EXPERT COMMITTEE ON MALARIA
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- Title
- EXPERT COMMITTEE ON MALARIA
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EXPERT COMMITTEE ON MALARIA
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REPORT
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LIBKA^Y
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MEDICAL AND HEALTH DEPARTMENT
GOVERNMENT QF RAJASTHAN
JANUARY, 1995
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PREFACE
)
Malaria was and still is a public health problem of
importance
great
in
considerable
Despite
country.
the
efforts since nearly last forty five years to eradicate or
■0
(
control it in the country,
malaria is still prevalent and
It undermines the
(
is one of the most devastating disease.
(
health and welfare of the families, endangers the survival
(
the
of
(
strains
(
(
debilitates
children,
(
both
excessive
and
country's
resources
scarce
productivity
low
costs,
health
public
people's
and
population
active
the
by
and
impaired growth.
i
(
The in-depth evaluation of modified plan of operation
(MPO)
of
1985,
in
NMEP
the
commented
malaria
the
on
situation that ’’the problem of malaria in India is grossly
underestimated1’ . According to an extrapolation made by the
Malaria Research Centre, Delhi on the basis of chloroquine
c
estimated that nearly
it was
consumption in the country,
35.5 million episodes of malaria were treated in addition
A
to
those
national
treated
from
level
stabilization
under
of
NMEP
any
1992 ,
till
1983
total
in
malaria
one
year.
the
has
been
although
P.
there
cases,
At
Falciparum problem almost doubled from 21.8 percent in 1981
to that of 43.9 percent in 1991.
In Rajasthan,
the lowest number of reported malaria
the
last
malaria
and
cases
during
cases
of
reported. However,
decade
14,006
were
in
1986,
P.Falciparum
when
54,618
cases
were
in 1994 there has been more than three
(i)
!
(
I
fold increase in total malaria cases and six fold increase
I
in P.Falciparum cases in the state,
j
x i-
great
concern.
1984 ,
Since
which is a matter of
repeated
been
have
there
epid,emics/outbreaks year after year in some of the problem
districts, although a few have maintained a downward trend.
i
The State Government took notice of the recent outbreak of
1994
in
addition
in
and
Jaisalmer
and
Barmer
to
implementing a very successful crash control programme in
b
problem districts, constituted an Expert Group to look into
trends and factors for resurgence and to suggest measures
to
prevent
recurrence
of
malaria
is
the
in
western
desert
the
detailed
districts of the state.
The
present
report
outcome
of
studies carried out by the members of the Expert Committee
,
•
31'
3.’
3 ,
4
jl
O''
P
information collected from the Directorate of
based upon
Medical
and
Hydrology,
Indira
Health
Rajasthan,
Services,
of
Department
Irrigation, Agriculture, Tourism, Sheep & Wool,
Gandhi
Canal
Family Welfare,
Board,
Regional
Office
of
Desert Medicine Research Centre,
interaction with
the
(SEARO),
New
Delhi.
In
officials
of
all
above
agencies,
Jodhpur,
WHO
and Malaria Research Centre
to
&
and
Directorate of NMEP
addition
Health
members
had
detailed
discussions with the Collectors and other officials of the
Oi
Department of Health,
Irrigation
and
Revenue,
Education
Public Health Engineering,
and
the
NGOs
and
public
i
■^\
representatives in the districts of Jodhpur, Jaisalmer and
Barmer.
(ii)
I
r
The report brings out urgency of revised strategy for
I
«
t
control,
malaria
I
■I
recommendations for immediate action.
The Committee makes
resource
a strong plea for sustained political commitment,
allocation
for
effective
implementation
of
review
and
including
strategy
control
malaria
revised
I
i
steps
and
and
f inally
and
resurgence
its
prevent
to
measure
recurrence
for
f actors
outlines
revision of drug policy and insecticide policy.
I
The Committee feels honoured to have been invited to
assist the State Government in their endeavour to cope with
the increasing problem of malaria. Members are grateful to
I
be
with
associated
this
task
significant
of
social
relevance.
The Committee received wholehearted cooperation
!
from
support
all
the
agencies
concerned
including
and
the
Directorate of Medical & Health Services, Rajasthan. Member
are grateful for the same.
Member
Secretary,
Dr.
Our special gratitudes to the
for
S.D.Gupta
his
very
competent
support throughout the deliberations and report writing.
It is hoped that the report would receive appropriate
and
due
consideration
implementation.
the
of
Government
may
State
also
like
Government
for
share
this
to
report with the Directorate of National Malaria Eradication
Programme,
Malaria
Research
Centre
and
WHO
(SEARO)z
New
Delhi.
I
JAIPUR
23 January,
RAMESHWAR SHARMA
M. D. , M. P. H . , F.A.M.S.
Cha irman
Expert Committee on Malaria
1995
(iii)
(
1*)
ACRONYMS
(
(
3
•*>
5
*
ACD
ANM
AMO
AC
AF
AS
API
ABER
CHC
CMHO
DPHS
Dy.CMHO
DMHS
DMRC
DDC
FTD
FRT
GOI
GOR ’
IRS
ICMR
IEC
MRC
MO
MPW
MPO
MOHFW
NMCP
NMEP
NICD
NGO
OPD
PHC
PV
PF
PFCP
PCD
ROHFW
SPR
SFR
SIDA
SC
WHO(SEARO)
i
Active Case Detection
Auxiliary Nurse Midwife
Assistant Malaria Officer
Anopheles Culicifacies
Anopheles Fluviatilis
Anopheles Stephensi
Annual Parasite Incidence
Annual Blood Examination Rate
Community Health Centre
Chief Medical & Health Officer
District Public Health Supervis-r
Dy.Chief Medical & Health Off i--'r
Dte. of Medical & Health Servi«'rs
Desert Medicine Research Centre
Drug Distribution Centre
Fever Treatment Depot
Fever Radical Treatment
Government of India
Government of Rajasthan
Insecticide Residual Spray
Indian Council of Medical Resf'arch
Information Education Communicat ion
Malaria Research Centre
Medical Officer
Multi Purpose Worker(M)
Modified Plan of Operations
Ministry of Health & Family Wr ,!3i'e
National Malaria Control Procn arno
National Malaria Eradication IN--iramme
National Inst.of Communicable Pi'-cases
Non Governmental Organisation
Out Patient Department
Primary Health Centre
Plasmodium Vivax
Plasmodium Falciparum
Plasmodium Falciparum Containrv-iH I ‘roq .
Passive Case Detection
Reg. Office of Health & Familv t'11 f arc
Slide Positive Rate
Slide Falciparum Rate
Swedish International Dev.Agervy
Sub Centre
World Health Organisation (So>Hb l ist
Asia Regional Office)
a
J
(iv)
4
0
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(
(
CONTENTS
(
PAGE
PREFACE
ACRONYMS
iv
PRELUDE
1
CHAPTER 1
MALARIA CONTROL- A NATIONAL PERSPECTIVE
5
National Malaria Control Programme
National Malaria Eradication Programme
Modified Plan of Operations (MPO)
P. Falciparum Containment Programme
5
5
7
8
Malariogenic stratificationRevised Strategy
Global Strategy
9
9
CHAPTER 2
RAJASTHAN : GENERAL PROFILE
11
CHAPTER 3
MALARIA IN RAJASTHAN
1.1
1.2
1.3 ’
1.4
1.5
J
0
1.6
RETROSPECT
14
.,3
3.1
3.1.1
3.1.2
•-a
3.2
3.2.1
3.2.2
3.2.3
3.2.4
3.2.5
3.2.6
3.2.7
a
3.3
3.3.1
3.3.2
3.4
CHAPTER 4
4.1
4.1.1
4.1.2
14
State Level
Trends in Annual Parasite Incidence
Emergence of P. Falciparum
14
15
17
District Level
Districts in Jodhpur Zone
Districts in Bikaner Zone
Districts in Ajmer Zone
Districts in Kota Zone
Districts in Jaipur Zone
Districts in Udaipur Zone
P. Falciparum in the districts
Entomological Profile
Prevalent Vectors and Vector Density
Vector Susceptibility
17
18
18
19
19
19
20
20
21
21
Drug Resistance
23
CURRENT SITUATION
27
State Level
27
Morbidity
Morta1ity
27
31
(v)
€
<
(
(
4.2
District Level
32
4.2.1
4.2.2
4.2.3
4.2.4
4.2.5
4.2.6
Ja isalmer
Barmer
Bharatpur
Jaipur
Ganganagar
Dungarpur
32
36
38
38
39
39
(
(
■2)
4.3
Transmission and Outbreak of malaria
40
4.4
Entomological Profile
41
4.5
Drug Resistance
44
4.6
Environmental Conditions
44
4.7
Malaria Control Activities
45
4.7.1 Organisation
Control Activities
4.7.2
Insecticide spray
4.7.2 . 1
Surveillance and Treatment
4.7.2.2
45
46
46
47
Control Measures in the
Current Outbreak
49
FACTORS ASSOCIATED WITH
MALARIA OUTBREAK
52
CHAPTER 6
RECOMMENDATIONS
70
CHAPTER 7
RECOMMENDATIONS EOR IMMEDIATE ACTIONS
98
*
*
4.8
CHAPTER 5
*
A
REFERENCES
ANNEXURE
‘A
□
a
(vi)
PRELUDE
The
Government
of
Rajasthan,
keeping
in
view
the
recent high incidence of malaria, especially in the western
™%
0
districts
of
constituted
Rajasthan,
a
Technical
Expert
Committee on Malaria vide order Fll(8) M&H/ Gr 3/ 93 dated
November
2,
1994 .
The
following
were
nominated
to
the
Expert Committee.
T
-4
4
4
J
1. Dr Rameshwar Sharma
Former Vice Chancellor
University of Rajasthan
Chairman
2 . Dr D.K.Jagdev
Former Director
Medical and Health Services,
Rajasthan
Member
3 . Dr G.S. Ganlot
Director
Medical and Health Services
Rajasthan
Member
4.
Member
Dr Kunal Kothari
Professor of Medicine
SMS Medical College
Jaipur
5. Dr S.D. Gupta
Joint Director (IEC)
Medical and Health Services
Rajasthan
Member Secretary
The following members were later co-opted:
3
3
5
5
u*
1. Dr T.P. Jain
Former Professor
Preventive and Social Medicine
SMS Medical College, Jaipur
Co-opted Member
2 . Dr Devendra Kothari
Professor
India Institute of Health
Management Research, Jaipur
Co-opted Member
i
ili
■ir
J
Terms of Reference:
Following terms of reference were set for the Expert
Committee:
1.
i
The Committee will assess the trend of malaria
incidence in various districts in thet state
specially the western districts which are more
endemic.
2.
identify
the
factors
will
Committee
The
associated with increased incidence of malaria.
3.
The ’Committee will suggest
check future recurrence.
steps
necessary
to
The Committee would submit its recommendations within
one month of its appointment.
General Approach
The
Committee
Expert
of
members
held
a
series
of
meetings to review the situation, finalise the methodology,
and develop tools & check-lists. The committee conducted a
detailed discussion with the state level health officials
*
focusing
■
on
current
of
status
malaria
in
Rajasthan,
i
previous
trends,
Eradication
implementation
Programme,
of
malaria
the
National
control
Malaria
strategy,
infrastructure,
logistics and supplies,and monitoring and
decision
system.
making
The
opinion
of
the
state
and
district level officials was also elicited on the possible
reasons for the current outbreak of malaria in the Western
5
districts. The Expert Committee also procured information
•A
from the Indira Gandhi Canal Board,
Department of Agriculture,
Irrigation Department,
Department of
Sheep and Wool,
Department of Tourism, Hydrology and the Regional Office of
Health & Family Welfare
2
'0
(GOT).
