‘-y76 and ' from 1984 to

a

SI No -

Name of the state/J
U-Ts-/Others
!

Pv-e-MPu
• 1976

12345678910 11 121314151617181920 21 222324-_<cr
26 2728 2930 31 32-

A n dh ra Pradesh
Arunachai Pradesh
Assam
BiharGoa
Gujarat
Haryana
Himachal Pradesh
'Jammu & K a s h m i r
Karnataka
Ke ra1a
Madhya Pradesh
Maharashtra
Man i p u r
Meghalaya
M i z o ram
Nagaland
0 r- i s s a
Punjah
Raj as than
Si kkim
Tamil Nadu
T ripura
Uttar Pradesh
West Bengal
A & N Islands
Chandigarh
D & N Haveii
Daman & Diu
Delhi
Lakshadweep
Pondi cherry

5-43
58 - 03
9 - 25
1 - 26
2 - 09
39 - 40
61 -09
7 - 35
14-76
1 1 - 02
0-21
19-01
12-26
1-18
5 - 78.
33-73:
2 - 2763-91'
30-315
14-120-72i
2 - 26.
4 - 23 .
3-59;
0 - 64 :
10 - 06;
37 - 02:

India Total

1988

VII PLAN
1 985 ! 1986

1984

1987

1988 *

2-0?'
9 - 76
2 - 78
0 - 67

0 - 86
43 - 84
2 - 89
0 - 69
0- 10
7 - 09
9 - 88
7-79
6-12
0 - 87
0 - 18
2 - 60
1 - 35
0 - 82
10 - 46
29 - 93
5 - 35
10 - 38
12-16
2 - 99
0- 13
1 -47
5 - 68
3 - 66
0 - 86
1 7 - 63
51-44
15-77
8 - 59
5-11
0 - 07
0 - 80

0 - 69
36 - 56
2-95
0 - 66
0 - 07 •
3 - 83
6 - 82
9 - 97
1 1 - 30
1 -07
0- 14
1 - 87
0-89 \
0 - 74
8 - 29
31 - 19
5-13
8 - 74
1 1 - 68
1 - 93
0 - 28
1 - 37
3 - 59
3 - 18
0 - 86
14 - 95
71-52
23 - 08
1 -79
4-37
0 - 02
0 - 45

0 - 52
32 - 03
5 - 27
O - 56
0 - 34
4-21
4 - 63
I 1 - 36
13-58
1 - 14
0- 13
2 - 80
0 - 67
1 - 10
9 - 60
35- 14
6 - 28
II - 08 •
9 - 02
1 -57
0-21
1 -.1 1
3 - 89
1 -92
T). 97
13 - 26
55 - 86
39-90 •
4 - 38
3 - 43
0-15
0 - 35

0 - 92
24 - 65
2- 92
0 - 42
3- 81
7 - 36
1-19
5 - 92
3 - 69
2 - 28
0-14
7 - 99
0 - S3
0 - 65
6 - 94
27 - 62
4 - 97
8 - 24
4 - 48
1 - 85
0-11
1 - 02
3-37
1 - 04
O - 82
12 - 53
33 - 65
54 - 09
4 - 27
1 - 82
0 - 07
0 - 34

1 - 07
27 - 35
. 2-51
. 0- 19
5 - 70
12- 04
O - 57
2 - 67
1 -39
2 - 39
0-19
4 - 52
1 - 16
0 - 65
7-40
34 - S3
3 - 46
7-14
1 -72
2-49
0 - 10
1 - 36
1 - 90
1 - 09
0 - 71
12 - 35
13- 45
56 - 20
9 - 86
1 - 84
0 - 02
0 - 42

11 - 25

3 - OS

2-57

2-43

2-21

2-35

*

1

D42

fi gures provi s iona1

vr.vizi tc “ .tnal €.•■?• r^
illalotrr.c-.iial-^.wx x-ir.-ily •» elf are
Eircctoruro Goac^cl of Health. Scra'icon

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Relation
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D44

X

1

REPORT OF THE INDEPENDENT APPRAISAL TEAM OF THE
NATIONAL MALARIA ERADICATION PROGRAMME-

13

INTRODUCTION

. Minist ry of Health and Family 'We Ifare. Govt.
Govt, of India constituted an
expert committee 'for an independent appraisal of the National Malaria
Eradication Programme.
The Independent Appraisal Team (IAT) comprised of
the following national and international experts.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.

Dr. V.P. Sharma, Chairman
Dr. D.C. Hazarika, Co-Chairman
Dr. V. Orlov, Rapporteur
Dr. G.K. Sharma, Rapporteur
Dr. P.R. Arbani
Dr. Udom Chitpraro
Dr. Mahindra Dutta
Dr. N.G.Gratz
Shri N.L. Kalra
Dr. O.P. Khattar
Dr. R.S. Pandey
Lt. Col. P.B. Pi llai
Dr. R.R. Purohit
Dr. E.S. Rahavendra
Dr. Rama lingeiswara Rao
Dr. A.P. Ray
Surg. Comm. Prakash Singh
Dr. M. Swaminathan

Members/Secretary from NMEPr .HQs
1.
2.
3.
4.
5.
6.
7.

Dr. B.N. Barkakaty
Dr. S.K. Chawla
Dr. S.C. Dutt
Dr. S.P. Misra
Dr. S.P. Rao
Dr. R.C. Sharma
Dr. G.P. Singh

IAi was appointed for 2 weeks
reference of the committee were :

(1-15

Dec.

1989).

The

terms

of

1.

To critically examine the po_l ixy—is_sues and control methodolog
incorporated in VIII Plan draft dorument prepared by7 the ~D5rector—of
N.M.E.P.

2.

a) To review the operations under the Modified Plan of Ooerat ion for
control of malaria.
b)
To determine the impact of operation on the epidemiological
situation.
&

E2

< I

its timing, frequency and adequacy of
operation,
'•
-- To review the spray. faced in its implementation.
coverage and problems
and extent of
j j'’,' 1;8.j the
To review the nature
financial and stajjjng constraints affect
a.._ i ng
programme, as well as
of the contro"Tof malaria operation.
the management
7z in pthe problems and extent off resistance, it anXz
undertaken
To review
other drugs^and measures u..
to chloroquine and/or c..._
. falciparum
the situation.
to deaI "with
u•
measures
no system on death_due to malaria,
the repqEti
, sSrSm and-tte adequgcy.< .an.ge.ent and
To
review
to prevent
undertaken
treatment of cerebral malaria cases.

3.

4.

5.

6.

-----

7.

8.

9.

review the impact
To
control operations.

To review
categories
•requi red.

the

malar-ia

Status and training needs of
Tn^the Programme and the type of

different
training

of multi-purpose

the training
of personneT

wojJce-r-s_.scheme in

and

to

aspects of
review the participation of community in different

the

recording, reporting and monitoring
To review the
recommend measures f or i r.provement.
To

system

10.
programme.

I
11 .

research projects being carried out
findings
of
various
feaEBTTTtEfS? incorporation in the
To examine the
and
suggest
thei
r
in
the country

1st December 1989 and the team was
by Dr.
the
team
IAT members met uu
Ueagues. At 5 P-M.
on 1st Decemo and his c0
colleagues.
M.V.V.L. Narasimham Dir^ct0/ N^ta
HeaLth and Family Welfare, Govt, of
Health a..met. Shri R. Srinivasan. ~
Secretary.
T
he briefing by the
The
India.
Members were
y d d
as we
ll. IAT was provided with
well.
The
Director NMEP continued on .he s
plan document.
year plan
reports, background
usefuL in the evaluation of NMEP
briefing and background matr al were
and in framing the recommendations.
Id areas trom
f rom 4-11
- ----visited fie
returned
onlyon
IAT divided itself into 7 groups
The IAT d1v!oeo
"t"dei;yed flights some teams
debriefing
i
A
(see fig- 1)
1' .- Due
uue to
.
and report
writing.
Dec ’ "989
‘
3
followed
discussions
at 5 P.M.
1989
Th i s
12 Dec.
Health on 14 Dec.
were
presented
to
taken
by
the
Secretary,
visits and recommendations
meeting was u —. of
the
field
v
Salient features
the Secretary.
y
Health and Family We^a^'
Ministry
of
to
the
NMEP,
r
field stations Corpora 1
2AT is grateful
State Deptts. •cf-Health, MRC „ provide ve oeble d t.
GOI, vJHO,
kind enough
the basts lor writ 9
other agencies who were , which constituted
c--discussions
participate in
report.

E3

^9^
SirtiE

1 •’
A

«.

IAT.depended heavily on the tour reports of 7 teafns for writing of this
report.
These reports are being submitted to the NMEP Dte. separately.
Some tour reports carry recommendations for special area/locality or they
address to a parti cular...problem ,.i n .that .State or district. It is suggested
that these recommendations may be placed before the Technical Advisory
Committee (7AQ of the NMEP for consideration and necessary action as may
be. deemed fit.

JAMMU
• AHO
KASHMIR

4

Dr. R.R. PUROH1T

■

Dr.E.S. RAHAVENORA
Mr. N.L.KALRA
Or. S.C.DUTT

U.Col.P.B.PILLAI
Dr. O.N.DARKAKATY

Or. A.R. RAO
Surg. Com. P. SING, I

/tlARYAH^

Dr.P.R. ARBANf
Or. S.P.RAO

DESK

31

Dr. Y.P. SHARMA
Or.M. OUT TA
Or. M. SWA MIN AT HAN
Or.S.P.MlSRA

Or. O.C.HAZAR1KZ4
Dr.A.P. RAY
il
Cr.U.CHITPRAROf
Or. S.K.CHAWtA \
ARABIAN SEA

■

■
■

Or. R 2. PANDEY
Cr.G.K.SHARMA
Or. 7.S.CRL0V
Or. R.C.SHARMA

Or. O. P. KHAT TAR
Dr. N. G.GRATZ
Dr. G.P. SINGH

E

A

■

'

\A ■

■
■

I
E4

WII

I

STT area’w ^ere-fore fuLL complement of peripheral
o be provided and administratively made to work r- surveillance staff has
as per schedule. There is
supervS .
S Senior Moratory technician
i for 10 PHCs to
peripheral laboratory workers
and
to
provide
on the spot
t raining, Besides IAT also feels the need
of
additional
mechani sm to supplement the MPW in hioh risk
surveillance
thit"', HTAG
'"L, of NMEP may
“y work
out detai Is of the mechanism. JAt’ fe^ s areas.
.
■
it^ib
LJidi
ail
a
11
urban
arppc
muni'cipa I ity, corporation or local bodies should be brought under the with
urban
malaria scheme (UMS) rather than
-- -- 1 towns with 40,000 population.
Epidemiological situation in the (—
is too driverse to be covered
by a uniform criteria as laid down incountry
the VIII
---- Five Year Plan document,
Therefore, the team felt that the criteria tor i
ntroduction/withdraw I of
spraying
requires
further
elaboration based''
on
the
operational
stratirication of the country taking cognizance of the
P-f.
_____
dynamics __
and
the degree of instability of malaria, fNevertheless,
" '
the extension of health
services at the periphery particularly, in
areas ’with prevalence of
in areas
falciparum malaria should get the highest priority.

It may be emphasised here that those r
■ • •
which earlier had high API
& AFI but now fall between 2 S 5 API are. at areas
this level of malaria
i nc i dence
due.to prolonged insecticidal
L----- pressure (even partial) over last decade
It
may be emphasised
phasised that once such pressure is taken away due ' to
inherent
transmission potential,
these
potential, these areas may record fulminating
Therefore., it is essential that in this 100 million* population epi demi cs.
alternate
vector control measures such
measures such as bio-environmental methods should be
instituted simultaneously to .forestall
---any deterioration in
ma I aria
situation.
$

It Jis
a great precaution should
be
i;,3ULa De taken while- chancing
insecti cides t
the areas where
Qr
deveL;
where vectcr
vector deyeLops
develops
or has
resi stance
used
are 3 en 3
^
SeCtiC
^es-. The
The alternate
alternate QP/Carbamate
insecti
cides.
insecticides
often
hazardous,
while
synthetic pyrethroids
whi le: syntheti
c
a re
costly.Application of new insectcides should be made judi
judiciously and
on ly
to bring down high inci ence.
---- This is being recommended with the background
of the fact that mosquitoes develop multiple resistance quickly, and there
are . not' • too many replacement insecticides available for use in public
health.
IAT wishes to record <
for a well
document by the Directorate ofcDpreciation
NMEP/
..... :

y * ’•

:

presented

VIII

plan

r

j- r„

Z.Progrsnime Review and-Impact Analysis

Nc>.ional

Malaria

Eradication Prooramme (NMEP) was nLa77nr'ri“—-ioro

NMEP
and full
a ch ieved
the
areas.
some
cases.
However focal outbreaks followed ir 3
LeSS thSn °ne Lskh
urban ’ and
phase -eas.
„alaHa sitL-stion1 started m
" some
"'
s-o snow ball on
technical, '
of
and
• fi nanc i a I
subsequent
”
In
-- years large scale resuraence of
of maiArn^
malaria was witnessed
u.
in the

■ • ysat±1' ■ ran1sati°naL

~

ob ":unt

F12
‘ J

... ---if-

■

'’5

■f-’1

count ry.
The programme was evaluated in 1971 whi ch resulted i n
formulati on of the Modified Plan of Operation
(MPO).
The MPO
:i mplemented i n 1977 with the following objectives :

J.

To prevent deaths and reduce morbidity due to malaria

2.

To maintain green revolution and industrial development.

3.

To retain the achievements gained.

the
was

The main operational components of the MPO were to replace
the
concept of eradication with that of control & containment through the :

$8

1.

Spraying of ;an appropriate residual insecticide during
period in areas3 with 2 API or above.

2.

ForLnightly blood smear collection from fever cases for case detection
and treatment.

3.

Anti larval operations in Urban a reas.

transmission

In addi t ion to- above measures, attempts were made to intensify the
efforts
in hard-core areas by establishing
Plasmodi urn
falciparum
Conta i nment Programme (PfCP) with the help of Swedish International
Development Authority (SIDA).
Research activity were intensified in the
country.
Basic and applied field research were taken up by the Malaria
Research Centre (MRC) and other institutions.
Operational
research was
Operat
iona I
launched by the NMEP Directorate under the auspices of PfCP-and ICMR.
Although field operations have been strengthened through research, and
other i...provements have been brought about in the programme, but the
overa 11 malaria situation has stagnated at about 2 million cases annually,
of which a oO/. constitute P. f a I c i pa run.
i he problem of insecticide
resistance in vectors and drug resistance in parasite are making the field
operations difficult and problematic. With this background GOI got the MPO
of NMEP evaluated in 1985 by constituting a committee of national and
international experts.
The in-depth evaluation team observed that the MPO
was a contingency plan which greatly helped in preventing epidemics of
malaria, but
in the present context of malaria situation it had out lived
its utility.
Recommendat i ons contained in this document have not been
(i mplemented.
I AT
feels
that immediate
implementation
of
these
recommendations would be a logical solution to many problems that have
plagued the programme.

Organisation

MPO of NMEP was envisaged as a vertical programme.
prog ramme. The■erstwhile NMEP
units and laboratories were re-organized and their boundaries
. —; were made co
terminus with the district/PHC boundaries.
This was the first step to
merge malaria control with the General Health Services.
In 1977, Govt, of
India decided to implement the Multipurpo:? Workers Scheme CMPW) in a
phased manner under the Primary Health Care System. Under this scheme, the

E13

In such States, uniform
c) States which did not
impact was observed barring
spray areas where inci
the year when epidemic
dence was brought down
to less than 2 API for,
.conditions prevailed follow
3 consecutive years, due
ing floods.
to earlier spray operations,
but sprayed other areas
with 2 API and above.

Andhra
Pradesh

d) States which followed
the pattern given above
in areas without ensuring
that
there
was
true
reduction in API based on
adequate surveillance and
laboratory services.

Because of inadequate sui— ■ Karnataka -veillance, true distribu
tion of residual malaria
in the community could not
be assessed resulting in
high incidence of
falciparum and P.
vivax on account of
deficient spray coverage
and thus no uniform
impact on malaria.

e) States not covering
the entire techni caI ly
tarcetted population - 2
API
or
above
but
the
areas
restri cti ng
under spray on- the basi s
of descending order of
API due to shortage of
funds, insecticides
insect i ci des and
manpower.

Gujarat
These states showed uneven
Maharashtra
impact of spray coverage
Madhya
although there was a
Pradesh
general decline in malaria
in some districts, there
was a rise either of P^
falciparm or P.
vivax cases depending on
the extent and time of coverage
during the spray rounds.

f) States which could not
give first round of spray
due
to
of
shortage
insecticides i.e.
DDT,
BHC or Malathion because
of
late
purchase,
recei pt,
or
delayed
release
of
funds
resulting i n delay
of
recruitment of staff and
purchase
of
anciliary
equipment.

Due to disruption of first
Assam
round of spray in highly
-Orissa
malarious areas and its’
-West Bengal
extension beyond prescribed .'Tripura
J&K
period of 75 days - DDT,
■
Manipur
45 days-BHC or Malathion
Raj asthan
sometimes extending to 180
TamiInadu
to even 210 days per
round, resulting in more
U.P.
than 2/3rd of the area
remaining without spray
coverage during peak
transmission, resulted in
high incidence of P.
fa leiparum and P.
vivax but the incidence
ArunachaI
Pradesh
fluctuated within a narrow
Bihar
range. Many of these areas
are hard-core areas with
Himachal
Pradesh
high malaria transmission
potent i a I.
Meghalaya
Nagaland.

g)
States
attempting
scheduled rounds of spray
in areas with 2 API and
above but failed to do so
because the spray operat
ions were either commenced
late or completed much
after the scheduled date.

E18
■S'

;S;i

surveillance and spray operations the
Having looked at the inadequacy of
tional problems are mainly on account
basi c reasons giving rise to the opera
of the following factors.

under NMEP under the MPW scheme.

i)

Low priority to the case detection

ii)

Delayed release of funds by the States

iii) Large number
workers.

of

vacancies

for field operations.

in the MPW

Scheme

of

male

peripheral

States

for

iv)

of financial resources at the Centre and the
Inadequacy
spray and surveillance.

v)

lack of FTD and DDC in the difficult areas.

vi)

due to financial constraints.
Inadequate procurement of insecticides

vii) Delay in release of funds for spray operations
the supervisory
viii)Large number of vacancies in
at the district level.

ix)

x)
$

staff as per NMEP

norms

Headquarters,
trained in
SZ,
do not hove rented technical Kncvledge for
planning and execution of NMEP operations.
NMEP tc generate
There is no provision for health education in
operations,. and
adequate awareness among the public to accept spray
thei r participation in case detection and treatment.

F„qu„t

REVIEW

changes

jn Che

a^'not

OF THE IMPACT OF THE MPU SCHEME ON NMEP OPERATION

and
out lir.ed in the
spray operations on account of the re=sons a r_ / have r5SuLte
resultedd in
paragraph on orgaMsatwn
^^^ are i) the adr-nistrative
adverse impact of the sc.-e.-e on t
X4:chief medical
control of MPWs rests
th 1 he PHC' °ri - ' of f i cer ' cannor take any
worker.
administrative^'corrective'neasures against t he ( def au Lt wg rjale
cases
do not
utilised
do so in some of the States, while m a rew Stctes
cas^' detection
properly iii) the
the main
main factor
factor which
which dmruoted
aisruoceo the
L “c pass .ve\ cas.
ra I and
l'Jweme W2S
throuch voluntary agencies was a policy
policy cecision
cecis.on tc en y :
ct-P as reoards to villace health guice
vh.en this -gunce scheme.
FTOs and ODGs establi shed under NMEP h-oecc ^defunc.
This sche.e had an adverse effect on both case

and VHG was performing this Tunction.
• -'e
is not working properly thus there is ceverse
detection.

E20

;
e..ec.

on

np=sive

case

I
Resistance to chloroqui ne i n P• fa Ic i pa rum

Twelve P_- falciparum monitoring teams of the NMEP Dte. are!
located in
in the
the offices
offices of the Regional Directors of Ministry of Health and!.
have
Family Welfare
Welfare in
different States.
States.
A large number of tests u
”"' been •
in different
there
carried out
and
it
has
been
observed
that
in
almost
all
States,
out
a Ic i pa rum.
From 1978
1978 to
evidence of
of chloroquine resistance in P. ffalciparum
1989(Nov),altogether 163 resistant foci of various levels were detecteo
Nicobar Tchndi
Islands 12).
(2), Assam (17), Andhra Pradesh (12),i
viz_
in Andaman Nirnhar
Pradesh
(4),
Bihar
(7),
Gujarat (19), Haryana (4), Jammu
ArunachaI
Kerala
(1),
Karnataka
(11),
Madhya Pradesh (9),Maharastra (5),
Kashmir (1)
Manipur (1),' Meghalaya (8), Mizoram (4), Nagaland (3),Orissa (27), Punjab
(3), Rajasthan (7), TamiLnadu (1), Tripura (2), Uttar Pradesh (8) and Westj
(3),
that largest number*
Bengal (7).Further breakdown of the situation indicates
—
Assam, Andhra
Gujarat,
of resistant foci were in Orissa followec by
resistance on|
falciparum
Pradesh.
There is no clearcut pattern of P.
regional or geographical basis.

isi

NMEP upto p
Further out of a total of 6156 tests performed by
47.57. had varying 0
1989(Nov) 52.57 persons were sensitive to chloroquine,
The :
level
of
resistance.
degree of resi stance only 1.9% showed RIII
vari
es•
RIII levels of resistance in the population^
di stribut ion of RII or
It was gratifying to note that between 1978-89 out of |
from area to area.
have
been
successfully0
of
RIII level of resistance
51
foci, 9
the.
by adopting intensive antimalaria measures such as
I i qui dated
insecticide and use of |
i nterrupt i oni of local transmission by an effective
long acting sulpha drugs.