2
(
(
Selection of districts
The committee decided to conduct detailed analysis in
selected
basis
of
districts.
their
Six
districts
geo-environmental
were
selected
position
and
on
the
Annual
Parasite Incidence. Following districts were selected:
High Incidence
Barmer and Jaisalmer
Medium Incidence
Dungarpur and Bharatpur
Low Incidence
Jaipur and Ganganagar
The Committee focused its special attention on the two
western desert districts namely Jaisalmer and Barmer.
Data Collection
The existing records available at the state, district
and primary health centre level and also in the hospitals
were the main source of
data and have been extensively
utilised for ana lysis. However, additional information was
also obtained from the selected districts on a specially
designed proforma for the districts and the PHCs.
Field Visit and discussion
The Expert Committee conducted intensive field visits
to Jaisalmer and Barmer districts to assess the situation
in the field first hand and carry out in-depth discussions
with
’3^
District
Collectors
and
other
district’ officials
including Chief Medical & Health Officers, Dy Chief Medical
and Health officers, district hospital specialists, CHC and
3
I
(
PHC medical officers.
laboratory
hea1th v/orkers and supervisors and
technicians.
The
representatives of people,
Group
also
interacted
with
non-governmental organizations
and the members of the public including patient s during its
visit to the villages and hamlets in the two districts.
•v
The
Expert
Committee
also
met
the
Directors
of
National Malaria Eradication Programme and Malaria Research
of
Division
Of f icer,
Programme
and
(ICMR)
Centre
in New Delhi,
Communicable Diseases, WHO Regional Office
issues pertaining to
for consultation on broad policy
modification in the
malaria control strategy and scope for
changing approaches to
strategy, research issues and the
malaria control, drug and insecticide resistance.
■J
□
3
0
0
4
(
f
CHAPTER 1
s
MALARIA CONTROL- A NATIONAL PERSPECTIVE
1.1 National Malaria Control Programme
Since
i
1953,
Malaria Control
Programme has undergone
concept,
objectives and strategy,
three major changes
in
The first change was with the
launching of NMCP in April
1953 with the objective to reduce malaria transmission to
a level at which it would cease to be a major public health
principal
The
residual
insecticide spray of human dwellings and cattle
shed,
establishment of state anti malaria organization to
carry out survey
A
operational strategy comprised of
problem.
and monitor malaria
incidence and make
anti-malaria drugs available to patients reporting to an
institution.
•A
1.2 National Malaria Eradication Programme
Later, the second change was that in keeping with the
■ j
recommendations
of
the
Government of India (GOI)
World
VIII
Health
Assembly,
the
decided to convert the NMCP into
National Malaria Eradication Programme (NMEP)
from 1958.
and it was to
The main objective was to eradicate malaria,
achieved
by
interruption
elimination
of
all
be
of
indigenous
malaria
cases
transmission
through
and
continued
radical treatment of the
search for all malaria cases and
eradication was achieved, to
same ; and finally after the
The basic philosophy of the
provide a maintenance service.
eradication programme, being the totality of coverage of
5
I
'a
in'
A /(
/
(
(
the
entire
for
community
residual
insecticide
spray,
to
anti-malaria drugs,
search all fever cases and administer
services through out
establishment of efficient laboratory
trained man power to
and to develop a
the country,
objectives. The programme was
accomplish the programme
be
vertical approach and was to
based on a system of
phase,
attack.
manner
phased^
a
in
implemented
. Strict criteria
consolidation phase and maintenance phase
to
of attack phase in
entry
for
down
laid
was , also
maintenance phase. By
consolidation phase and later into
t
(
0
0
>
1965
1966 , total malaria cases
search
had
reached
a
all
time
detected through intensive
low
level of
0.1
to
0.14
estimated in 1952. Further,
million against 75 million as
million deaths a year as
there were no deaths against 0.8
sudden withdrawal
estimated in 1952. In 1965, there was a
of bilateral assistance, including supply of insecticid
3
t
(
(
5
i
at a time
on the programme
which had serious repercussions
This resulted in
H
II
when the programme was ” in midstream
malaria cases upto 1970, after which
gradual increase in
and doubling phenomenon from
there was a rapid escalation
i
had reached a level of
1971 onwards. By 1976, the incidence
were
which 11.6 percent
out
of
cases
,
million
6.46
during the resurgence
P.Falciparum. The data showed that
77
incidence of p.Vivax rose
between 1965 and 1976,- the
times while P.Falciparum
increased by 29 times.
3
In
observed in Rajasthan.
A similar resurgence was also
Chittorgarh,
districts namely;
addition to this, 7
6
o
(
4
(
(
Jalore,
Kota,
Udaipur,
Bikaner
Barmer,
identified with areas of persistent
(
and Jodhpur were
transmission even after
operations
13 to 17 years of spray
and 8 to 11 years of
i
surveillance.
<
<
1.3 Modified Plan of Operations (FIFO)
(
(
(
(
in Malaria in the
In the light of this rapid increase
Consultative Committee
country and on recor.rendation of the
was
Plan of Operation (MPO)
of Experts, the Modified
entailed considerable changes in the
adopted in 19 7J7, which
operational aspects. Some
policy related to technical and
in the operational strategy are as
important changes made
follows:
1.
2.
3.
4.
malaria
units
were
of
erstwhile
The
boundaries:
boundaries.
to the district
u.
rearranged to conform
c
1 i and laboratory
The Active case3 detection (ACD) the PHC level.
1 ised to t*._ -services were decentra
c.
>1^2 for case detection
focal point
PHC was made the
and spray operations.
system, laboratory services i.
the task, the
Because of the specraliseo
pec ia1ised mature of
direct
under
spray
operations
were
conti
responsible
supervision of Malaria Inspector who was
to the district Malaria Officer.
5.
6.
7.
8.
the
the areas where P.
Special atten-ion was focused on dominant and showing
Falciparum species of ‘malaria was
rising trend.
Chief Medical &
The Medical Cfficer of PHC and theresponsible
for
were
made
Health
Officer
implementation of the programme.
were established for the
Zonal Entomological\ teams
1 studies.
promotion of entomologica
c..—
taken up in 1971, was
Urban Malaria Scheme, which was
further extended.
□
□
7
(
>•
(
through
centres
9.
available
drugs were made
Anti-malarial
drug distribution
as
agencies
voluntary
(DDCs).
10.
In addition, at fever treatment depot (FTD) and VHGs
located 1 for 1000 population, would collect blood
smears.
the
. Further,
phasing system of NMEP namely attack.
(
were abolished. The
consolidation and maintenance phases,
Annual Parasite Incidence (API) was considered as the main
r
deciding
factor
spray
insecticide
for
of
delineation
the
Because
activities.
a
of
areas
for
number
of
"A
(
constraints, anti-malaria measures were restricted to areas
only with API levels of 2 and above. There was no specific
time
prescribed
element
the
for
spraying
activities.
In
the situation was to be assessed and judged on
each case,
its own merit.
(
<
1.4 .P. Falciparum Containment Programme
-*4
Considering the increase of P.Falciparum incidence and
development of P.Falciparum resistance,
was
priority
and
later
given
special attention
the
contain
to
spread
of
the country and a special
P.Falciparut to other parts of
was
programme of P. Falciparum Containment Programme (PFCP)
launched with the help of SIDA/WHO in 1977.
Starting from
55 districts in 1976-1977, the PFCP was expanded in stages
to
a
of
total
disbanded
in
81
districts
in 1981.
1989
primarily
on
account
international and bilateral support.
covered
m
Rajasthan
under
this
Udaipur, Dungarpur and Banswara.
8
’StBrrsJwr-,-----
This
of
programme was
tapering
of
Three districts were
special
programme
(
t
(
(
1.5 Malariogenic stratification
(
(
✓
On
experimental
an
abortive
made
(
effort
Directorate
of
NMEP had
stratification
of
various
the
basis,
of
activities under the
sections/sectors for malaria control
it was learnt during
However,
MPO of NMEP in 1993 .
various
that for
discussions’ with the Director, NMEP
reasons, this approach was
administrative and operationa1
found feasible by the
not implemented by the State and nor
for the present. This was to be
NMEP and hence abandoned
Karnataka and Rajasthan
up in two States namely
taken
i
r
only.
(
<
(
1.6 Global Strategy
not the least,
Last, but
with the adoption on World
malaria by the Ministerial
Declaration on the control of
(
(
o.
in Amsterdam, a need
which took place in 1992
re-orient the malaria control programme
has now emerged to
Malaria Control Strategy and its
in accordance with Global
health care. The
implementation in the context of primary
health care
n f irmly rooted in primary
is
Global strategy
and national
strengthening of local
approach and calls for
community
for
control,
diseases
for
capabilities
decentralisation of decision making,
partnership and the
with
of malaria control activities
the
integration
for
'and for involvement of
related disease control programmes
concerned with education,
other sectors especia Uy those
and Environment”.
agriculture, social development
Conference,
9
J
(
(
c
• It is in this context, that the expert committee has
(
J
and
entomological
aspects
(
reviewed
(
malaria in the State along with the achievements
various
malaria control programme so far. The
epidemiological
of
i
<
in the
socio
the
economic factors which contribute to malaria problem,
J
(
(
and vector resistance
e merging problem of drugs resistance
of malaria
and newer developments in tools and technology
(
control have also been considered.
(
(
t
3
(
(
(
(
<
<
i
(
(
-a
10
II
(
I
<
(
CHAPTER 2
(
RAJASTHAN : GENERAL PROFILE
is the second
Rajasthan, situated in the north-west,
largest state in the country in terms of geographic area
3
with a population of about 44 million (1991). It accounts
for about 10.4 percent of the land area and 5.2 percent of
the population of the country. The major part of the state
is arid and semi-arid. The state has 31 districts including
four districts,
namely;
recently Hanumangarh,
Dausa,
Rajsamand and more
Baran,
which have been newly created.
The
districts have been grouped in six administrative zones,
namely; Bikaner, Jodhpur, Jaipur, Kota, Udaipur and Ajmer.
(
state
The
predominately
is
population living in the rural area.
A
percent
77
rural,
of
17.3 percent of the
population belong to scheduled castes and 12.4 percent are
tribal.
Two
districts,
predominantly tribal with 73.4
tribal
population,
Udaipur
(36.8
Sawa imadhopur
The
Sirohi
percent),
percent),
Dungarpur,
Bundi
are
65.8 percent
percent and
respectively.
(22.6
and
Banswara
other
districts,
(23.4
percent),
(20.3
percent)
and
Chittorgarh (20.3 percent) also have a fairly large tribal
population.
11
*
Bikaner,
Churu,
Ganganagar,
Pali,
Nagaur,
Sikar
and
predominantly desert districts which
are
districts,
Jodhpur,
Jhunjhunu,
Jaisalmer,
are
Barmer,
Jalore,
I
11
i
characterised
low
by
density,
population
low
literacy,
high population growth
host ile climatic conditions and a
dr
rate .