i

A team
team located in Shillong is carrying out trials with alternate
drugs for treatment of resistant strains of P.
P. falciparum.
falciparum. The drugs likeg
me
"combination
have been tried m
Quinine, long
Lone acting suIpha-pyrimethami
Meghalaya and Arunachal Pradesh.
These trials
Assam, West
VJest Garo Hi Ils, f
I
and combinations of long 'acting sulpha-pyrimethamine
indicated that quinine c..- — results in majority of cases. In addition, in-vitro t^ts
cave encouraging
‘
Amodiaquine and Quinine were also carried
out by t.is
with Mefloquine,
Fi
organisations
like Malaria
team.
However, it has been observed that ot.ner
'
' ) large number of areas there i s
Research Centre have demonstrated• that
in
tn rhloroauir.e in P. falciparum and resistance to
evidence of resistance t~
----- ——•• •
although cases t
Metakelfin was
was reporteo
reported for the first time from Delhi, from other P. I
refractory to
to Metakelfin
Metakelfin and Fansider are being reported
falciparum dominant areas as well. It is apparent that the problem has not
Efficiently delineated as yet.
was felt that the numcer of ;
been suf f i ci ent Ly delineated as yet.
iit•- wcs
'are
inadequate
to
delineate
the
problem
teams are
prebte.. of chloroquine resTs.ance u.
falciparum
in
the
country.More
tests,
Y'Jonin-'nt
P. falciparum in the country..More tests, especially
falciparum
,alciparum precom a
Yest are reoui red to be taken up extensively m P.
The State organisations, can play an important role in Jns
y
areas.
falcioarum
[
arranoement
to
carry
out
such
tests
in
falcioarum
pre
-cminanc
making
areas.
As regards use of antima lari a Is for treatment of- p. falcioarum,
Iternate antima lari a Is are being used iinn some
it was observed that the all
on
cruo
policy.
In view of recent evidence of many
a reas based on 1982 drug policy.
foci in
in the
the country,
country, there
there is
is an urgent need to chance the drug
resistant -rnr-i
policy and extend use of alternate drugs to ether areas.

E21
................... 1117

: II
Proper treatment schedule for complicated and cerebral malaria
cases i s; being practised in many States using appropriate
antimalarial
drugs,
However, in some States the PHCs, hospitals are
not
following
the
standard treatment.
It was felt that i) orientation training to all
medical personnel including medical officers of PHCs,
sub-division and
district hospitals even medical colleges, nursing homes etc. in treatment
and management of serious cases of- malaria especiaIly cerebral malaria
should be imparted on large scale.
ii) At present there is no referral
system through which a peripheral
worker
—
— can
--- refer cases not responding to
chloroquine to PHC or from PHCs to other hospitals for treatment.
In view
of the prevailing situation, it is
‘ essential to develop a referral
system
especially in P, falciparum predominant: areas.
Deaths due to malaria

In 1974,
a few deaths due to malaria were reported from DNK
project, a re-settlement colony,
Thereafter instructions were issued to
all States to report malaria deaths.
In the initial stages, some of the
States, reported direct mortality due to P. vivax infection also.

.
Considering that direct mortality occurs in p.
falciparum
infection only, a detailed proforma was issued for investigation of malaria
deaths.
Since that time atleast suspected deaths due to malaria are fully
investigated. Every year, deaths are being recorded from different States
It has been observed that the States of Assam, Bihar (South Bihar), Madhya
Procesh, Orissa, Tripura, Arunachal Pradesh, Mizoram have been reportina
eaLhs regularly.
The deaths are also reported from other States during
focal outbeaks.
Recently a large
Large number of deaths have been reported from
urban areas especially BarodaJ in
’ Gujarat,
The observations of the Independent Appraisal Teams indicate
that
-Oitality reports are mainly available from hospital statistics whi ch
caters to the surrounding population ii) mortality occurring in
tri ba I
hill yJ areas
under reporteo.
reported.
In~these
- --- with intense transmiss
w. U...OIU < oo ion is
.b unuer
in
these areas
the mortality will affect the infant ana
chile death rates,
rates
iii) the
and child
ourt5LUy.-iS
dUe
t0
deL3yS
in
referrin
9
-he
cases
to
treatment
centres
is due to delays
referring the
at
PH. or district hospitals (iv)) in sene areas malaria deaths occur due to
improper management of serious malaria cases. especially in pregnant women.

i)

It
felt that malaria deaths can be prevented if comp Iicated
malaria cases can be quickly referred and transported to a well
equi poed
hospital at an early stage.
Focal Outbreaks

It has been observed that a large number of focal outbreaks
o c c u r red
in
different parts of the country
country since
since 1984,
1984, (Fig 2) and
t h ere were repeated focal outbreaks in some areas.
There was” high P.
areas.
falsi rarum incidence and deaths due to .malaria in these focal
f oca I outbreaks.
The
s‘,t_uat1.on indicated that focal cutbreaks have occurred (a)
in areas where P, fa lei parum is predominant- b) m foot-hill areas or high
transmission areas due to failure of rspray
—
operations and break down in
surveillance (c) in other plain epidemic prone areas, the focal outbreaks
hac occurred because of complete breakdown ct case detection mechanism over

•4

--- E22

conditions suitable
Long periods during transmission season
The cUmatic
Such focal
for high transmission triggered focal outbreaks w such areas. fortnightly
outbreaks could have been avoided by regular case detection at
intervals alongwith timely spray operations.

JAMMU
AHO
K ASHHlR

CHANDIGARH

H.P.
PA KI S TA N

1AMALPUR -1904

SAHGRUR, PATIALA.

SHAHJAHAN

1984

/

PUP

MASALPUR - 196’

1984
1986

MAHJA “

MATHURA

U £. G H A L A1.1

.'Adelhi

1983

Z

NEPAL

SIKKIM
BHUTAN

R A J A 3 T H AH

EMARTPUn

ua»ip7j«<193{

1983

'

ACHAT

0ANOL A

s

i 98DI

11 hipun a

^.<11 on.-.u
GUJARAT

OIU

dam/.*;;'j

A

A’ULMDARAO/
nMA-VHAGAR

MAI<AR A5 T R A

C

JAl.PAlGUC'. AJ'JDHA HILLS

J

\V.B.~’982 CH V.CRC5

I

SUJGH PH'JM IMUSAPAHII

198 4

(
\

Q AY

Of

D G NO A L

[QHS I

"ARCDA

ANDHRA

ARAOIAH sea

P RADE SH

INDORE

X

OMAR
JABALPUR

GULBAROA,

euapur
1983

UJJAIN

\r.ARNATAKA

1207

MAN CL A

\

•

0 arwani

GOA

rajgmar

I?
A H D A U A !<

1987, 1988

r

A MO

K

NICOBAR

E
R

LAKSHADWEEP

V-

I? POMOICHE R RT

] TAMIL NADU

/

v<?

\L )
\a ;

0

ISLANDS

RAMNAD

1988
/

9

Fig. 2: Focal

outbreaks of malaria during last 5 years.

1
E23

i'i

Training

All categories of personnel under the programme including the
' ' the PiPW scheme require orientation training
officers and field staff under
towards malaria problem in the community and to
to change their attitude t-- for performing the tasks allocated. . A few
impart adequate skill to them
of NMEP for PHC
orientation training courses were conducted by the Dte. c....
It
is
necessary
to give
medical officers and these are not adequate.
It
was
seen
that
in the
orientation training to all malaria MPW workers.
are allocated
a Ilocated for ten
training curriculum’ of MPWZ hardly 14 hours
is
inadequate
for
a
widely prevalent
The time
comunicable diseases,
Therefore, it is necessary that there should be a
disease like malaria,
training
of MPWs for malaria.
The laboratory
of
separate orientation
ns m ine rnu c.. a working in isolation.
Most of them do not have
technicians in the PHC are
technical knowledge regarding staining, identification of
adequate
It is essential that they should be regularly trained through short
etc.
or,station.
a°d
term

“el

HeaUl

participating collaborating agencies and other identified groups.

Supervision
The technical supervision and guidance, in planning and execution
of field activities is conspicuous by its lack in almost all states
The
f f Ld
ffirprs zonal officers and in those states where DMO is a
^Lr^e™ ThVseTfiicers come in the programme for a short period of
time. The officers lack expertise and they hardly have any concept .of
They also do not take any interest
malaria epidemiology and its control,
scon they may leave this position.
or try to improve as they know that very
Thus the supervision does not improve.

3.
Community participation
The in-depth Evaluation Report 1985 had placed a great emphasis
’ i in NMEP activities.
In case the community is
on community participation
i table to them under
of malaria' problem and the services available
the
not aware the importance of various control activities undertaken by th
programme,
it is very difficult to obtain their active participation in c°"tr°
NMEP,
However it was observed that there is no machinery at PHC o
of malaria,
level to impart health education for enlisting
community
district
. and because of lack of awareness in the community people c.
participation
forward for blood examination ar.c take acecuate antima lama Is
o
not come to the PHC and other referral centres in case of .c°™^cat.d
report
malaria. They also do not accept spray operations tor transmis.on contro
it is difficult to visualise. improve..e
•
Under the circumstances,
operations without active community participation unless newly
peripheral
deve loped health education techniques are applied through a network 0.
dedicated peripheral workers.

E24

URBAN MALARIA

Under NMEP, in urban areas with 40z000 population or more, •
regular insecticidal indoor spraying was done in the peripheral belt only.
In the township, antilarval methods along with minor engineering, source
reduction,
drainage etc.
constituted main methods of mosquito and'
transmission control supplemented by case detection, active and passive and
chemotherapy.

This policy was adopted mainly because malaria was considered to be
a major problem in rural areas. In urban areas, insecticidal spray was not I
acceptable to the community.
However, as early as 1961, some urban areas
in TamilNadu recorded high malaria incidence.
From 1967 onwards, t
proportion of cases contributed by the urban areas was quite substantial. I
The problem arose mainly due to the urban vector A. stephensi and the fact J
that antilarval operations were not implemented properly by the local ;
bodies for the control of A. stephensi breeding. It was also observed that I
urban areas provided focus for dissemination of malaria to rural areas '
where incidence had been brought down to a very low level under NMEP.
In
addition to this, focal outbreaks of dengue fever transmitted by Aedes
aegypti were occasionally reported.
Therefore, Govt, of India decided to
implement the Urban Malaria Scheme (UMS) in 1971 covering 23 towns.
The
scheme was gradually expanded and at present 127 towns in 17 States and two
Union Territories, protecting nearly 62 million population. Inspite of the
intensification of antilarval methods under UMS, the incidence of malaria
in some urban areas is still very high, notably Madras city in TamilNadu A
records nearly 60-70% of the total incidence of the State.
There had been
epidemics of malaria in Delhi and in some other major towns.
At present,
the situation in Calcutta is also rapidly deteriorating,and in Baroda city a
large number of malaria deaths have been reported during 1988.
!

S

The teams observed that malaria in urban areas iiss man made
problem.
Rise in incidence is due to i) rapid construction expansion,
industrialisation and consequent movement of migratory population to urban
areas.
ii) The breeding potential of A. stephensi in cities is enormous
and vector densities are also high.
In peri-urban areas, malaria
transmission is maintained by A. culici facies. iii) The residual spray or
iv)
even the focal spray is objected to by the people, except in slums.
often
The medical practitioners treat the patients on clinical basis and
the cases are mis-diacnosed and given wrong treatment.
v) In migratory
population radical treatment is difficult to be instituted.
vi) a similar
situation exists in hospitals whether government or private in regards to
malaria treatment As a result case reporting from urban areas is only by
the health department of local bodies and the true malaria situation
remains unknown.

i

.1

;i

Voluntary agencies do not come forward for any assistance in
and they are more inclined to support programmes like
programme

malaria
immunisation and family welfare.
Due to financial constraints in almost
all
the Municipal bodies.
Health Education could not be imparted
extensively and the use of mass media is non-existant.

A

I

critical study of the present urban malaria scheme revealed that

E25

li

j

.1)

11)

At . present .urban areas with 40,000 or more population and showing
>2API are under the UMS.
Since malaria incidence in urban areas i s
not monitored in any meaningful manner, it is recommended that all
towns with municipality, urban or notified areas, with malaria risk
should be brought under the UMS.
Construction activities and lack of vector control leads to focal
Vector breeding is maintained by the open
outbreaks of malaria.
Legislative measures are not
overhead tanks cisterns and wells.
There is need for
uniform and penal provisions are not stringent.
uniform legislation applicable to all urban areas with stringent penal
provisions.

i'i) There is no active surveillance component which may be instituted
atleast iinn slums.
In other areas activated pass i ve surveiI lance
should be started.

iv)

There should be one malaria clinic for each 1 lakh population,
Entomological component in urban areas is either weak or non-existant
and it is not possible to implement any intervention measures without
entomological support, and therfore it would be advisable to provide
this support to the urban areas, A committee may go into the problems
and suggest norms.

v)

Urban local authorities lack adequate funds to buy insecticides,
therefore finances may be supplemented by the NMEP.

vi)

Hospitals, (govt, or private) should be made to examine blood
for malaria of all fever cases.

and

smears

vii) Frequent workshops involving doctors of General Hospitals, private
hospitaIs/private practitioners should be arranged in urban areas.

the
viii)Engineers
of
the urban areas should be educated
about
proi
ects
mosquitogenic conditions created as a result of construction
and method: to avoid or improve -such conditions.
i x)

All construction plans should be referred to health ceoartment for
clearance as was done in the past. A public health encir.eer should ^e
involved in checking of designs ano in the teaching programmes.

x)

Mass media should be exploited fully so that people are aware of
programme and they know the ’Do's and Dent’s.

C)

Recommendations of a suitable mechanism of inter-sectoraI coordination
should be evolved in each area. In some urban areas committees have
been constituted involving all agencies. They meet once in six months
require is the time
or so but no follow uo action is taken.
What is required
bound targets and accountability of each agency.

E26

the

I
Pr°ject malaria

The development projects
like sn industrial
resource <development
’
project,
forests
<2nd the .projects complex, water
expoitationn of natural
connected with
movement of population, cesouces, are all- associated with o large
associated ma lari a problem This tropical segregation of labour and scale
IS a well-known phenomenon'
the
from different areas
A labour migrating
bring
about
a
mixture
of
populat ion with parasi te
i mmune and
non-immune
reservoir of different
conducted by Dte.
strains.
Some
NMEP.
have
revealed
that
studies
moves r
-nearly 100 million
every
year as agricultural labour.
population
involved in•’ road and other
About one mi I[ion population
construction activities
and urban
ndust ri
a I complexes
Zn iindust
rial
areas everyday.
In the past, ih krecorded in many projects,
high malaria
incidence
-■
incidence was
like Hirakund,
Pradesh,
in
fl
SUeru
'
Srisailam
in Andhra
Hasdebango, Gandhi
Srisailam in
i s a g a r W r>ladhya Prad«h and
TamiI Nadu,
Sathanur
The industrial projects like Mirzapur
and Sathanur Dam
Dam in
recorded malariia epidemics.
Thermal Power had also
Tropical aggregation of
urban areas is often
labour in
responsible for Starting a focus construction
of
- transmission.
IAT feels that the problem
of tropical rm

neglected most.
aggregation of labour was
There was rc
no _special jprovision
* ■
for taking malaria control
measures or treatment or Labour
’—' force through the
This aspect was left
programme organisation.
to the health organisation of the
a result there were focal outbreaks
' Project itself.
As
|
Problem needs to be addressed on : of malaria in the project
areas.
Thi s
agricultural
Priority basis since the industrial
growth of the country
and
infrastructure
is one of the most
ror sustainable development.
i mportant

i

The independent appraisal t
Andhra
irates of
Of Karrataka,
cadesh and Gujarat and observedJ that'inl^ States
Karnataka, malaria
r
Krishna
— .a incidence iincreased
~to API 0<
Pr°jeCt °f
of P.
Project
area
of
th^
d^trict
sJ
Pr°P=rtion
in
the
p.-^
Guj a'rat, U<ai and Kakrapar Dam
the district.
c’
in sseveral
~ in h i g h i n c i d e n c e
Talukas of Kheda
District of
low lying
^ujarc...
extensive
txt
ens ive inundation of
J areas had increased the ma
m a I a r i a m neighbouring villages. lariogenicc potential leaving a trail of
Projects J Surat district presented IAT also
-O observed that
a very alarming malaria industrial
because
poor
o
ooor water management.
s i tuat i on
Similarly in Andhra
Vi sakhapatnam ma laria
Pradesh in
incidence prior to
Plant Proj ect
jetting up of Visakhapatnam
was very low. Jn this project
Steel
thousands
ma larious areas
of labour from
of Orissa, Madhya Pradesh
--- --1 are engaced i n
activities.
In labour coloni
es malaria incidence is^vvery highcons t ru c t ion
198S there were 9199
e-g., in
cases of malaria with
fam;lies. Io 1989, the
■■-1 r_
nearly 30X
faiciTarum'i
in 1500
situation has further
i
or worsened. "
very (’ ‘
Pr°^ts- It A is
larce^umbe^^b"^
to provide eesu .mates of all on_coing
A large number
projects
have been taken up during the last 3
to - decades, and atleast about
300
major
project
thermaI
s are connected with iron,
-- power and mines etc.
Apart
from
these. a large number of big and
small water
resources development schemes
the country.
sre located
- iin different parts of

---jo

Consider; ng the epidemiological si
gnificance of events
with the tropical
associated
aggregation
of
labour
IAT
is of
priority should be
the opinion that a high
given to project malaria which
would tackle the problem

E27

..d< Al

id

and also benefit poeple of

of migratory population tribal and non-tribal areas.
status both belonging to

poor

socio-economic

Field Operations Research
also looked at
IAT discussed malaria research in India and
organi sat i on
activities of the MRC and -----NMEP. MRC is a
research,
for undertaking both basic and applied
H^eve
th
research capability and organisation tor
for t.eld operat i ons
under
are very peak and inspite of the reco-eodattons. of in-depth
evaluation 1985 it has not been strengthened.

fie Id
IAT identified
some priority
priority areas
identified some
areas of research to improve
operations in addition to the ongoing research
activities in
e country.
—
A list of suggested research topics is given below.

s li de

1.
in

field conditions and to recommend quality assurance.

to develop clinical parameters for malaria survei Hance
A study
help collect blood smears from malaria cases so as to avoid
workers to
screening of all other non-malaria fevers.
resource
malaria i n water
A longitudinal study on i rrigation
development projects.

2.

3.

and test the feasibility of engineering
A
study, to develop,
control of mosquito breeding to interrupt
intervention methods in the
malaria and filariasis transmission in selected localities.

4.

of

bio-envi commenta I

5..

A study of the sociological impact
intervention measures.

6.

A study of involving voluntary agencies in the
integrated methods of diseases vector control.

7.

r. study of factors relating to delays and inadecuate
orovis i on and how to ensure their tinely release.

cont roI

ir.olementat ion

of

budgetary

malaria as a
Socio-economi c researcr. on (i) people's perception ot
; (iii) peoples excectati ons i n
siseases (ii) priority of communities
(iv) behavioural problems and (v) reasons of
terms of malaria control
view to find mechanism to improve the field
refusals etc. with a
operations.

g

o_

10.

vivax wit h (5 day RT)
in P.
Studies to evaluate pattern of relapse
di fferent
racical t reatment i n ma lari a zones of
with or without
encemicity and P. vivax prevalence.
■ ? in P. faIciparum in areas showinc
y.onitoring of chloroquine resistance
7-day short in-v ivo test by PHC
drug refractory behaviour through
t
y.edical officers.

E28

TABLE _!

State

1.

Sibling
species
composition &
different
•sympatricities

Disc. Katlma

A and B

Other areas

D

Haryana

Insecticides
being used

DDT & IICH

Jommu & Kashmir

2. ' Himachal Pradesh

3.

RESISTANCE STATUS OF A, culicifacieg SIBLING SPECIES AHI) IHSF.CT1CIDAL

A and B
(predominantly B)

A and B

5.

r

Punjab

A and D

Uttar Pradeah

Western

A and B

Eastern

D

No information

DDT and IICII

No information

HCH and
malathion •

Both species A &
B are fully resis
tant to HCH.
Species A is more
susceptible to
DDT than species
B. Malathion
resistance in
spcies-B-5O-6O.X &
in species A-5-1OX.

DDT, HCH and
malathion

A r c u 11 c 1 f a c. 1 o s s.l.
resistant to IICII
and DDT. Fully
susceptible to
malathion.

Most areas
under HCH
and a few
under DDT.

Species A and B ore
almost fully
resistant to HCH:
Species A is more
susceptible to DDT
than species B.
Both the species
arc fully suscep
tible to malathion.

m
.ro

4.

- Resistance
status

STRAY RECOmF-HUATlOUS

Recommendation

Stop HCH &
spray DDT

Remarks

Aj-' Sill! 91.

generally is Cully
resistant to
dieldrin but shows
2O-3OZ mortality
No spray required
when exposed to DDT
(AZ 1 hr) in b t oS p r n y only D DT
assuy tests. Among
Sibling species A and B,
Sibling species A is more
Discontinue malath
suscept I bio than
ion, otherwise
species B to DDT.
resin tonco to
As Sibling species A is
malathion will
the primary vector of
increose. Spray
P. fa 1c i pa rum and
only DDT.
P. v i v a x malaria
DDT spray would
bring epidemio
logical impact. It
may , however, be
noted that conti
Spray DDT. Use
nuous spray of DDT
Malathion
in
may reduce the
focal outbreaks.
susceptibility of Sibling
species A ns well,
and DDT spray may
become ineffective
over a period of
time.
Data
collected from
llnryonn where
malathion spray was
introduced in 1982
shows that it
tnkvs 6-7 years for
resistance to
Spray DDT. Stop HCH. develop in Sibling species
'A'. This year in
Use malathion for
focal outbreaks only. 1989, for the first
time malathion
resistance was
No spray required.
observed,in Sibling

s

1

s
1

I
i

I
I
I
r
I

%

I?

r

)

i

AIS'-*-

I t

6. Tamil Nadu

7.

Andhra Pradesh

8.

Bihar

/\ and B

B and C

DDT,HCH and
Malathion

No information

DDT <S HCH

B and C resistant
to DDT, HCH and
also to malathion
in cotton/chlllies
growing areas.