The
state
is
to
considered
be
a
demographically
910 females to
backward state as the sex ratio is as low as
(28.44 percent)
1000 males, the high decadal growth rate
population). The infant
and • birth rate (35 per 1000
i
continue to be
mortality rate and maternal mortality rate
higher than the national average.
The
literacy rate
is only 38.6 percent with female
literacy only 20.4 percent. About 30 percent of population
*
lives below poverty line. The State is yet in the process
(
(
of industrial development.
(
The
state,
however,
has
an
impressive
health
There are
infrastructure with an extensive rural network.
283
218 .CHCs, 237 Block PHCs, 1216 PHCs, 8000 Sub Centres,
These
Dispensaries and 218 Hospitals at various levels.
curative and
health and medical institutions provide
preventive services, including implementation of various
3
national
health
programmes.
A
large
health manpower
is
engaged in delivery of health care to the people in rural
and urban areas.
3
The
3
□
2
'3
climate
conditions.
is
characterised
by
extreme
weather
The average annual rainfall is about 277 mm.
12
1
(
(
(
It.
(
*
The temperature ranges between 45-49 degree Celsius during
are
(
summer and non-rainy days. The extremes of temperature
(
recorded during winter when it goes down to below 4 degree
r
Celsius.
The Barmer and Jaisalmer districts,
<
which
faced an
epidemic of malaria during the current year are typical
desert districts with very low population density, being 51
and 9 per sq.km, respectively. The average village size is
about
33
sq
km
in
Barmer
and
74
sq
Rm
in
Jaisalmer
district, thus greatly limiting the accessibility in these
O
areas. The average rainfall is 262 mm in Barmer and 151 mm
in Jaisalmer district. A fairly large population in these
i
districts is migratory and the migration is seasonal.
(
J!
-5
O
■
□
13
(
CHAPTER 3
RETROSPECT
MALARIA IN RAJASTHAN
3.1 ’STATE LEVEL
Trends in Annual Parasite Incidence
3.1.1
<
to
continues
Malaria
be
an
health
the disease has maintained
However,
problem in Rajasthan.
public
important
(
a low endemicity level in the state with focal and sporadic
f
rise in incidence in the different parts of the state.
the
(
level,
state
review of malaria
a
situation based
At
on
available data, reveals that the Annual Parasite Incidence
an
(API),
used
indicator
measure
to
incidence
the
of
i
(
malaria z
the
<
-A
launch
control
1977
that
showed
of
the API
Modif ied
in 1977.
Plan
sharply declined
of
Operations
since
malaria
for
recorded as high as 7.7
The API was
in Rajasthan.
has
no clear trends in malaria
Thereafter,
incidence have been observed in the subsequent years.
*
(
API has shown rise and falls
the highest
of
3.4
in
the
in
The
in the following years with
1983 .
year
The API
remained
below 2.0 during the period 1984-1988 and in the year 1991.
There was a
i
slight rise in the API
then
1992
focal
outbreaks
and
1993 .
during
of
epidemics
in 1989
there
these
years
of
malaria
confined
to
December,
it recorded a all time high API
post.
loca1i sed
modified
plan
of
areas.
During
operation
have
which
1994 ,
period.
1990 and
and
remained
as
on
of 3.94
The
been
in the
data
presented in the TABLE 3.1.
14
“’S’®?’"fV':-yr-'•1
15th
are
(
-J
3.1.2 Emergence of P. Falciparum
(
While the state average API
t
st:*/
has not fluctuated to a
occurred in the type of
gr.e^t extent, a significant change
- \
. Falciparum species of malaria
malaria with emergence of P
<
over
a
During
of
these
years,
accounted
years
ten
last
period
starting
f or
malaria
t
malaria cases in the state.
accounted for as many as
*
1984
P.
or
1993 .
Falciparum
all
more
cases
of
i . e.
1994 ,
it has
This year,
percent of total
38
to
cases.
The
Falciparum malaria has great public health
emergence
of
relevance.
Firstly,
associated
with
secondly,
1984
from
percent
20
(
between
causes
it
high
case
fatality
which
malaria
cerebral
and
malaria
is
deaths;
care
it requires better and an immediate patient
(
and case’management; and thirdly, the falciparum malaria is
(
to usual antimore frequently associated with resistance
*
(
malarial drugs.
it is significant to mention that there has
However,
been
a
malaria
(
(
nearly
four
fold
increase
a
six
fold
in
and
in
of
cases
of
the
state
in
number
P.Falciparum
in
the last decade in
• 1994, from the all time lowest figure of
this
1986 . On the other hand, during the similar period,
fold
1.4
increase has been to the tune of 1.2 and
respectively
at the
national
level.
In
1986,
there were
i
million were
1.79 million cases of malaria out which 0.64
of malaria
P.Falciparum in the country, and in 1993, cases
level wex^L-Qgly 2.27 and
and P. Falciparum at the national
-^\th Associe£o^;
0.87 million, respectively.
VHAI LIBRARY
o
o o u u u
IJ
■
1*
'>
(
w/
(
</
J
V/
VJ
\J
TABLE 3.1
INCIDENCE OF MALARIA IN RAJASTHAN FROM 1977 TO 1994
YEAR
POPULATION
ESTIMATED*
30064015
1977
30883543
1978
31192347
1979
31594377
1980
32491968
1981
32912715
1982
33582802
1983
34164217
1984
34680856
1985
34680856
1986
34680856
1987
35377565
1988
35377565
198936375875
1990
43880640
1991
43880640
1992
44005990
1993
44005990
1994
(Upto 10.12.94)
Source
:
BLOOD SLIDES
COLLECTED
MALARIA
CASES
3318047
3140166
3515605
4200295
3991672
3264810
3161398
2901731
3029792
2941659
3219417
3494559
3074207
3567539
3178381
3833881
3644944
4296155
231834
146295
83394
96118
100694
75320
115177
- 101993
66730
54618
65523
104109
112316
114688
77577
121499
107797
208872
P. F.
CASES
13660
5668
4803
15071
14752
12 3 9 6
36395
20784
12812
14 006
14086
29467
24228
32887
16098
41727
26719
78483
Directorate of Medical & Health Services,
16
%PF “
API
SPR
SER
DEATHS
5.9
3.9
5.7
15.7
14.6
17 . 1
31.6
20.3
19.2
25.6
21.5
28.3
21.5
28.6
20.7
34.3
24.8
38.0
7.7
4 .7
2.6
3.0
3. 1
2.2
3 . 4
2. 0
1.9
1. 6
1.9
1.8
3.1
3.2
1.8
2.8
2.5
4 .7
6 0
4 6
2 3
2 0
2 5
2 3
2 6
3 5
2 2
1 9
2 0
2 0
3 7
3 2
2 4
3 3
3 0
4.9
0.4
0.2
0.1
0.4
0.4
0.3
1.2
0.7
0.4
0.5
0.4
0.3
0.8
0.9
0.9
1.1
0.7
1.8
0
0
0
0
0
0
0
0
4
2
0
2
1
50
10
55
19
395
Rajasthan
KJ
*
/
(
(
(
3.2
DISTRICT LEVEL
(
(
Malaria has a typical epidemiological behaviour that
(
its distribution is focal
it is a localised disease and
depending upon geo-environmental conditions, socio-economic
characteristics and cultural practices and human behaviour.
Thus,
level average may not truly reflect the
state
the
the
of
therefore,
undertaken using
the
of
records
health
the
The
I) •
respective
zones
at
various
levels
have
been
grouped
in
districts
to
Kota,
Ajmer,
Bikaner,
Jodhpur,
namely z
the
from
department
-i
(Annexure
available
data
was,
analysis
district-wise
A
problem.
magnitude
s \ ;
Jaipur and Udaipur. The district-wise trends in API during
<
1984 have been
the period of past ten years starting from
*
presented in graphic form for each zone.
i
3.2.1 DISTRICTS IN JODHPUR ZONE
This zone includes Jodhpur,
Sirohi
and
Barmer
rising in 1987
The
districts.
in Jalore,
Sirohi and
in 1988
1). Jalore recorded peak API
Sirohi
in
1988
(8.0)
and
1989
initially
API
Pali,
Jalore,
Jaisalmer,
started
Pali districts
(7.9)
(13.5)
(Fig
and 1990 (7.7),
Pali
in
1990
recorded
a
high
and
(10.5).
the
districts
incidence
of
malaria
affected
district
All
in
in
(API
this
1990,
17.3).
zone
with
The
Barmer
the
worst
API
in
Barmer
next three years till 1993
consistently declined over the
17
L
i "• -/ I'i ) '<>
•>
r
the increased malaria incidence remained unnoticed, the API
i
‘tr
1994 .
(15.6) has increased significantly in the year
two districts,
in the other
The API
namely Tonk and
Nagaur, has remained low.
-i*-
DISTRICTS IN KOTA ZONE
3.2.4
The Kota zones includes Kota,
<
Bundi,
Jhalawar
Baran,
districts. No significant trends in API
and Sawaimadhopur
The API in all the
in these districts have been observed.
districts has consistently remained below 5.0 (Fig 4).
DISTRICTS IN JAIPUR ZONE
3.2.5
includes
The
Jaipur
zone
Dholpur,
Jaipur,
Jhunjhunu
*
and
Bharatpur,
Alwar,
Sikar districts.
a
(
in this
districts
zone have recorded
(
since 1986
(
(Fig 5).
However,
a
low
Dausa,
All
the
level of API
there was a gradual rise in
Bharatpur district, starting from the year 1989 with a peak
4
(
*
light decline in 1994 (API
in 1992 (API 8.4) followed by a s
5.4) .
4
3.2.6
DISTRICTS IN UDAIPUR ZONE
Udaipur
The
(
.‘0
(
includes
Banswara,
Dungarpur ,
districts,
Among these
Rajsamand and Udaipur districts.
which is a tribal
the Dungarpur district,
district,
API with peaks
has shown a turbulent
Chittorgarh,
3
zone
in
1985
(8.6), 1987 (10.5), 1988 (11.8) and 1993 (8.7), the highest
(
(
being in 1988. Banswara,
initial
high
API
during
the other tribal district, showed
1986-88
19
■2
■5
0\
(7.6-4.6),
followed
by
f
( '
(
relatively lower API in the yes.rs following this period. In
t
{
(
continues
malaria.
the Udaipur district,
be
to
a
problem
over past ten years with a hiqih API during the period 1986
(
IS 92
then
and
(8.0-6.7)
89
*
(•3.9)
and
1993
(6.2) .
(12.6)
and 1989
(11.1),
Chittorgarh, with high API in
1988
maintained a lower API levels
m the other years (Fig 6).
P. FALCIPARUM IN THE DISTRICTS
3.2.7
•i
Falciparum
F .
of
proportion
The
has
cases
significantly increased ir. several districts over past few
years. A review of district le -el malaria cases during past
•1
/
five years,
infection consistently
case's
i
<
revealed that P. Falciparum
from 1990 to 1^94,
for
ascour led
in many districts
1 east
at
i
districts
These
(
Jodhpur,
Jalore,
(
Bundi, Kota, Baran, Jhala-ar,
Udaipur,
for
Dungarpur,
percent
or
more
years
in
this
3-4
Jaisalmer ,
are :
period.
25
Barmer,
Banswara,
Pali,
Sirohi,
Tonk, Bharatpur and Dholpur.
As noted earlier, this emerging situation calls for special
*
malaria control measures.
u.
3.3
ENTOMOLOGICAL PROFIT-
The group
A
the
(
area
from
collected entomological
the
studies
reports
Malaria Research Centre(_CMR)
Research Centre,
information about
conducted
New Delhi,
by
the
Desert Medicine
Jodhpur, Reg Tonal Office of the Ministry
of Health & FW, Govt.
of India,
Section of the Directora.e c_
Rajasthan, Jaipur.
2. D
Jaipur and the Entomology
Medical
& Health Services,
/<
(
3.3.1 Prevalent Vectors and Vector Density
(
<
of
species
prevalent
The
Mosquitoes
Anopheline
(vector) responsible for malaria transmission in Rajasthan
are
for selected
A.Fluviatlis. The vector profile since 1990,
districts,
has been given in TABLE 3.1
.
Annularis
A.
and
Stephensi
Culicifacies,
A.
As evident,
the
data are not available for all the districts and also for
individual vector species. However, it may be observed from
the
table
that
the
vector
density
was
districts and particularly in the year 1993 ,
'W
certain
the density
was higher than previous years.
Vector Susceptibility
3.3.2
The
(
(
Group
reviewed
has
the
information
The available
susceptibility of the vector of Malaria.
data
on
susceptibility
given
are
in
on
TABLE
3.2.
The
mortality of mosquitoes has been given as percentage. These
*
districts
studies were conducted in various
i
-A
in
high
years
in the
past.
The
susceptibility
in different
of mosquito to
found to be low.
various insecticides except Malathion was
in A.
The resistance against the insecticides was higher
Culicifacies as compared to A. Stephensi.
21
•)
8
- 0 -
Si ‘
/
J - ‘ (J ' L
J i
(J
J.
c
J
’C
TABLE 3.1
Average Per Man Hour Density of Malaria Vectors in Selected Districts in Rajasthan
1990-1993
District
AC
Udaipur
Bikaner
Jodhpur
Jaipur
Kota
Bharatpur
Ajmer
Bundi
Chittorgarh
Dungarpur
Banswara
Jhunjhunu
Sikar
Jalore
Ganganagar
AC
AS
AF
2.1
0.4
3.5
2.0
0.4
"1990
AF
• AS
4.4
0.8
5.1
1.5
0.5
AC
3.5
0.5
0.6
1.4
0.2
1.7
0.3
2.5
2.9
1.1
2.0
0.9
0.2
3.7
0.8
1991
AF
AS
AC
2.8
0.8
0.8
1.4
0.5
2.1
3.1
0.9
1.5
0.8
1.9
0.7
2.4
2.8
1.0
1.2
1. 1
1.5
1.1
AC
1993
AF
AS
6.5
1.7
4.1
4.0
5.6
5.0
0.7
3.0
3.0
1.9
3.1
2.0
0.8
3.8
2.2
Anopheles Culicifacies
Anopheles Stephensi
Anopheles Fluviatlis
Source : Malaria Research Centre
1992
AF
AS
(ICMR), Delhi
22
r
TABLE 3.2
Susceptibility (Resistance) of Anopheline Culicifacies and
Stephensi Mosquitoes to Insecticides in Selected Districts
in Rajasthan
'V
Anopheline Species
Culicifacies Stephensi
District
Insecticide
Bikaner
DDT 4%
19.3%
NA
Ganganagar
DDT 4%
DLN 04%
6.6%
5.0%
NA
NA
Jodhpur
DDT 4%
DLN 0.4%
10.0%
25.0%
40.0%
35.0%
Barmer
DDT 4%
4 0.0%
32.0%
Alwar
DDT 4%
DLN 0.4%
Malathion 5%
10.0%
11.0%
100.0%
Jaipur
DDT 4%
DLN 0.4%
Malathion 5%
2.5%
7.5%
100.0%
A
25.0%
50.0%
75.0%
A
•<
(
Source : Malaria Research Centre (ICMR),
Delhi
(
r
3.4
■A
DRUG RESIST/kNCE
*
(
The
resistance
information
collected
Group
also
to
chloroquine
by
the
malarial
on
drug
parasite.
A
review of studies has been presented in TABLE 3.3. Most of
these studies have been conducted to evaluate resistance to
-A
i
-A
i
chloroquine by P. Falciparum.
In
10
different
out
years,
of
19
the
PHC
areas
malaria
in
various
parasite
districts
showed
RIII
in
level
resistance. The overall RIII resistance was 10.1 percent in
23
■
3
0
r)
(
i
<
t
v
the state. These studies also showed 11.9 percent RII level
Furthermore,
the RI resistance
However,
was to the level of 48 percent.
it may noted that
resistance to chloroquine.
only RIH level
for declaring resistance,
is taken in to
account.
WHO report,
According to a
P.
the malarial
Falciparum species of
in many parts of
found
chloroquine resistance by
parasite
including
India,
some
been
has
parts
of
(Annexure II).
Rajasthan. The same has been in the map
carefully
number
of
results
the
However,
these
of
the
results
interpreted
as
samples.
But
these
and
the
4
(
resistance
does
exist
this
fact
in
take
stra'tegy;
and
to
when
7
predominates.
I
(
3
24
are
studies
should
for
P.
be
on
small
reflect
that
based
programme managers
account
especially
studies
should
planning
programme
Falciparum
infection
G U
<U 0 U V
£
■>
€ €
O C <
'j.
'>
TABLE 3.3
Results of Sensitivity of P.Falciparum to Chloroquine in Selected Districts in Rajasthan
District
PHC
Year
No.
Tested
No.
'S'
No.
S/RI
RI
RII
RIII %RIII
Banswara
Kushalgarh
1982
1988
1993
2
14
13
1
1
0
14
11
0
6
0
0
1
2
0
2
0
0
14.3
0
TaIwara
1986
1937
1989
6
17
13
1
9
5
3
0
3
1
6
3
1
0
0
0
2
2
0
11.8
15.4
Barmer
Baitu
1990
1992
1994
59
33
12
11
0
0
4
29
8
38
1
0
2
2
4
4
1
0
6.8
3.0
0
Bharatpur
Roopbas
1980
1984
30
33
0
32
30
0
0
1
0
0
0
0
0
0
Kolayat
1992
20
5
10
5
0
0
0
Bikaner
Bundi
Minduli
Kapren
Tilwara
1990
1992
1990
8
36
3
0
14
0
4
4
1
3
12
1
1
0
1
0
6
0
0
16.7
0
1989
9
2
0
1
0
0
Dungla
6
Chittorgarh
Dungarpur
Bichhiwara
1987
1989
1993
18
15
35
2
5
0
0
1
26
13
6
1
1
1
4
2
2
4
11.1
13.3
11.4
Danmod
1988
1993
14
14
1
0
0
8
10
0
2
5
1
1
7.1
7.1
25
x b
l>
d J
G
1 b
i I
. L
L
>
2
<>
(1
h
J.
J, ■ LX
Contd table 3.3..
PHC
Year
No.
Tested
No.
'S'
No.
S/RI
RI
RII
RIII % RIII
District
Jaisalmer
Pokhran
1992
1994
20
12
9
0
2
12
9
0
0
0
0
0
0
0
Ahore
1993
35
6
7
18
4
0
0
Jalore
Salwas
1991
11
0
0
5
2
4
36.4
Jodhpur
Kota
Modak
1988
1989
1993
13
5
31
3
0
0
1
5
25
6
0
0
3
0
2
0
0
4
0
0
12.9
Swarupganj
1991
13
3
1
6
3
0
0
Siroh i
Udaipur
Dhariwad
Rishabdeo
10
8
5
4
3
3
8
1
0
2
3
0
2
2
0
0
6.9
11.8
0
0
Bijoliya
17
29
27
12
2
14
11
7
Bhilwara
1990
•1987
1991
1994
National Malaria Eradication Programme, Delhi
Source: Directorate of
S = Sensitive
R = Resistant
26
(
CHAPTER 4
(
CURRENT SITUATION
(
>• /
(
4.1 STATE LEVEL
4.1.1 Morbidity
During
the
year
1994 ,
malaria
assumed
an
alarming
clearly in excess
situation. The total number of cases were
the previous years. As on 10th
this year as compared to
of malaria have
December z 1994 , a total of 2,08,872 cases
and passive surveillance,
been detected through active
reported in 1993 during the
almost twice the number
P.
the
significantly,
More
period.
corresponding
than three times,
Falciparum malaria cases increased more
during the
recording an absolute increase of 48,799 cases
are
malaria cases in Rajasthan
same period. The data on
4
(
A
given below in the TABLE 4.1
•
TABLE 4.1
„ . over
—
1993 in the
Increase in Malaria Cases in 1994
Incremental Factor in
Corresponding Period and the "----Rajasthan
*
A
A
Cases
A
1993
1994
Increase
in cases
Incremen
tal Factor
4
A
A
99,041 2,08,872
1,09,831
2.11
76,448 1,30,389
53,941
1.71
P. Vivax
22,593
78,483
55,890
3.47
P.Falciparum
Tota 1
Malaria
Cases
(
Health Services,
Source: Directorate of Medical &
Rajasthan
27
■3
f
2
The district-wise cases of malaria are shown in TABLE
(
4.2. The disease in 1994 was more localised in the western
<
districts namely,
Barmer,
the Jodhpur zone ;
and
Jaisalmer, Jodhpur and Pali in
Ajmer and
Bhilwara districts of
Ajmer zone. These districts accounted for about 52 percent
0
of all malaria cases in the state during the current year.
Further, these districts accounted for about 65 percent of
all P.Falciparum malaria cases in the state. The districts
0
whic^ showed a substantial increase in malaria, at least by
percent over the past year, are shown in the TABLE 4.3.
50
3
J
■5
1
-4
(
4
’’O'
28
-J)
(
(
0
0
,
TABLE 4.2
District-wise Population, Blood Slides, Malaria Cases API,
SPR and SFR in Rajasthan (As on December 10, 1994)
(
District
<
Population Blood Malaria
slides Cases
•
< K
(
<
J
(
i>
(
4
(
(
4
(
4
<
(
4
4
Alwar
2296580
Bharatpur 1651584
1010883
Dausa
749479
Dholpur
3871445
Jaipur
Jhunjhunu 1582421
Sikar
1842514
Bikaner
1211140
Ganganagar2 62 2777
1543211
Churu
1435222
Barmer
Jaisalmer 344517
1142563
Jalore
2153483
Jodhpur
1486432
Pali
654029
Sirohi
1155600
Banswara
1484190
Chittor
Dungarpur 874549
Raj samand 957557
2093544
Udaipur
770243
Bundi
810326
Baran
956971
Jhalawar
S.Madhopurl803471
1220505
Kota
1729207
Ajmer
1593128
Bhilwara
2144810
Nagaur
975004
Tonk
196441
154851
79349
71077
246336
122694
177851
46187
164938
89581
339615
81963
156171
222697
195116
67113
137504
128377
91680
90158
200869
66780
111522
103160
130119
117670
179195
238795
199903
88443
1966
8989
288
663
4068
3100
648
1309
4889
5457
3494 1
18129
5364
11961
12264
3928
2863
5002
7127
2693
13034
2838
3523
1427
2275
4813
11084
24916
5000
4313
44005990
4296155
208872
PF
SPR SFR
0.9 10.0 0.3
396
5.8 0.8
5.4
1227
0.4 0.1
0.3
68
0.9 0.3
0.8
237
1.6 0.5
1.0
1482
1.9 2.5 0.7
843
0.4 0.2
0.4
457
2.8 0.4
1.0
175
2.9 0.2
3.9
338
6.1 1.4
3.5
1249
17172 24.3 10.6 5.2
12261 52.6 22.114.9
4 .7 33.4 1.7
2646
8. 3 4 . 2
7282 11.7
6.3 1.8
8.2
3592
5.8 1. 1
6.0
767
2 . 1 1. 1
2.2
1429
3.9 0.8
170 10.3
7.8 4.0
8
.