DDT

A. culiclfacles s.1.
resistant to DDT.

Spray DDT.
Malathion to control
epidemic situations.

Spray DDT.
Malathion,or a
synthetic pyre
throid for
outbreaks.

m
GO
GO

9.

North

B

South

B and C

Orissa

B

No spray required.

Spray DDT.

and C

DDT and HCH

A. culic1facles s.1.
resistant to DDT
and HCH.

Spray DDT. Reserve
Malathion for
outbreaks.

B and C

DDT, HCH and
ma la th ion.

Both B & C are
resistant to HCH
& DDT and also to
malathion in areas
where malathion is
being sprayed. .

In HCH areas,
spray DDT.
Replace malathion
with a suitable
insecticide.

DDT & HCH

All species are
equally resistant
to DDT and HCH.

Spray DDT. Reserve
Malathion
for
epidemic situations.

V ■
10. Gujarat

11. Rajasthan

A,B,C and D

species A, 5-10% and •
in species B-50-60%.
This suggested that
resistance preci
pitates foster in
Sibling species B
than in Sibling species A.
In species B it might
have developed
earlier but due to
low proportions of
species B in these
areas it might have
gone unnoticed.
Both Sibling species
B & C in Andhra Pradesh
were fully resistant
to DDT and dieldrin
in bio-assay tests.
Further, in Andhra
Pradesh, it was
observed that with
in 3-4 years of
exposure to mala
thion both the
species developed
resistance. In
Gujarat resistance
developed within
4 years of spray.The Sibling
Species C was incri
minated as vector of
malaria but it was
not as efficient as
Sibling species A or D.
It may be noted that
of propoxur or
fenitrothion are
used continuously,
cross resistance
may develop to all
OP and carbamate
compounds.

s

i
■

<

L

t

y

h
12. Madhya Pradesh

i!
A,B,C and D
!,

DDT & IlCII

A. cul lei facies s.1.
resistant to DDT,
HCH and also to
malathion in areas
with cash crop
cultivation.

I 1

I ■

DDT, IIC1I
and
malathion.

13. Maharashtra

.•'

• Cl|l ieifneies s. 1.
resistant to IlCII
and DDT and also

,■ to malathion in
areas where it is
being sprayed.
Dist. Aurangabad
& Sholapur

A.B.C and D

Dist. Deed &
Jalgon

A,B and C

Dist. Kohlapur

B,C and D

Dist. Sangli

B and C

DDT.IICIi and
malathion

14Karnataka

Dist. Gulbarga

A and B
(predominantly A)

Dist. Bijapur

A,B and C

Dist. Belgaum

B,C and D

Southern Areas

A and B
(predominantly B)

•—.---r

---

Spray DDT.
Regarding species
Reserve Malathion D no specific
for outbreaks.
data is available
However, with
reference to
other biological
characters it
behaves like
species A.
Species D was
found to be the
As suggested
primary vector of
for Gujarat.
malaria in
districts Mandla
and Jabalpur of
Mndhyo Pradesh.
This suggests
' that resistance
to malathion
may take time to
develop in
species D as in
species A.

A . cu11c1facles s.1.
resistant to HCH
and DDT and fully
susceptible to
malathion.

Spray DDT

Continuous spray
not required
except during
outbreaks when DDT
should be sprayed.

j

EVALUATION REPORT

OF THE
P.FALCIPARUM CONTAINMENT PROGRAMME
UNDER

NATIONAL MALARIA ERADICATION PROGRAMME

OF INDIA

JANUARY/FEBRUARY 1989

Fl

The Government of India appointed a Committee for the Evaluation
of the PfCP programme vide Order No. P 14017/2/88-MAL dt.5.1.89 under
the Chairmanship of Dr.

Commission.

Harcharan Singh, Adviser (Health), Planning

The Government of India is seriously concerned about the

resurgence of Malaria in the country from early 70s to date.

A special

feature of the resurgence is the emergence of P.falej parum malaria.
The usually stronghold of P .falciparum malaria in North-Eastern part
of India is giving way to larger dissemination of the infection in the

country coupled with the serious problem of drug resistance.

The Indepth Evaluation Committee has gone into the details of

financial, operational^ training, research and development aspects of
the programme and is of the view that the speical strengthening for
the containment of falciparum malaria in the country, the PfCP initiated
in 1978 with the assistance of SIDA,, need continued support.

Over the years the PfCP has been able to successfully contain
It is
the falcifarum malaria in the country to a reasonable extent.
strongly felt that in areas where the falciparum infection is high
a special strengthening would be absolutely essential, which will have
to be modified keeping in view the regional/local realities.
Apart from the speical strengthening for the successful containment

of the serious falciparum malaria problem in India a few more areas
would need special attention.

These are the areas of Training, Research

and Development, Community Participation and Health Education.

It

is further strongly felt that all developmental projects must have
clearance from the health angle before they are implemented in the
country.

Such aa mechanism needs to operate at the National/State/
Such

District/Local level.
The whole issue of the control, containment and eradication of

malaria is bound to be incomplete in India without seriously handling
the problem of falciparum malaria.

DR. HARCHARAN SINGH',
Chairman Evaluation Team,
Adviser (Health), Planning Commission

F2

DR.A.P.RAY,
Co-Chairman,
Evaluation Team

CONTENTS

Page No.

Acknowledgement
Introduction
1.

Summary of observation

F9

2.

Recommendation

no

3.

A brief overview of PfCP under MPO

F12

4.

Intervention measures in PfCP Areas

F17

5.

Epidemiological Surveillance

F18

6.

Chemotherapeutic Aspect

F20

7.

The epidemiological Scene in PfCP Areas

F22

8.

Research

F25

9.

Training

F31

10. Manpower

F32

F3

ACKNOWLEDGEMENT
At the outset the Team wishes ito extend its sincere appreciation
to the Government of India for• the opportunity given to it for
undertaking the Evaluation of the P.falciparum Containment
Programme, under the NMEP.
The Team also wishes to thank the authorities of the Ministry
of Health and Family Welfare, for the opportunity given to it

to meet and present the observations of the Team, to Mr. R.

Srinivasan, Secretary of Health and Family Welfare, Dr. G.K.
Vishwakarma, DGHS and other officials of the Ministry.
Thanks are also extended by the Team to the State authorities

specially to the Programme Officers for providing all facilities
and unstinted co-operation to the visiting Members of the Team.
Grateful appreciation is also extended by the Team to the World

Health

Organisation

SEARO

and

the

Swedish

International

Development Authority for their extremely helpful gesture and
all the support for the conduct of this evaluation.

Finally, the Team extends its most sincere thanks to Dr. M.V.V.L.
Narasimham, Director NMEP PfCP officials and staff in providing

enormous amount of documents on relevent information on the
activities of PfCP as well as briefing the Team on the subject

of Evaluation.

Contribution by the Secretarial staff of NMEP and PfCP is highly
appreciated.

F4

INTRODUCTION

Evaluation of PfCP on different aspects like operational, research

and training was to be done as per SIDA agreement.

The Govt.

of India, Ministry of Health and Family Welfare therefore appointed

a committee of experts vide order No. T.14017/2/88-MAL dated
5.1.1989 the composition of which is given below:
1.

Dr. Harcharan Singh,
Adviser (Health), Planning Commission

- Chairman

2.

Dr. A.P. Ray
Eminent Malariologist and
Retired Director, NMEP

-Co-Chairman

3.

Dr. T.P. Sharma
Director of Public Health and
Family Welfare (MP)

- Member

4.

Dr. R. Reuben
Director for Research in Medical
Entomology Malaria (TN)

- Member

5.

Dr. J.P. Gupta
Director, National Institute of
Health and Family Welfare

- Member

6.

Dr. V.P.Sharma
Director, Malaria Research Centre

- Member

7.

Dr. S. Pattanayak
Retired Director, NMEP

- Member

8.

Dr. R.R. Purohit
Retired Director of Health
Services, Rajasthan

- Member

International:

1.

Dr. J.A. Najera
Director Malaria Action Programme
WHO HQ. Geneva

- Member

2.

Dr. W.W. Macdonald
School of Tropical Medicine, UK

- Member

3.

Dr. M.V.L.P. Samarasinghe
Director Malaria Programme
Sri Lanka

- Member

4.

Dr. Udom Chittrarop
Regional Director (Malaria)
Chianghai (Thailand)

- Member

1.

Dr. G.J. Gille

- Observer

2.

Mr. Gordon Tamm

- Observer

SIDA:

F5

The period of evaluation was from 23 January to 6 February, 1989.
The terms of reference of the expert committee as specified

by Government of India were:
To assess performance of PfCP from 1984 to 1989 in respect

i)

of defined objectives with reference to operational, research
and training aspects.
To give recommendations

ii)

including imminent

approaches

to accelerate the reduction of malaria incidence particularly
P.falciparum

incidence in the country with reference to

operational, research and training through Primary Health

Care system.
The committee met on 23 January, 1989 and was briefed extensively
by Dr. M.V.V.L. Narasimham, Director, NMEP on the working

of PfCP (Plasmodium falciparum Containment Programme) and

the current malaria situation including the P.falciparum in the
country as well as in the areas under the PfCP in the various States

and Union Territories.
The following documents were provided to each member of the

committee:

1.

Annual Report of PfCP for the year 1985, 1986 and 1987.

2.

The three quarterly reports of PfCP for the year 1988.

3.

The Annual report of NMEP for the year 1987.

4.

The

Status

paper

on

NMEP

India

by

Dr.

M.V.V.L.

Narasimham, Director, NMEP.
5.

The situation analysis PfCP 1981-1987.

6.

In-depth Evaluation Report of the MPO under NMEP of

India-1985
7.

PfCP Research Review and Recommendations for practice
in field research in malaria in India - 1986.

8.

Modified Plan of Operation - Stretegy and guidelines

9.

SIDA agreement 1984

F6

10.

P.falciparum

Containment

Programme

-

Ten

operation in India (1978-88) by Drs. A.P. Ray,

years

of

M.V.V.L.

Narasimham, A.V. Kondrashin and Anna-Kari Bill.
In addition to the above documents a copy of the recently proposed

training curriculum for the various training courses, by a team

of National experts, was also handed over to this committee.
In order to get first hand information about the programme and

the working of PfCP component the Committee divided itself
into four teams and visited a number of States.

The details of

the tours undertaken are indicated in the accompanying map.
The committee had the previlage of meeting and discussing with

malaria programme officers of the States and their Zonal/District
level officers as well as the Co-ordinators of PfCP Zones and

their Special and District Epidemiologists.
The committee including SIDA observers met the Health Secretary,

Government of India, Ministry of Health and Family Welfare on

6 February, 1989.

The report was presented by the chairman

of the committee and the Health Secretary interacted with various
members of the committee.

The Director General of Health

Services, WR and WHO staff and SIDA members were also present

during the discussions.