1
3714
2.9 0.4
3
.
3
449
6.5 1.9
6.2
3944
4.2 1.4
3.7
963
3 . 1 1.6
4.3
1843
1.3 0.5
1.4
581
1.7 0.3
1.3
354
4 . 1 1.4
3.9
1674
6.2 1.6
6.4
2972
6334 15.6 10.4 2.6
2.5 0.6
2.3
1291
4^. 8 1.8
4 .4
1633
•4
Total
API
78483
4.7 4.9 1.8
4
Source
: Directorate of Medical'1& Health Services,
Epidemiological Report (10.12.94).
29
5 I
4
Weekly
TABLE 4.3
Districts Reported At least 50.0 Percent• -Increase in Total Malaria Cases in 1994 Over the Cases
in the Corresponding
period (10th December)
Reported in the year 1993 i_~
-
Falciparum Cases
Total Malaria Cases
DISTRICT
Absolute Incremental
increase Factor
1993
1994
6
6
4 2
3 6
1.8
791
1467
743
432
866
17172
12261
7282
2646
3592
16381
10794
6534
2214
2726
21.7
8.4
9.7
6.1
4.2
3877
3 5
49
1249
1200
25.5
4068
3100
648
3580
2361
578
3
2
2
58
51
5
1482
843
457
1424
792
452
25.6
16.5
91.4
4217
Ajmer
Bhilwara 10183
1401
Nagaur
2366
Tonk
11084
24916
5000
4313
6867
14733
3599
1947
6
5
3 6
1.8
397
1852
77
294
2972
6334
1291
1633
2575
4482
1214
1339
7.5
3.4
16.8
5.6
1697
2967
3523
4813
1826
1846
2.1
1.6
578
1047
1843
1674
1265
627
3.2
1.6
2693
1082
1.7
215
449
234
2.1
Rajsamand 1611
1993
1994
Absolute Incremental
increase Factor
Barmer
Jaisalmer
Jodhpur
Jalore
Pali
5354
2875
2849
1469
6652
34941
18129
11961
5364
12264
29587
15254
9112
3895
5612
Churu
1580
5457
Jaipur
Jhunjhunu
Sikar
488
739
70
Baran
Kota
Source:
' * of Medical & Health Services, Weekly
Directorate
Epld^FoLgical Report (10.X2.94) and
corresponding report of 1993.
30
(
increasing and the
The P. Falciparum infection is now
districts with proportion of p.Falciparum in 1994 , have
been shown in the TABLE 4.4. It is clearly obvious that the
P.
u)
Falciparum accounted for more than 40 percent malaria
cases in Barmer, Jaisalmer, Jodhpur and Jalore districts in
western Rajasthan; Dungarpur and Banswara in tribal area;
and Kota and Baran in the Kota division.
TABLE 4.4
Districts with Falciparum Infection As Percent to Total
Cases of Malaria in 1994
Name of Districts
Number
of Districts
Percent
Falciparum
Less than 20
6
Bharatpur, Bikaner, Ganganagar,
Sirohi, Sawaimadhopur,Rajsamand
20
30
10
Alwar, Dausa, Jhunjhunu, Churu,
Pali, Chittorgarh, Udaipur, Ajmer,
Bhilwara, Nagaur
31
40
5
Dholpur, Bundi, Jhalawar, Tonk
Jaipur
41
50
4
Banswara, Baran, Kota, Jalore
5
Jaisalmer,
Jodhpur,
Barmer, Sikar
i
(
A
A
a
51 +
Dungarpur,
A
A
4.1.2
Mortality
a
As
of
31st
December,
1994 ,
452
deaths
have
been
reported due to malaria. Almost all the malaria deaths have
occurred
due
percent
of
to
all
P.
infection.
Falciparum
deaths
occurred
Jodhpur and Bikaner districts,
in
where
Barmer,
Seventy
two
JaisaImer,
as these districts
accounted for about 40 percent of all malaria cases in the
TH
•A
■
31
(
(
The highest number
of deaths,
<
state.
(
occurred in Barmer district,
(
<
12.4 percent)
in
percent)
Jalore,
Baran,
percent)
and Jaisalmer
(56,
The deaths were also reported
in that order
Bhilwara,
(23.9
followed by Bikaner (94, 20.8
15.3
(69,
Jodhpur
percent),
108
Pali,
Sikar
in
depth
Churu
and
districts.
4.2
DISTRICT LEVEL
Expert
The
malaria
Group
situation
Jaisalmer,
in
mainly
did
1994
in
Bharatpur,
Barmer,
six
of
analysis
districts
namely;
and
Gangangar
Jaipur,
Dung.arpur districts.
4.2.1 JAISALMER
4
JaisaImer
was
the
worst
<
Annual Parasite Incidence
A total
1994 .
i
4
16,767
(API)
positive
affected
district
with
an
48.7 as on 3rd December,
cases have reported
with
An excess of
10899 (57.8 percent) p. Falciparum infection.
P. Falciparum cases have
13,899 of total cases and 9,477
1993 .
been reported as compared to the year
The trends in API in the three
Panchayat Samiti areas,
Pokaran, Nachna and Sangarh, have been shown graphically
Fig 7.
in
It is obvious that within the Jaisalmer district,
an API as high as
Pokaran area was the worst affected with
11.3) Panchayat
Nachna (API 25.7) and Sangarh (API
84.3.
incidence but was relatively
Samities also showed a high
All the Panchayat Samities have
much lower than Pokaran.
since 1990 and Pokaran has
shown a rising trend in API
32
j
(
shown a steep rise over last one year.
(
(
In Pokaran,
(
65.4
<
0
(
percent
10,785 cases have been reported, of which
were
The
Falciparum.
P.
all Falciparum cases in the entire Jaisalmer district.
of
distribution
The
(
Block
accounted for 64.3 percent of all cases and 60 percent of
(
(
Pokaran
malaria
was
localised
and
focal within the Pokaran block with pockets of high API.
The API was very high,
over 50,
in 17 sections out of 40
(
The most severely affected
(
sections in the Pokaran area .
(
sections were: Pokaran, Bhaniyana, Lava, Ujla, Madwa, Balad
and Ramdevra.
P.
Falciparum infection predominated in all
the sections.
*
<
(
Age and sex distribution of all the reported cases in
(
the district showed that predominantly the males were more
(
(
affected as compared to females.
cases
among
occurred
males
and
About 60 percent of the
remaining
40
percent
in
females. About 11 percent of all cases were children below
A
five years age,
33 percent were children in 5-15 year age
and 56 percent of the affected persons were above 15 years
age.
The
proportion
P.
and
Falciparum
followed
infection
similar
similar
occurred
in
as
that
pattern
of
all
areas
of
malaria cases.
Similar pattern was
observed
Jaisalmer district.
33
3
in the urban
(
(
(
c
In Jaisalmer,
among children
occurred
percent of deaths
14
so
been reported till
have
deaths
56
far.
About
(
below
5
(
remaining 26 percent over 35 years. About 55 percent deaths
(
in
percent
59
45
and
women
among
have occurred
(
age,
years
age
years
5-35
and
Among the
among males.
males, 28 percent deaths occurred in children below 5 years
V
I
and 48 percent above 35 years. Where as among the females,
67
J
<
percent
occurred
deaths
reproductive
early
in
period
between 15-30 year age.
i
During the first week of December,
the
Expert
visited
Group
area,
the
1994 during which
the
severity
of
the
outbreak, appeared to have reduced as evident from drastic
of
number
in
admissions
due
to
malaria.
The
bed
district
hospital
Jaisalmer
was
reduced
<
(
<
of
number
and
deaths
reduction
hospital
occupancy
almost
in
the
to
50
percent as compared to flooding of the hospital during the
94 .
peak period of the outbreak in September-November,
of
transmission
still
malaria
Nevertheless,
the
disease
was
persisted
still
and
continuing
the
as
observed during the visit of the hospital and in the field.
are as under:
Some salient observations made by the group
1. The blood slide positivity rate in the hospital OPD
1994 ,
cases was still very high. On the 3rd December,
39
slides
which
26
were
collected
from
the OPD patients.
(66.7
percent)
were
positive
parasite.
0
34
3
for
of
malaria
I
v
2 . Ninety two percent of the positive slides showed
the presence of P. Falciparum malaria parasite.
3. About 50 percent of the patients attending the OPD,
I
(
(
had already suffered 2-3 episodes of malaria in the
last two months and were given standard Fever Radical
Treatment (FRT) that included 600 mg Chloroquine and
(
<
(
v
v>
(
(
(
(
*
45
mg
that
Presuming
Primaquine.
the
had
patients
taken full FRT, in all likelihood, these patients had
re-infection.
The
drug
partial
of
possibility
resistance could not be ruled out.
4 . A quick survey in the OPD, revealed that about 30
contacted the private
patients had
percent of
practitioners prior to coming to the hospital.
A
(
• A
5.
About
70-80
Of
percent
the
adult
hospitalised
A
patients, OPD cases and patients examined in the field
■A
had enlarged spleen. About 30 percent of the children
(
A
had enlarged spleen. This signifies that the malaria
has taken a persisting endemicity. The enlargement of
among
spleen
A
I
also
children
signifies
fresh
and
continuing transmission.
6.
symptomatology
The
cases
appeared
to
and
have
presentation
changed,
of
malaria
especially
the
Falciparum malaria. Very often the patients would not
report with typical fever and chills,
abdomen,
gastritis,
but with pain
vomiting and headache only.
The
35
- A
I
)
An
slide examination would reveal positive results.
malaria cases in the
analysis of symptoms of positive
had upper
hospital showed that 46 percent of cases
X
r
• abdominal symptoms
which include nausea, vomiting and
■>
pain abdomen,
prominent
<
22 percent reported with diarrhoea as
percent
23
complaint,
symptoms and only 9 percent
with
respiratory
with cerebral symptoms.
(
&
(
increased tendency for abortions and
7 . There was an
obstetric wards.
pre-term delivery as observed in the
(
(
However, it requires further
(
studies and confirmation.
some women in
Puerperal psychosis was also seen in
Its
recently delivered.
who had
area,
Pokaran
be confirmed.
relationship with malaria needs to
-4
A
4.2.2 BARMER
A
(
Barmer
positive
district
malaria
has
cases
state, a total of 34,941
reported
during
the
the
highest
current
year
number
in
the
malaria cases have been reported
with P. Falciparum
so far with 17,122 (49.1 percent) cases
have shown a 6 times
infection. The number of malaria cases
increase over the past year
and P. falciparum 20 times
The API was as high as
during the corresponding period.
has earlier
to Jaisalmer. Barmer
24.3 in 1994, next only
that time the P. Vivax
reported an outbreak in 1990 but at
has reported
infection predominated. In contrast, Jaisalmer
(API 52.6) for the first time
of
this
magnitude
an outbreak
predominated.
in 1994 where p. Falciparum has
*
36
i
)
■
The most affected area is Baitu Panchayat Samiti, with
<•
9306
f
cases with
of
percent
'r
in
falciparum
cases
malaria
all
the
Baitu
62.0.
of
API
an
The
district.
accounted
for
29
percent
of
P.