F7

IN DIA
JAMMU
AND
KASHMIR

TEAM-IIl
CHANDIGARH

PUNJAB

T..^iaryan^

Dr. S. Pattanayak
Dr. T.P. Sharma
Dr. Udom Chittrarop
Mr. Gordon Tamm

J^.DELHI

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P R A DESH

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D|U OMwb
TEAM-I

BVkY OF BENGAL

Dr. Haracharan Singh
Dr. J.A. Najera
Dr. J.P. Gupta
Dr. R. Reuben

$
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ARABIAN $EA

PRADESH

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TEAM-II

AKARNATAKA
Team-IV

Dr. A.P. Ray
Dr. V.P. Sharma
Dr. M.V.L.P. Samarasinghe
Dr. G.J. Gille

,s

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Dr. R.R. Purohit
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Dr. W.W. Macdonald\k

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F8

1.

Summary of observation and recommendations by the evaluation
“

“

team

—

Team noted that
1.1

The epidemiological component provided to the programme through

SIDA/WHO assistance has been able to provide substantial support

at the various tiers of the state antimalaria organisation (NMEP).
In some instances it played a dominant role.

1.2

Residual insecticidal spraying strategy is seriously handicapped
affecting attainment of the targets on account of

(a) vacancies of key posts for long periods and frequent transfers
(b) financial constraints related to spraying operations

(c) interference like mud plastering of spraying walls
(d) refusals to spraying
(e) lack of intersectoral co-ordination, community participation

and health education

I

(f) actue shortage of roadworthy transport seriously affecting

the mobility of supervisory officers
(g) these problems are compounded by inadequacy of epidemiological

surveillance, on account of 30-40% vacancies at the MPW
level and the corresponding supervisory tires.

1.3

With regards of blood smear cross checking activities in the States,
it was noted that except for two States in PfCP areas, the task

has been relegated entirely to Regional Co-ordination Organisations
of the NMEP Directorate.

The team felt that with the volume

of collection of blood smears and the existing facilities at RH&FW
the services are inadequate.
1.4

The numbers of DDCs and FTDs, which were opened at the time

the MPO came into existence, has gone down to a point beyond

their usefulness. One of the main factors is inadequate and lapses
in supply of drugs to the voluntary agencies.

Thus this aspect

of the programme is mostly rendered ineffective losing an important
element of M.P.O. which is people’s participation.

F9

1.5

The present status of sensitivity of P.falciparum to chloroquine

indicates that while in some PfCP hard core areas high level
resistance (at R III level) was encountered over a number of years,

the situation improved very considerably and such a level of
resistance was absent upto 1986.

Later however, there has been

evidence of isolated and unrelated foci in a few areas detected
through intensified monitoring system.
1.6

Entomological studies under PfCP, both in Zcnes-Iand II gained

momentum and systematic studies were undertaken on vector,
biology behavioural studies, vector incrimination and their role

in transmission of malaria mainly in the context of the epidemiology

of P.falciparum.

Team confirmed the presence of main vectors

which existed earlier and studied their bionomics in relation to

malaria transmission.

Besides, new species not reported earlier

were detected and thus the scientific staff of the PfCP fulfilled

its primary objective.

The time was ripe to focus attention to

specific problem areas where active transmission was continuing

under varying geographical areas, inhabited by tribal population

as well as to the problem of migratory population.
2.

Team Recommended

2.1

That there is an immediate need to consider the provision in an
effective form and on regular basis of an additional component
should there be withdrawal of external assistance presumably

in a phased manner with necessary coverage during the interim
period to ensure maintenance of the gains achieved.
2.2

NMEP must strive to ensure adequate coverage to make the existing

operations cost effective. A switch over to any alternative approah
without demonstration of its effectiveness in lieu of the existing

activities was likely to create explosive situations especially in
areas with high transmission potential.
2.3

There is an urgent need for:
(a) motivated community participation

(b) sustained health education and maintenance of regular dialogue

between the programme and its beneficiaries

F10

(c) re establishing

the

appropriate communication system with
the district and peripheral authorities as per policy laid down
in the past, and

(d) initiating action to accelerate the process of development

of intra and intersectorial co-ordination.
2.4

In many areas residual insecticidal spraying has not yielded desired
results

on account of various problems/constraints and gross

organisational

deficiences.

Team

considers

malariogenic

stratification as basis for according priority for a realistic approach

to select areas for spraying, and felt that continuation of the
activities on the present pattern will not only be unfruitful but

also present a false sense of security.
2.5

There should be a provision of a senior technician for one over
10 PHCs in a district who is required to visit PHC within his ambit
and^he^.iS'-responsible forQua^ty> staining, streamlining a system
of cross checking, help in clearing the backlog, paying attention

to microscopes and ensuring proper functioning of the laboratory
2.6

To minimize deaths due to malaria and reduce morbidity NMEP
should re-open more DDCs and FTDs as per the norms of MPO
after identifying suitable voluntary agencies such as school teachers

and to ensure regular flow of anti-malarials to these agencies
as school teachers and to replace the drugs consumed.
2.7

Anti-malaria drug policy of the NMEP should be reviewed in view
of the discovery of more foci of drug resistance in P.falciparum
backlog in slide examination, the problem of migration and tropica/
aggregation of labour and the ease with which long acting sulpha
drugs are available in the market.

2.8

There is a need of immediate strengthening of the entomological
component

of

the

on
field
experimentation.
Additional field research units should be
established and given sufficient resources and freedom of action
programme

to carry out goal oriented research.

Fl 1

with

emphasis

There are 72 zonal entomological units in the country in addition

2.9

to the PfCP research units working in entomology. This important

resource should be co-ordinated and linkages established through
a research committee for launching mission oriented time bound
entomological research of relevance to the control of malaria.

2.10

NMEP should promote and help sister institutions in the conduct

of applied field research on malaria and take up operational reseach

to remove bottle necks in achieving malaria control targets set
out in plan documents of the Govt, of India. In order to achieve
this objective a cell should be created within the NMEP to supervise

and co-ordinate inter and intra-institutional research.
2.11

Training should be strengthened at all echelons.

This should be

taken up immediately through the training of trainers, for organising
regular training courses at the periphery and organising specialised
(e.g. entomological, epidemiological and vector control) training

for senior level officers at the central and state level.

Team

underscores the importance of utilizing the experienced and well
trained staff of the PfCP in strengthening the training programme,
as well as in deploying them in operational research and such

other activities.

2.12

A health committee may be consituted at the state level to examine
all developmental projects from malaria point of view and accord

It should be mandatory for all developmental projects
to obtain clearance from this committee and follow the
recommendations of this committee during the construction and

clearance.

maintenance phase.

3.

A Brief overview of P.falciparum Containment Programme
under Modified Plan of Operation-

3.1

Background Information

3.1.1

On the wake of heavy resurgence of malaria in the country from
early seventies, compounded with the problem of serious constraints
both in the field of logistics and financial resources and others

it was necessary to revise the strategy of NMEP both in technical
of view. Hence the plan came for a switch
and operational points
over to Modified Plan of Operation (MPO) from NMEP with effect

from April, 1977.

F12

3.1.2

Meanwhile from a review of the whole malaria situation it is noted
that besides rapid escalation of falciparum malaria.

(a) In those areas where the species was known to exist

(b) there was appearance of large scale foci of this species in
the areas where P.vivax had been present normally.
It was also evident that in the former areas malaria prevalence

moderate to hyperendemicity and transmission is

varied from

prolonged or perennial with predominance of P.falciparum infection.
Furthermore, there are some common features such as the terrain,
with hilly areas and forests with difficult accessibility ccmplicated

by heavy rainfall.

Most such areas are inhabited by tribals of

various ethnic groups having their own ethos and dialect which
compound the problem of communication.
All along these have been categorised as hard core areas with

stable malaria.

3.1.3

In view of operational and other problems, at the very outset

these clearly pointed out the necessity of additional in-put at
different tiers in the organisation though with some degree of
flexibility.

3.1.4

Meanwhile following the successful conclusion of the Small Pox

Eradication

Campaign

the

Swedish

International

Development

Authority (SIDA) which had rendered some support, became deeply

interested in assisting the Govt, of India in combating the malaria
problem at this juncture specially in areas inhabited by Tribal

population which is economically the weakest section of the
community.

3.2

P.falciparum Containment Programme

3.2.1

Operational Aspect
The additional component which was provided in the hard core

areas mentioned above and with intensification, the operation
became the key-note to TP.falciparum Containment Programme’

which is built within the framework of M.P.O.

F13

Besides the general objectives defined under M.P.O. such as
minimising deaths, ensuring reduction of malaria morbidity and
such others, the other tasks assigned under the PfCP are:
(a) To direct the main thrust of the operation in the hard core

areas populated mainly by tribal population.

(b) To improve case detection system and laboratory services
and to ensure prompt radical treatment.
(c) To strengthen adequate intervention measures under effective
supervision and to ensure timely operation.

(d) Considerably

improve

rapid

and

analysis

of

. epidemiological information with prompt reporting system

to

all the concerned

transmission

echelons.

(e) To accord high priority of activities wherever there is evidence

of emergence of drug resistant P.falciparum foci, and to prevent
dissemination of such resistance to other parts of the country.
3.2.2

It was also considered necessary that PfCP is to develop some

specific Operational Research activities.
3.2.3

Besides, Training Programmes were also incorporated under PfCP,

including training of Medical Officers of PHC which under the

present context constitutes the main springboard of action.
3.2.4

In view of the enthusiastic approach by the Centre and States

during the initial stages it was envisaged that the problem of

resurgence with particular reference to falciparum malaria could
be contained promptly.

The prospect seemed to be brighter on

account of the keen interest taken by WHO with the support
received from SIDA.

3.3

However during their visits to the programme the members of

the Team observed that despite efforts from various quarters,

there are a number of shortcomings, some of which had been pointed
out on earlier occassions as well, by other assessment teams.
In the present context the Team considered that a realistic

presentation on all aspects should help in full appreciation of

F14

and NMEP Units were equipped with suitable laboratory
facilities. These helped cross checking activities at,
i) State HQ.

ii) Zonal Tier
iii) At the R.C.O.

3.3.2

Against the above background, the following are noted under MPO.

3.3.2.1

Against an Operational Un it developed on population basis and
some basic epidemiological stratification, the M.P.O. Units cover

an entire district irrespective of population load, epidemiological

strata or operational feasibility.
3.3.2.2

The

sub-units

ceased

to

function

and

all

activities

were

decentralised to PHC level but without much accountability.

3.3.2.3

The laboratory services were established at the PHC with one

Technician thus without supervision and functioning in isolation.
3.3.2.4

The only cross-checking mechanism now is based at RCO, which

is incapable of dealing with the large volume of blood smears
even on a small per centage basis.

3.3.2.5

The case detection system became the responsibility of the PHC.

IVIoreover, geographical coverage in the present context is not
feasible because of large number vacancies under the MPW system.

Although the PHC has some overall responsibility, it is not
accountable for the quality and coverage.
3.3.2.6

The Zonal tier exists but the Team has great doubts about its

capability in the present context and thus usefulness because,
(a)

Most of them are untrained/inexperienced and posted for
short periods, sometimes on interim basis.

Thus there is

no sense of commitment.
(b)

All administrative powers over

the perihperal staff are

removed.
(c)

Laboratory cross checking activities are no longer their
responsibility.