27
and
other
i
areas were Ramsar
(API 21.0),
Gunga
affected
severely
32)
and Chohtan
namely,
Gudamalani,
(API
i
<
(API 19). The API in other PHC areas,
Mandii,
(
(
Sindhari and Samdari was also above 12.0
(Fig 8).
The trends in API in all the Panchayat Samiti areas showed
maintained
continuously
endemicity
high
(
that
(
level with an API over 10 since 1990. This year again, API
(
in Baitu Panchayat Samiti
(
Panchayat Samiti has shown a continuous but a gradual rise
Baitu
has
has
shown a
Gunga
steep rise.
i
in API over this period.
i
even more in some PHCs,
Almost half the cases,
were
(
P.Falciparum
positive
except
cases
Samdari
Sindhdri
and
PHCs where the proportion of P. Falciparum was about 30-35
<
percent only.
4
i
The age and sex distribution of cases was similar to
that observed
in Jaisalmer district approximately.
Sixty
percent of the cases were males and 40 percent of the cases
were females. The children below the age 5 years accounted
for about 11 percent of cases, and children in school going
age
were
33
percent
of
cases.
all
cases occurred in age group above
specific
distribution
of
P.
Remaining
15 years.
Falciparum
56
percent
There was no
which
generally
followed the distribution as ’that of P. Vivax infection.
37
(
A total 108 deaths attributed to malaria have occurred
f
<
in the district.
About
5
years
children below
percent
14
age and
deceased
the
of
are
31 percent above 35 year
(
predilection, The ratio of
age. There was no apparent sex
<
<
deaths among males and females was almost similar. However,
i
males.
than the
more female deaths occurred in younger age groups
(
<
(
4.2.3 BHARATPUR
(
Bharatpur district reported 8989 malaria cases
(
Falciparum
were P.
(13.6 percent)
out which 1227
with an
(
API '5.4,
(
cases.
(
high API, while Sewar and Kumher
(API 10.1) have reported a
The other
respectively.
6.4
2.8 and
reported API
3
(API 22.9)
Deeg
Out of nine PHC areas,
and Roopwas
(Fig 9A &
less than 2.0
remaining five PHCs reported API
9B) .
-a
(
(
Deeg and Roopwas, and to some
extent Kumher, have been
with
reporting consistently high API since last three years
peak incidence in 1992.
4*^
4.2..4 JAIPUR
In Jaipur,
(36.4
percent)
4068 cases
were
P.
of malaria,
Falciparum
although API was as low as 1.0,
P.
Falciparum
was
very
high
increase over the year 1993 .
6.4)
out of which 1482
cases.
As
evident,
however the proportion of
and
there
was
Out of 13 PHCs,
a
25
time
Bichoon (API
and Kotkhawda (API 3.5)' reported highest incidence in
-2)
the district.
PHCs reported API
Remaining all other
38
less
(
(
(
(
>1)
than 2.0. It is worth mentioning that the increase in cases
(
(
in
f
Kotkhawda PHCs, also increased only this year indicating a
Jaipur
was
about
8
times.
The
Bichoon
in
API
and
(
focal outbreak in these areas (Fig 10A & 10B).
i
(
(
4.2.5
GANGANAGAR
(
(
(
J
(
(
(
■4
4889 malaria cases (API 3.9)
In Ganganagar district,
(
were
reported
during
the
current
year.
The
number
P.
Falciparum cases (338, 6.9 percent), though was very small
as compared to other districts. Out of ten PHCs, all except
one,
reported API
less
than
2.0.
The
PHC
Sangaria
has
reported the highest incidence (API 9.0). A review of API
for last four years, revealed that only this PHC has shown
an abrupt
(
(
(
increase
in
the
incidence
indicating a
focal
with
consistently
high
outbreak (Fig 11A & 11B) .
4.2.6 DUNGARPUR
Dungarpur
is
a
district
endemicity for past several years. The district reported
5
7127 malaria cases (API 8.1) during the current year. The
P. Falciparum cases accounted for 52.1 percent cases. Among
five PHCs,
Bichhiwara (API 12.5),
Punjpur
(API 11.1)
and
Simalwara (API 7.3) reported high incidence of malaria. The
same PHCs continued to show high API in previous years. The
(
•5
i
•
other PHCs, though showed a lower API as compared to above
PHCs, but higher API than 2.0 (Fig 12).
J)
0
39
t
! (
%
(
4.3
transmission and outbreak of
MALARIA
in
JAISALMER ANk
% ’?
BARMER DISTRICTS
(
Both the desert districts have experienced an outbreak
(
(
of
(
district.
(
in
malaria
1990
which
Since then
was
a new
more
pronounced
in
Barmer
level of high endemicity has
1991 when the API was very
established
except
the
year
been
district the
In the Jaisalmer
Jaisalmer
district
.
low in
in 1992 and continued
number of cases started building up
Barmer
steep rise in 1994.
finally
recorded
a
in 1993 and
this period except in
high API level over
a
maintaining
was
level.
had declined to relatively lower
when
the
API
1993
r
(
(
(
(
(
Weekly
(
reports
of
cases
malaria
have
been
transmission
changing levels of
establish
rhe
considered to
malaria cases
The number of
year
.
current
during the
current year are presented
during
the
week
reported per
5
(
14 .
graphically in Figs 13 &
of malaria was observed
level of transmiss ion
districts.
1994 in both the
week
of
July
last
until the
started rising as
number of malaria cases
the
Ther'eafter,
Rajasthan.
malaria season in
usual
the
in
it happens
started consequent to excessive and
activity
Intense vector
a sudden
districts resulting in
rains
in
these
spread over
1994 . The
week of september
first
in
the
spurt in cases
district and then in
spurt was first observed in the Barmer
and the number
rise was steeper
the Jaisalmer district. The
compared to
in Barmer district as
also
higher
of cases was
transmission was
The high level of
district
.
Jaisalmer
the P. Vivax
of time. Initially,
sustained for long period
A low
i
□
of
40
(
<
the
predominated
malaria
(
(
transmission,
later
the
in
1994 .
P.
Vivax.
The
November,
of
half
prolonged
With
outbreaks.
(
falciparum took over and predominated over P.
(
peak of the outbreak occurred between 41st to 44th week of
(
<
the year.
(
(
(
4.4
is mainly the A . Culicifacies
In these two districts it
<
(
ENTOMOLOGICAL PROFILE
(
(
(
(
prevalent in the area.
and A.Stephensi which are
is
found
species
which
A.Subpictus
Another ’
no
or
1ittle
has
epidemiological relevance. A. Stephensi which is primarily
is
has
vector,
urban
an
been
highly
be
to
reported
(
prevalent in the desert areas.
i
Due to excessive and prolonged rain this year,
there
(
A
(
area and increase
was an intense mosquito breeding in the
main sources of
in the vector density. There were Four
ground tanks,
of spilled water around drinking water over
and household tankas. The
large water tanks for cattle
A
water
has
collected
there
was
.an
(
i!
y|
in
the
mosquito
and
tankas
have
tankas.
breeding.
on the
villages
full
Mostly it
were
found
with Anopheline
provided
'!•
breeding.
mosquito
an
to
be
larvae.
opportunity
and
The
larva
of
banks
of
these
the house hold
Besides these water bodies,
water bodies.
tankas
large
in abundance
bodies
water
constituting
intense
Anopheline were seen
swarming
with
fact
these
house
hold
In
for
which breed in these
a s A.. Stephensi
has been established
A micro climate within home
41
A
collection
large surface water collection,
viz ;
breeding,
<
mosquito breeding and
and providing a continuous source for
(
transmission of malaria. The other sources of breeding were
(
(
over ground
spillage
(
(
(
(
<
(
<
community
and
collection
of
Rajasthan till October 1994,
water
have been shown in TABLE 4.5.
TABLE 4.5
f
Per Man Hour Density
1994
t
District
(
(
The
occurs.
as found during the
provide a breeding place for mosquitoes
sources for mosquito
visit. As a result of increased
has
areas
these
in
density
mosquito
the
breeding,
some selected
significantly increased. Mosquito density for
entomological zones of
as reported by the
districts,
(
A
water
around which
reservoirs constructed for drinking water for animals, also
(
(
tanks
drinking water
of
Malaria Vectors
in Rajasthan
in
Per Man Hour Density of Malaria Vectors
Stephensi A. Annularis
A. Cuiicifacies A.
Jaisalmer
Barmer
Jodhpur
Bikaner
Ajmer
Jaipur
Udaipur
Kota
Pali
Bundi
Alwar
Source: Malaria
7.4
6.1
11.7
6.0
2.7
15.2
8.3
2.5
0.5
2.1
9.5
4 .5
4 .0
4.5
0.5
3.3
3.0
5.2
0.0
1.5
0.5
0.3
0.0
4.5
0.0
0.0
0.3
Research Centre (ICMR), Delhi.
in November 1994
A recent entomological investigation
area in
Pokaran Panchayat Samiti
in three villages of
Research
conducted by the Malaria
Jaisalmer district,
that the indoor and outdoor per
Centre, Delhi, have shown
are
The data of the studyman hour density was high.
summarised in TABLE 4.6.
42
5
(
I
(
TABLE 4.6
Per Man Hour Density of Anopheline Mosquito in Pokaran
(November 1994)
(
i
<
Per Man Hour Density
Indoor
Outdoor
Anophelines
(
(
(
Human
Dwelling
Cattle
sheds
5.3
8.0
1.3
0.3
16.3
16.7
2.3
0.3
(
(
(
(
(
A.
A.
A.
A.
Culicifacies
Subpictus
Stephensi
Annularis
(
(
Source : Malaria Research Centre
(ICMR),
3.0
2.7
2.0
NA
Delhi
(
Vector Susceptibility
J)
*
(
most
village
affected
of
Pokaran
PHC,
Bhaniyana,
the
Jaisalmer,
low susceptibility to
the mosquito has shown a
i
(
■A
in a village
A recent investigation in November 1994
A
insecticides.
The
results
this
of
study
are
summarised
below in TABLE 4.7
TABLE 4.7
<
Vector Susceptibility (Resistance)
to Insecticides
Mosquito Mortality
One Hour
24 Hours
Insecticide
DDT 4%
0.0%
30.0%
Dieldrin 0.4%
0.0%
20.0%
Malathion 0.5%
100.0%
100.0%
Source: Malaria Research Centre (ICMR),
Although
3
the
information
susceptibility
is
been obtained from
avaLiable only for few districts and has
the
that
indicate
do
results
the
samples,
small
43
3
5
on
Delhi
fl '
(
(
susceptibility to the frequently used insecticide DDT is
low.
(
(
(
DRUG RESISTANCE
4.5
►
A review of available data presented in the earlier
(
section of the report and recent studies done in Barmer and
<
Jaisalmer districts during the current outbreak, there was
'i
little evidence to implicate marked degree of resistance of
i
However,
these results are
(
P.
(
base'd on small samples and difficult to interpret. One more
Falciparum to chloroquine.
(
(
i
i
•5
(
(
■4
with
aspect to consider is that these studies were done
1500
mg
while
chloroquine
of
of
presumptive
treatment
Chloroquine.
For brevity,
the
malaria
prescribed
the data of
for
mg
of
600
only
was
dose
recent resistance
studies in October 1994, are presented in Table 4.8
TABLE 4.8
Results of Drug Resistance Study in October 1994
District
PHC
Barmer
Baitu
S/RI
RII
RIII
12
8
6 6.6%
4
33.3%
0
-
12
12
100.0%
0
0
Number cases
taken for test
77
Jaisalmer Pokaran
1
Source: Malaria Research Centre (ICMR), Delhi
(
i
4.6
ENVIRONMENTAL CONDITIONS
This year the monsoon arrived earlier in Rajasthan and
western districts
was marked by a late departure. The
Pali and Bikaner
Barmer, Jodhpur, Jalore, Jaisalmer,
0
44
5
r
(
0 ‘
(
(
received an excessive rainfall this year. The rainfall was
(
(
’0
(
(
*0
heaviest in the Barmer district. A fortnightly analysis of
rainfall in Barnier district showed the rain were excessive
and sustained during the period of 16th July to 15th Sept.
(
(
except
(
Jaisalmer
also
received
excessive
from
June
till
July
during
the
f ortnight
to
16th
August
31st
94 .
continuously
rainfall
(
16th
(
*>■
(
September to
i
Irrigation Department,
31st
then
f rom
1st
the
report
of
of Rajasthan,
1994 r
as
and
According
September.
15th
94
Government
to
(
i
(
many as 16 water tanks in Jaisalmer
damaged/breached
during
excess rainfall.
The excess
monsoon
(Pokaran Tehsil)
season
as
were
result
a
of
(
large
<
and
water
small
rainfall has
bodies.
led to numerous
bodies
water
These
have
become an important source of breeding of mosquitoes.
The
(
•i
relative humidity was not only very high during night and
early morning hours during the months of July to September
■A
94 ,
but
was
also
very
high
in
time
and
evening
implementation
of
malaria
the
day
1
(
hours in these districts.
<
4.7
■a
a
A
MALARIA CONTROL ACTIVITIES
4.7.1 Organisation
i
A
At
the
level,
state
control
programme
Director
(Rural Health),
Director,
Medical
is
&
the
the
responsibility
of
the
Addl
under the direct control of the
Health Services.
At the state
level,
one Joint Director and two Assistant Directors assist in
T9
the implementation of the programme. At the zone level, the
Joint Director (zone) and Dy Director, have been given this
responsibility.
The
state
has
45
5 1
four
entomological
zones,
s ■
i
(
each headed by an assistant entomologist.
r
<
the
At
t
(
Sr AMOs in selected districts
activities in the district.
key
the
are
district,
each
in
AMOs
control
malaria
for
responsible
directly
is
Officers,
(
Health
&
who is assisted by Deputy Chief Medical & Health
Officer,
and
Medical
Chief
the
levelz
district
persons
for
organising malaria control activities.
(
(
(
At peripheral level,
the programme is implemented on
(
(
(
A
r
The medical
horizontal
leve1.
supported
by
programme
implementation.
health
Blood
PHCs,
of
responsible
is
for
s1 ides
collected
by
the
are
examined
by
the
activities
are
sub-centre,
the
at
workers
inspector,
malaria
the
incharge
off icer
laboratory technician at block PHC level.
<
(
A
(
’ In
•M
the
under
undertaken
cities,
-4
urban
areas,
the
control
Malaria
Urban
Scheme
Bharatpur, Jodhpur,
Jaipur,
namely;
malaria
six
major
Bikaner,
Kota
in
and Ajmer. The scheme is implemented in the municipal areas
of these cities.
(
4.7.2 Control Activities
i
The
Control
two
in
major
the
rural
activities
areas
are
undertaken
for
insecticides
Malaria
spray
and
(
surveillance and treatment.
(
4.7. '2.1
Insecticide spray
Two rounds of spray DDT and three rounds of BHC are
I
46
4 '
b-
t
(
■v
(
recommended t the first round during the period of 15th May
(
to 31st July, 94 and the second round during 1st August to
V
(
15th
October
selection
The
DDT.
for
area
of
for
spray
(
(
depends on API levels. The coverage in the 1st round of the
(
spray
was
both
in
inadequate
highly
the
districts
for
various reasons. Only 10.6% of the targeted population was
(
The Ilnd
(
covered in the 1st round in both the districts.
(
round could not
(
spray operations were undertaken by the district Collector
(
(
(
be
started
in time and
subsequently the
and his staff through teachers, revenue staff, school boys
and members of the community in October,
1994 .
(
(
The spray operations
in 1993 could not be conducted
new Malariogenic
effectively due to confusion created by
stratification proposed by the NMEP in 1993 and the action
A
could not be implemented.
A
The spray operations were also
I
hampered by the change in the policy for hiring the labour
(
for spray on contract basis. Ho labour was available on the
(
rates prescribed under the government rules.
A
Further,
the
malaria control activities have been adversely affected by
restricted mobility due to non -availability of vehicles for
supervision and
A
monitoring, transportation of insecticides
and drugs and spray squads.
(
4.7.2.2 Surveillance and Treatment
Surveillance
is
the main
for
activity
detection
of
t
lido collection
malaria cases in the community . The blood s
from
fever
norms,
cases was apparently
however,
the
slide
47
0
-A
o
close
to
collection
the
prescribed
through
active
<
'V
(
(
V
surveillance has been less than the passive collection.
(
The yield of passive slide collection was higher in terms
(
of detection of positive cases of malaria.
(
■k)
28.7
percent
slides
(
collected
by
passive
surve i1lance,
(
compared to
(
1
(
(4,320
out
of
out
(12,349
district
In Jaisalmer
43,015),
as
positive.
were
13.6 percent positivity of active collection
of
Similarly,
slides).
31,863
the
in Barmer,
percent, 21,190 positive out
(
positivity was higher (13.6
(
1,56,173) on passive collection than active collection (6.9
those who h a v e fever,
percent, 10,128 out 1,47,045) . But
health centres, thus it
only they come to the hospital or
not be representative
is a selective population which may
(
(
(
i
(
of population in the community
has
the advantage
The active case detection
it provides
that
the situation
in the
community and help identify focus of infection.
5
suffered mainly due to
The active case detection has
(
<
shortage of field staff,
who were mainly
The
active
particularly male health workers
responsible for blood slide collections.
surve i1lance
severely
also
is
affected
by
inaccessibility and large distances.
The
treatment
is
activities in malaria.
an
important component of
control
This is also adversely affected by
various factors
delayed blood examination reports due to
namely; delay
in sending the slides to the PHCs, slide back
5 .
logs,
shortage
stains
and
of
delayed
malaria
technicians,
communication
examination.
48
of
microscopes
results
after
and
blood
1
(
(
4.8
Rajasthan
launched
crash
malaria
control
programme
information
of
malaria
outbreak
in
(
Rajasthan.
The
crash
programme
was
(
October,
(
K
intensive
(
(
’L.
a massive
of
The Government
(
V
CONTROL MEASURES IN THE CURRENT OUTBREAK
(
(
(
(
(
some
on
and
receiving
districts
of
from
2nd
launched
which showed high incidence
1994 in 15 districts
was held under the
of malaria. A high level meeting
to draw out a
chairmanship the State Health Minister
of the strategy were:
control strategy. The main features
intensified insecticide spray, anti-larval measures through
(
distribution of anti-malaria
(
oiling of water reservoirs,
(
drugs, strengthening of hospital services and better case
(
A
<
management,
strengthening
laboratory
support
for
faster
and
examination of blood slides collected from fever cases
important features of the
intensive IEC support. The
(
strategy were:
i
(
1.
2.
3.
4.
5.
entrusted to the
The malaria control activities were
district Collector.
sanctioned for purchase of
Additional funds were
for
and
medicines,
microscopes
oil,
equipments t
enhanced wages for spray squads.
revolving funds to
The Collector were provided with
meet out expenses.
at the state and district
Setting up> a Control Room
with
hotline.
level and connecting them
Within the district, a mechanism for
on wireless was developed.
7.
inter-sectoral
entailed
programme
The
crash
government departments,
coordination, involving all organisations, etc.
etc.
youth
NGOs, school'children,
c---affected districts.
Intensive IEC campaign in the
did
health department
The district administration and the
control
in 'executing the malaria
a commendable job
6.
49
3
..5
3
&
daily information
<
» X
W
(
The
of
Collectors
Barmer
and
Jaisalmer
(
activities.
(
districts
(
mobilisation and inter-sectoral coordination. They prepared
have
set
an
excellent
example
mass
of
(
1
(
(
(
i
(
The insecticide spray
a district plan for malaria control.
school
was undertaken with the help of revenue staff,
children and teachers,
local villagers and locally hired
were made in
labour. Special arrangements for patient care
staff was
the district hospitals, CHCs and PHCs. The
mobilised from other districts to man the vacant positions
r
i
(
and to provide additional manpower in Barmer and Jaisalmer
(
districts. The state government also empowered the district
(
collectors/CMHOs to appoint doctors on temporary basis at
their own level.
Special arrangements were made for disease management
(
(
in the hospitals by providing additional drugs and beds,
Surveillance system was activised and the reports of blood
examination were available same day in the hospitals/PHCs
and within a week in remote areas.
IEC Bureau mounted an intensive communication campaign
4
through
public
awareness
press
advertisements
in
the
newspapers, handbills and posters. The Bureau also prepared
(
information booklets and material for training of health
functionaries and other non-health department.
In the Barmer district,
the district administration
intensive Jan
along with the health department organised
Chetna Shivirs to educate people.
50
The
(
(
(
A
was developed.
. In impressive information system
district and the state
reports were monitored daily at the
the PHCs were being
Even rhe reports from
levels.
(
(
communicated on wireless everyday.
A
(
(
>
(
(
(
(
(
c
(
(
(
(
(
(
(
-1
-*4
(
(
(
(
(
3
(
-A
(
A
DIS
(
z>cis'g’
ro r ti
r
mA
k
y
AND
''I
0OCUM RATION )
’ i!n
N' G A L
CHAPTER 5
<
FACTORS ASSOCIATED WITH MALARIA outbreak
(
(
(
i
(
(
(
(
(
(
(
(
(
(
<
section z Jaisalner and
As evident from the previous
epidemic of malaria
Barmer districts were in the grip of
1995. The infection was still
during September - November,
malaria was continuing
persisting and the transmission of
members of the Expert
at the t ime of visit of the
implicated in resurgence
Committee. Several factors may be
outside the
of malaria in these districts. Many factors are
some are within
natural or man-made; and
health sector
broadly categorised as
the hea1th sector, which may be
administrative, technical and operational.
A.
FACTORS OUTSIDE THE HEALTH SECTOR
5.1
Climatological factors
(
(
(
i
The
increased
main
climatological
incidence
malaria
incr iminated
factors
are
excessive
temperature and high relative humidity.
in
ra infa 11,
These have played
malaria outbreak.
a precipitating role in current
(
5.1.1 Abnormal Rainfall:
rainfall
abnormal
This year there was an
(more than 60 percent of normal)
percent
excessive
(20-60
district.