F16

3.3.2.7

The Programme Officer at the State HQ. is the only component

at this level without support from other staff provided under NMEP.

4.

Intervention measures in PfCP Areas
At the outset it is mentioned that based on experience and

consideration of the cost factor, application of indoor residual
spraying in rural parts, though restricted to areas with 2 API and

above, continues to be the key operation for the control of malaria
under M.P.O.
This policy was adopted in PfCP areas as well,

The insecticides

used are mostly DDT and BHC to some extent.
However, the Team recorded serious shortcomings in the spraying

operation both in terms of quality and coverage. The Team noted

that to a great extent such a situation exists because of
(a)

Inability to meet the technical target because of resource

constraints in many states
(b)

In some cases the operation becomes ineffective because

of delay and breakdown of the activities on account of late
release of funds and often on piecemeal basis which is not
conducive to follow the time schedule nor the target.

(c)

Serious constraints in the organisational aspects on account

of vacancy

This

has

inadequate.

of

key

affected

personnel

supervision

at

which

different

has

echelons.

been

grossly

Even where personnel are available there is

absence of mobility.
(d)

Non-complj ance of policies laid down relating to spraying
activities such as,

i) Multichannel approach

ii) Lack of advance notification system
iii) Co-ordination with the Department of Tribal Welfare

and their representatives at all levels in other to improve

acceptibility of spraying operation and to minimise the

risk of mud plastering.

F17

iv) Non involvement of Department of Forest and other

Agencies.
v) Lack of inter-sectorial approach
vi) Incomplete appreciation of the wage structure of labour

for spraying operation who are to be treated as skilled
labour and thus failure to meet the minimum demands.

4.1

Under the MPO the field activities like intervention measures

have been decentralised to the Primary Health Centres with the

expectation that the MO, PHC would take active interest.

But

under the present situation and workload involved in medical care,
it is rarely the case, even in respect of those who had been exposed

to short orientation course on malaria.
4.2

Considering the points itemised above, the Team expressed its
doubt about the degree of commitment of the Government to

this health programme under the cost of intervention measures

alone is estimated to be about 55 per cent of the entire cost of
M.P.O.

S
5.

Epidemiological Surveillance

5.1

Case Detection Procedure is continuing through ACD and PCD

with PHC as the base.
However, under ACD the two weekly home visits can rarely be
maintained because of large number of vacancies which exist
now after introduction of the Multipurpose Workers System. This

has raised certain other serious questions.

Under the M.P.O. it

was envisaged that DDC/FTD should be concentrated more in
remote areas, as domiciliary workers may default. But at present

there are only a few, voluntary agencies and that the Health
Agencies like PHC are not too close.

In many instances the Team noted that PCD agencies are providing

effective service and hence it considered as logical to stimulate
activities of these agencies.
5.2

Laboratory Services

5.2.1

One of the greatest drawbacks of decentralisation of the laboratory

F18

services to PHC is that only a single technician is working in total
isolation. Neither he can consult nor is there anyone to supervise
his work.

5.2.2

Though initially it was envisaged that the introduction of MPW
scheme, a second technician would be provided besides the one
posted to PHC under M.P.O., so far this has not materialised even

after a lapse of 10 years.

It is also noted that the specific and urgent recommendations,
made by the Technical Advisory Committee five years ago that

a Senior Technician was to be provided at the rate of one per
10 PHC (for supervision, cross checking and other assistance)
remain ignored.

5.2.3

This aspect has already been presented earlier indicating inherent
weaknesses under M.P.O.

5.3

Stains and Staining Process
The In-depth Evaluation Team of 1985 and some of the members

of the present Team have been sceptic on the advisibility of the
continued use of JSB stain. This is on account of wide variations
in the quality of stain and staining of blood smears with J.S.B.*.

To a great extent this is understandable as from all accounts

supervision is deficient in the preparation of the stain with
reference to,
(a)

Procurement of proper material

(b)

The required degree of oxidation (polychroming)

necessary and the determination of the end point
(c)

Maturation before use.

As the stain is prepared at District level full attention can be
focussed at this vital aspect.

*
Incidentally, comparative studies on JSB, and other stains,
Giemsa had been undertaken over 40 years ago.

F19

6.

Chemotherapeutic Aspect

6.1

The policy

of

Presumptive and

Radical Treatment has been

formulated under the M.P.O. both for areas where falciparum
malaria is sensitive or resistant to chloroquine.
However, in areas where the malaria incidence is quite low (with

low SPR) there are some doubts in some quarters on the continuation

of presumptive treatment.

This aspect needs urgent and deeper

consideration in the light of emergence of large number of resistant
foci believed in some quarters to be because of wide scale drug

pressure.
6.2

With

regards

to Drug Distribution

Centres (DDC) and Fever

Treatment Depots (FTD), which played an important role at the

initial stages, the Team is concerned to note that the number
of such institutions have been dwindling down from year to year,

despite periodic advice issued from the NMEP Directorate/MOH

(see in Annexure), and discussed annually at the Conference of
the Malaria and Filaria Workers.
It had been the concensus that the availability of chloroquine
at village level had an impact on mortality and morbidity.

The

In-depth Evaluation Team of 1985 reported "that the chemotherapy
provided by drug distribution has indeed had a substantial impact

in preventing deaths.”

In the opinion of the present Team which studies the problem

carefully, there has been dramatic decline of the number of DDC
and FTD and it is likely to result in serious consequence on mortality
and morbidity.
The M.P.O. has stressed on the importance of people's Participation
particularly in this field.

The categories of volunteers to be

involved particularly the School Teachers have often been stressed
in all circulars. Although NMEP Directorate has been periodically
urging the States to focus attention to this area, the situation

has deteriorated to an extent that the system seems to have
collapsed without the necessary support from any quarters.

F20

In this context an urgent review on the regular supply of drugs
to voluntary agents is a must. In view of the reduced frequency

of visits by the M.P.W. for Active Case Detection, more often

than not, the stock of antimalarials at the voluntary centres run
short

of requirements and, therefore,patients lose interest in

these centres.

Hence there is need to explore for alternative

arrangements for regular flow of the drugs to the periphery.

In this areas the Team studied the role of PfCP personnel. Since
they have neither capacity nor authority to establish DDC and

FTD, at best they could stimulate the medical officers of PHC

to take action. But here again the crux is making drugs regularly
available to the agents.
6.3

Emergence of chloroquine resistance P.falciparum and prevention
of dissemination of such resistant strains

While reports were forthcoming from neighbouring countries about
the emergence of chloroquine resistance, it was not till 1973 when

evidence of chloroquine resistance at R II level was noted in two
adjoining

districts

of

Assam

(Karbi

Anglong

and

Nowgong).

However, it was not till 1978, that systematic studies were initiated

in this field through monitoring units for undertaking sensitivity
tests.
In two PHC of Karbi Anglong of Assam resistance was recorded

at R I to R III level in 1978, and the levels seemed to be retained

for a few consecutive years, The maximum per cent of R III cases

was 16.7.
Incidentally, all these areas had already been brought within the
sphere of influence of PfCP. Studies in other PfCP areas indicated
resistance mostly

R I and R II levels, the same as in many non

PfCP districts.

The main concern of NMEP was the risk of dissemination of
resistance at

R III level from N.E. Zone to other parts because

of movement of thousands of itinerant labourers between PfCP
Zone-II and Zone-Ill and on one side and in Zone-I (N.E. Zone)

F21

At the very outset it should be stressed that in view of the very
many inherent problems, a study of a programme of this nature

needs close scrutiny and for this very purpose the present Team
was furnished with a large volume of epidemiological and other
data.

Although the time assigned to the Team was very short,

a few members were in a position to study the data carefully
and the report is based on the same observation.
7.2

However, the following important issues should be noted in the

Analysis and Interpretation of the data.

(a)

The PfCP areas were developed in stages from 1977 to 1981

when all the areas which exist to-day were brought within
its zone of influence (see PfCP map attached.)
(b)

For various reasons in 1983 there was need for restructuring

It is of significance to note that

the operational areas.

in this process about a fourth of the areas taken up by 1981

was withdrawn from PfCP as the areas had attained the
objectives def ined under PfCP.
7.2.1

Analysis of Epidemiological Data
Considering the points mentioned above the progress of the zones

of PfCP cannot be measured in the same time scale.

Thus in

the first instance comparative studies of the Parameters for the

entire PfCP areas are presented,
(a)

For the year 1987 against 1981 (Table-I)

(b)

As well as for 1987 against 1984 as per terms of reference
(Table-II).

TABLE - I
Year

ABER

API

API

SPR

SfR

1981

11.13

7.83

5.45

7.03

4.90

1987

10.45

5.39

3.94

5.16

3.77

-31.1

-27.7

-26.6

-23.0

Changes %

F23

TABLE - II

Presenting 1987 data against 1984
Year

ABER

API

A fl

SPR

SfR

1984

9.84

6.14

4.56

6.24

4.64

1987

10.45

5.39

3.94

5.16

3.77

-12

-13

-17

-23

Changes %

From Table-I, it is noted that though not commensurate with

the time element (7 Years) there had been reduction in API and

Afl by about 30 per cent*.

There had been somewhat similar

reduction in SPR and SfR. Compared to the above the downward

trend under Table-II is marginal indicating an almost static condition
during the four year period (1984 to 1987), attributed to a few

large scale focal outbreaks.

But on the whole the overall picture

shows that falciparum malaria has been kept contained which

has been the primary objective of PfCP.
7.2.2

Zone-wise Analysis

For better appreciation of the actual situation of data have also
been analysed, Zone-wise as indicated below.

The tables are

appended. In these zones the data for 1988** have been compared
to that of base line year.

(a)

Zone-I, the decline in API is significant and has been somewhat

faster than Afl. This is also reflected in the other parameters.
(b)

Zone-II, the trend of reduction in API and Afl is

somewhat

similar but significant.

(c)

Zone-Ill, the decline in API and Afl over the ten years has
been by about 50 per cent.

To some extent this could be

on account of somewhat lower rate of ABER.
*

In view of the significant reduction recorded in those areas,
which were taken out from the sphere of influence of PfCP from
1983, the decline seen now, would have been somewhat steeper.

**
In all the four Zones, data for the entire year 1988 are
available.

F24

(d)

Zone IV, compared to the three other zones the downward
trend in all parameters has been quite significant specially

in terms of API and Afl though the decline in API is somewhat
steeper.
7.2.3

Volume of falciparum malaria cases
(a)

Comparative studies show that against 1981 and 1984, there

has been a downward trend in total falciparum malaria cases
in PfCP areas in 1988. This is somewhat slow no doubt

but

there is positive indications of the same (see Bar Diagram).
(b)

Studies have also been made in respect of PfCP data for

1987 against the situation in the rest of the country showing

a 15 per cent decline in falciparum malaria (see Pie diagram).
(c)

When the situation is studied in non-PfCP areas for 1987

against 1981 it is noted that while there has been appreciable
reduction in API per contra there has been a steep rise in Afl
(See Table below).

Epidemiological Data in non-PfCP areas

Year

ABER

SPR

SfR

API

Afl

1981

10.08

3.43

0.26

3.45

0.26

1987

9.40

1.79

0.41

1.69

0.38

-48%

+58%

-51%

+46%

8.

Research

8.1

General Remarks

Modified Plan of Operation has defined Research as one of the

supportive processes in the programme and during the initial stage,
a number of projects were undertaken after 1978.

Studies on sensitivity of P.falciparum to antimalarials were also
emphasised and initially six monitoring teams were provided for
the entire country, later increased to 12.

8.2

Two Entomologicl Projects were undertaken, one in Zone-1 and

the other in Zone-II of PfCP from 1980 onwards.

F25

P.falciparum Incidence
Main Four Zones
No. of Pf cases

500000

400000

300000
!

“H

I ro
200000

1
100000

19?1

1984 ,

1988

□
Bi

LU
UJ
Q

O

z

E

□u
o
Q

£
a:|
•o
U-4

p-<

o
LT>

c>
co

F27

8.2.1

In Zone-I where doubts were expressed in some quarters about

the presence of the well known vectors like An. minimus and
An-balabacensis (dirus), two Units were established under PfCP,
one in Assam/Meghalaya border area, and the other in Nagaland.
The observations are summarised briefly:

(a)

In the first unit (kept unsprayed), An-minimus was detected
In the forest areas An.balabacensis

throughout the year.

(An.dirus) also played an important role.
(b)

In Unit II established in Nagaland An.minimus played the
dominant role but An.balabacensis was not frequently
encountered because of large scale deforestration.

(c)

Besides, An.fluviatilis was incriminated by both the Units

(not reported in N-. E. Zone earlier).
(d)

As to the bionomics of the species it was noted that both

An.minimus and An.fluviatilis are endophilic whereas An.
balabacensis is exophilic.
(e)

Although a large number

of other species were dissected
such as An. annular is and An. philippinensis to mention a

few none showed
8.2.2

infection in either gut or gland.

Zone-II; Its HQ. is at Bhubaneswar, with three Field Units all
in Orissa. An.fluviatilis was detected and incriminated in these
field stations.

An.culicifacies was also established for the first

time as a vector in Mayurbhanj District of Orissa.

8.2.3

8.2.4

The Central team at HQ. developed se rological technique using
Gel Diffusion method to determine the source of blood meals.

As

to

the

susceptibility

to

insecticides,

it

was noted

that

An.culicifacies continued to be resistant to DDT while An. fluviatilis
showed 94% mortality.

8.2.5

In summing up the Team noted that:
(a)

After many years systematic entomological studies have
been taken up under PfCP.

F28

I

(b)

Besides the known vectors, it is for the first time An.fluviatilis

has been incriminated as a vector in North East Zone.

In

the same way An. culicifacies has been found to play an
important role at least in some areas of Orissa.
While the Team acknowledged the role of PfCP in undertaking

these activities and showing some definite findings, it felt that
any further continuation on the same lines would not be meaningful

any more. This is particularly with reference to the Entomological
Unit in Zone-II.
The team noted that Units under Zone-I are being relocated in

other malaria problem

where there had been no such

areas,

activities over a few decades.
8.3

Epidemiological Studies

A few Epidemiological research projects were initially identified

such as:
(a)

Malaria

Mortality and

Morbidity studies under different

eco-epidemiological strata,

One area has been identified

in Orissa in Phulbani while the other in Andhra Pradesh
in S.Kota area.

Eight rounds of demographic surveys have been carried out in
Phulbani and five in the other area, The observations indicate
ineffeciency in the case detection system by the multi-purpose
surveillance teams. It was also brought to light during mass blood
surveys that there were high prevalence of asymptomatic malaria

cases. The observations are being continued.
(b).

Studies on the Relapse Pattern of P.vivax infection, a project
undertaken on the basis of one of the recommendations
of a special research committee under PfCP.

A total 500 cases were detected.

But the research project could

deal with 80% of the patients, half of which received radical

treatment with chloroquine single dose and Primaquine for five
days while the other half received a single dose of presumptive

treatment with chloroquine only. Observations are continuing.

F29

The main objective is to determine the effectiveness of a five

days regime of primaquine, the schedule which is being followed

for about three decades.

(0

Under PfCP there is another project also supported by SIDA
Research Fund on monitoring of chloroquine levels in Plasma.
The project initiated shortly at the MRC field Station at

Haridwar in Uttar Pradesh, after necessary training of the
Research Officer in Sweden and procurement of equipment.

It is added that the intervention measures with alternative methods
of bio-environmental control in Kheda was recently assessed In

Depth.

8.4

Operational Research on Intervention Measures

During the field visits the Team Members have noted that one
of the most disturbing features of the spraying operation besides
high refusal rate is the habit of interference with the wall surface
soon after spraying operation,

$

This is most common in tribal

villages.
However, the Team noted that invariably the ceilings are not
disturbed and the insecticide is visible where spraying has been

carried out. Considering this observation, the Team recommended
strongly that where residual insecticide operation must be carried

out, full cognisance be taken of this aspect and a few PHC in
every zone in tribal areas be taken up as study areas. The spraying
operation could be restricted to aeves and ceilings of the rooms

only during both the rounds. The data are to be compared against
the

neighbouring

PHC

(comparative

study

area)

where

the

epidemiological conditions should be of the same level as in the
experimental area. The operation in the comparison areas should

be according to the routine pattern followed by the State.
In view of the its importance the team felt that this aspect could

be taken up immediately prior to the malaria transmission season
and continued through December 1989 under the SIDA assistance
pattern for research.

F30

9.

Training

9.1

Training constitutes a principal component of PfCP

During the initial phase, the training activities were related to
the conduct of 4 week

courses for District Epidemiologists to

be deployed under PfCP. It is meant for fresh medical graduates.
Subsequently these personnel were sent for field training in each

of the Zones prior to actual posting at district levels to assist

the District Malaria Organisation.

The total number of courses

run were 24 involving 372 participants during a period of 10 years.

But in view of the job insecurity the turn over of such personnel

has been

enormously

high, necessitating continuation of the

training programme.
9.2

The PfCP personnel at the HQ. Cell at the NMEP Directorate

had also been assisting the National Institute of Communicable
Diseases in the conduct of regular courses on Malariology to meet

the needs of NMEP.
9.3

Subsequently under the SIDA/WHO agreement a component has
been provided for Training of the Medical Officers of the Primary

Health Centres, which are the base for all health activities.

During the course of three years PfCP has been able to hold 45
short orientation courses for 799 MO PHC of various PfCP zones.
Committee notes

with interest that new educational activities

have been taken up by Directorate NMEP during 1988 in conducting
5 workshops to 208 clinicians of Medical Colleges, District Hospitals

on management of Severe and. Complicated P.falciparum cases

and workshop to Engineers of developmental projects which must

be continued.
9.4

While appreciating the role played so far as per plan, the Team

consider that in order to help in developing the conduct of
antimalaria activities under the Primary Health Care System,

a large

group of personnel engaged in the programme must be

of trainers to deal with
given teachers training to build a core
<

the increasing number of participants.
y

Dis 3^

—

<

'A

library

AND
\ OOCUMtNTATION

F3i
■

IB

J

The Team therefore feels that,

(a)

Not only the training programme for the MO PHC be continued
but the tempo has to be increased. For this the pre-requisite

is to build a core of trainers.

(b)

Attention is also to be focussed to refresher training for
those showing substandard performance.

(c)

Although

training

of

Malaria

Inspectors

is

the primary

responsibility of the Regional Co-ordination organisation,

job oriented course should also be held for Multi-purpose
supervision.

(d)

The Team fully acknowledges the necessity of holding courses

for Training the Teachers, to meet the training demands
defined above.

(e)

In view of ever increasing workload it is most essential that

some of the major States should be encouraged to build
their own Training Centres for the sub-professional staff

as had existed under the NMEP.

Serious note should be taken by the Centre and States on this

issue.

10.

Manpower
It is generally agreed that there is acute shortage of trained and
experienced manpower and that it is one of the most serious
constraints under MPO/PfCP.

Initially the possibility of deputation of NMEP personnel from

the State for PfCP was explored but only to note the inevitable
depletion

of

State

technical

resources.

This

necessitated

development by NMEP Dte. of suitable training programme for
PfCP

personnel

with

assistance

from

NICD

at

the

time of

recruitment of young medical graduates to work at district levels.
The Team noted with considerable interest that inspite of a very
high rate of turnover as mentioned earlier, there is number of

experienced personnel under PfCP who have been working for

several years, some even for ten.

F32

Therefore, the Team expressed much concern that despite the
difficult process of building technical component, now it is most

likely to be disbanded soon after withdrawal of SIDA assistance,
unless immediate steps are taken to redeploy these personnel

for Training, Research and such other activities.

The possibility of their absorption by the State should also be
explored, as most of these do not have adequate trained and

experienced technical manpower.

F33

ANNEXURE

Directorate of National Malaria Eradication Programme,
Delhi - 110 05T

Role of F.T.Ds and D.D.Cs:

Under the M.P.O. it has been recommended that F.T.Ds and D.D.Cs

should be established in rural areas. Directorate NMEP and Ministry
of Health and Family Welfare have issued lettters to the States

from time to time drawing their attention to energise these

voluntary agencies.

It was also impressed upon them to instruct

peripheral Health Workers to visit the FTD and DDC holders
regularly to replenish drugs/slides.

Some of the circular letter

issued from the Central level to the States are given below as

a reference:

£

1.

No. 8-1/80 NMEP Mai. 5.3.80

2.

No. 8-1/80 NMEP Asst. 19.6.80
No. T.14011/8/83-Mal, dated 17.8.83, from MOH&FW, GOI

3.

4.
5.

6.

7.

No. T.14011/1/84 Mai, dated 15.2.84, from MOH&FW, GOI
No. 4-40/82-NMEP(Asstt)/Genl. dated 12.8.83 from

Dte.

NMEP.
No. 8-l/86-NMEP(Asstt.) dated 17.9.86 from Dte. NMEP.

Besides stressing the importance of establishing these Centres
at every Annual Conference of Malaria and Filaria Workers

F34

appeendix
Date for 1988 against the base line

(a)

Zone-I:

Year

(b)

ABER

SPR

SfR

API

Afl

1977

7.84

7.68

3.43

6.02

1988

2.69

8.94

3.69

2.12

3.30

1.90

Variation

14

-52

-38

-45

-29

Year

ABER

SPR

SfR

API

Afl

1979

13.55

11.04

8.11

14.96

1988

10.99

12.61

6.86

5.71

8.65

7.20

S

-38

-30

-42

-35

Year

ABER

SPR

SfR

API

Afl

1979

7.46

5.15

3.03

3.84

2.26

1988

5.12

3.65

2.12

1.87

1.09

Variation

-31

-29

-30

-51

-52

Zone-II:

Variation

(O

(d)

year of the Zone

Zone-Ill:

Zone-IV:
Year

ABER

SPR

SfR

API

Afl

1979

13.32

10.38

5.12

13.82

6.81

1988

12.38

3.73

.2.67

4.62

3.30

-64

-48

-67

-52

Variation

F35

H-

INDIA
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FROM 1ST JULY 1983
KASHMIR

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ZONE-I

P A K ISTAN

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J * A FA ST HUTH ■

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BURMA

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F36

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