Besides
this,
more
than
ra infa 11
in Barmer,
normal)
was
and
in Jaisalmer
prolonged
and
excessive and abnormal
continuous till mid-september. The
collect ion thus providing
rain not only lead to water
mosquito breeding, but also created
opportunity for intense
relative humidity.
a favourable temperature and
2
52
3
•A
I
(
The tota 1
(
(
(
rainfall and
span of
rainfall during the
rainy season are two critical factors which influence the
particular
in a
transmission
vector density and malaria
(
<
t
area. Similarly, two other important climatical factors are
temperature and humidity.
i
5.1.2
Temperature:
degree
Celsius
The average temperature is around 26
the
in
districts.
two
the
Jaisalmer,
In
minimum temperature ranged between 24.3 to 26.6 and maximum
(
<
between 34.5 to 35.1 degree Celsius during July-September,
was.closely similar.
1994 . In Barmer also, the temperature
The ideal condition for transmission of the disease is
the mean temperature between 21 to 30 degree Celsius.
Rajasthan,
(
high as
(
summer
(
(
50
degree
temperature
Thereafter,
the temperature reaches as
in extreme summer,
48
some
in
sharply
falls
In
districts,
with
however
onset
of
this
rains.
remains
for a number of weeks the temperature
conducive for transmission of disease.
With the onset of
low as 0-4 degree
winter, the temperature comes down to as
January when the
Celsius in the months of December and
'4
(
transmission practically ceases to take place.
*
4
5.1.3
Relative humidity is important
Relative Humidity :
factor which influences the
life span of mosquitoes.
At
low relative humidity, the life of mosquito gets shortened,
on
the
other
hand,
with
high
longer period.
0..
s'"
life
the
span of
mosquito survives for a
i
transmission of malaria,
mosquito is a critical factor in
53
0
The
humidity,
(
i
0
relative
(
(
as no transmission is possible unless the infected mosquito
(
survives for a minimum period of 7 to 10 days.
(
The relative humidity was high, ranging between 49-63
percent in daytime, and 79-85 percent during the night and
V
i
period of July-September,
early morning hours during the
i
1994
(
in the
Jaisalmer
Similarly,
district.
the
relative
humidity also remained high in Barmer district.
(
5.1.4
c
Surface Water collection:
With heavy rainfall and
favourable topographical conditions such as low lying areas
(
•v
(
(
and natural collection of surface water, the area available
so also the density
for breeding of vector has increased,
of mosquitoes,
leading
to prolonged disease transmission.
(
3
(
5.1.5
Breached/damaged Reservoirs: A large number of water
reservoirs,
.ii
as
many
as
16
were
breached/damaged
in
Jaisalmer district which lead to creation of pools of water
<
lying areas.
These
collection in the down stream and
low
new areas of breeding of mosquito,
have also contributed
greatly to increased malaria transmission.
Taking
(
above
factors
was
rainfall.
54
! ;
it
can
be
conclusively observed that the recent resurgence of malaria
in the selected districts
<
consideration,
into
greatly
influenced by
the
<
(
(
b-
5.2
(
Water Tanks
developmenta1
new
many
With
(
(
undertaken
in
activities
also
may
being
sometimes
these
happens
it
state t
the
activities
lead
creation
to
of
(
developmenta 1
(
environment favourable
(
(
in desert districts of
was visible in a number of villages
(
Barmer and Jaisalmer.
This
for transmission of malaria.
(
(
b-
For
<
(
(
providing
to people
close
undertaken
safe
adequate
and
in villages and hamlets,
rura 1
water
supply
schemes.
(
*
provision of community water tanks.
4
4
<
facility
of
water
State
the
This
has
includes
These water tanks are
around leading to
at times over flowing and water spills
collection of surface water, creating a mosquito breeding
(
area.
Another
■4
1
(
(
noticeable
water
reservoirs
at
the
village
a circular
level were the cattle drinking water reservoirs,
reservoir and spilled
reservoir of 10 meter diameter. The
breeding places
over water collection also have become new
habitation.
for mosquitoes close to the human
(
4
(
Similarly,
tanks
i
*
■A
’’TANKAS”) ,
have become an
Developmental activities in Rajasthan
construction of new
Developmental activities such as
k
k
(
■3
ideal breeding
In these 'Tankas' , the
place in the house premises itself.
swarming with mosquitoes.
1arvae were growing and were
5.3
k
(known as
that household
the committee also noticed
55
<
u
i
(
facility,
intensified
(
agricultural activities,
(
breeding of mosguito and
create favourable condition for
evidence
transmission of malaria. Though no such positive
(
(
(
(
J
irrigation
of
dams,
(
*
development
(
change in crop pattern may also
however, in districts of
to this effect was established,
Jaisalmer, Barmer and Bikaner
Kota, Bundi, Banswara, Baran,
understand the
detailed studies need to be carried out to
malaria
in
activities
developmental
the
of
role
transmission.
(
t
(
5.4
Migration of Population
from within
There is significant migration of labour
(
the state as
<
<
well as outside. People migrate in search of
dams,
employment in activities like construction of roads,
start of new
laying down of railway tracks, mining,
industrial complexes and power projects. So also there is
movement
of
population
(
(
A
construction etc.
for
grazing
cattle
or
house
to other states where malaria incidence
On return this migrant population brings
breaks of
disease and may lead to focal out
could be high.
back
the
malaria.
i
This
aspect
also
need
to
be
looked
in
to
in
similar role at
detail. Nomadic population also plays the
7
times.
*
B.
✓
5
FACTORS WITHIN THE HEALTH SECTOR
5.5
Administrative
5.5.1
Policy decision and their implementation
The policy decisions for changes in the strategy and
taken at
implementation in malaria control activities are
56
I
c
<
'0
(
workers, 65 percent post of female supervisors, 56 percent
(
posts of male supervisors and 37 percent posts of malaria
(
<
inspectors were vacant. The situation in Jaisalmer district
was no good. There were large number of vacant posts of key
(
c
(
health personnel.
(
(
•o
’ The shortage of key health manpower seriously impeded
(
(
0
(
the malaria control activities, specially, the surveillance
and the treatment part of the programme.
(
0
(
Lack of training
5.5.4
<
training programmes
On going through the
(
1
' 0
(
during the last five years,
(
number
(
of
key
supervisory
organised
it was noticed that a large
staff
like
District
Officer and Malaria Inspectors had remained untrained.
(
0
(
0
(
MPO envisages involvement of medical officers of PHCs
<
as
5
Malaria
well
as
Medica1
Chief
&
Health
Officers
of
the
no short orientation training has yet
districts. However,
been organised for these officers.
Epidemiological
entomological
and
knowledge
is
critical for identification of epidemic prone areas, focal
outbreaks,
vector bionomics,
forecasting and surveillance
and insecticide resistance etc. However, due attention does
not seem to have been paid to create an epidemiological
3
division
at
the
state
leve 1
and
for
orientation of district and field staff.
0
3
3
5
59
epidemiological
c
(
(
The recent reorganisation of district health system,
(
(
(
District level reorganisation
5.5.5
with Chief Medical & Health Officers having been given the
'i
all
of
responsibility
including financial powers,
within the district,
(
V
to
(
i
i
(
and
confusion
activities,
and
programmes
health
among
disenchantment
the
has lead
Chief
Deputy
Medical and Health Officers. In the process, they have lost
implementing and
interest in the programmes they wer e
duties, even the
supervising. With this reallocation of
(Malaria) as such
Deputy Chief Medical and Health Officer
in malaria control
may have lost special focus and interest
activities.
5.6
Logistics
Inadequate and delayed supply of insecticides
5.6.1
(
There
has
been
(
insecticides specially DDT,
(
to delay in spraying operation.
and
in
adequate
technically appropriate
ineffectiveness
of
supply
of
during last few years leading
(
schedule
inadequate
and
delay
doses
Spraying has to be as per
insecticides
of
Otherwise this may
time.
insecticide
spraying
in
and
at
lead to
checking
of
transmission of disease. The difficulties are also faced in
procuring BHC and Malathion.
i
Statement showing amount and
dates of supply are given in Annexure IV.
5.6.2
Inadequate and delayed supply
Anti-malarial
drugs
are
of anti-malarial drugs
also
not
available
in
as such there
appropriate quantity at the- state level and
the
to
supply
delayed
and
irregular
inadequate,
is
•w
□
60
\ '
3V
(
(
(
districts and peripheral units,
Statement
FTDs and DDCs.
showing amount and dates of supply are given in Annex-IV.
(
<)
(
v)
(
O
(
5.6.3 Procurement of Equipment
Procurement of spraying equipments and other materials
(
\D
(
is the responsibility of the State. However, due to paucity
of funds, the state has not been able to procure microscope
C
<
and
other
material
in
(
appropriate time.
(
5.6.4 Shortage of vehicles
adequate
quantities
at
and
k)
i
J
Acute shortage of vehicles is seriously impeding the
(
progress of MPO and affecting all aspects of programme,
3
(
(
(
(
both- for supplies and supervision. For last few years, the
state government has not been able to issue sanction for
purchase of vehicles for which the funds were identified by
within the
the Directorate of Medical & Health Services,
(
plan provision. There seems to be little administrative and
financial flexibility for taking such vital decisions.
(
<
"5
5.7
Technica1
5.7.1
Insecticide resistance
Spraying of insecticides and administration of anti
malaria drugs were critical elements of MPO.
only, insecticides used from 1953 to 1957 .
DDT was the
However,
with
emergence of resistance to DDT, another insecticide BHC was
later introduced.
developing
to
Over a period of time with resistance
the
both
the
above,
another
group
of
insecticides Malathion - though costly, was introduced in
61
5
the programme. Thus the emergence of resistance in vectors
<
critical constraint. This
to the insecticides has been a
in the present report. Presently
has been well documented
both
A.
Culicifacies
and
A.Stephensi
(
in
<
shown resistance to DDT and BHC to varying degrees.
Rajasthan,
have
(
%
(
i
<
o
Drug resistance
5.7.2
The
(
<
f
further
has ■ become
problem
compounded
with
p.Falciparum to Chloroquine,
development of resistance of
even though
the frontline anti-malarial drug. In Rajasthan,
(
firm evidence
done to
f ind
further studies need to be
is not visible,
the
out
extent
and degree
through properly
organised studies.
i
it was
During visit to Barmer and Jaisalmer districts,
in OPD and Indoor
found that number of patients, both
treatment against
wards, reported to have t a ken rad ica1
staff and still they
malaria duly prescribed by the health
blood slides
showed the presence of malaria parasites on
of drug
examinations-. It obviously indicates possibility
number of drug
resistance. However, there were not adequate
of the state
resistance tests done in all the districts
with adequate sample size.
5.8
Operationa1
5.8.1
Inadequate Surveillance
Surveillance,
o
(ACD),
which
is
especially
essential
for
the
Active
Case
monitoring • of
Detection
the
disease
great deal due
occurrence in the community, has suffered a
D
62
(
(
to various reasons.
C
(
(
(
(
(
(
(
With integration
of malaria
control
activities with
general health services and introduction of multi-purpose
workers scheme at the peripheral level, the staff was drawn
from different programmes, such as Malaria, Family Welfare,
It has been observed
Smallpox and other health programmes.
that
workers
drawn
in
malaria
interest
f rom
other
take
disciplines
do
not
shown
by
erstwhile
as
surveillance
(
<
surveillance worker.
(
(
Under MPO also, domiciliary visits are expected to be
<
J
made on fortnight basis.
(
mention that with large number of vacancies in the cadre of
<
limited
male MPWs and female health worker playing a very
role in malaria surveillance.
have
been
reiterated
5
it m ight be worthwhile to
Here,
(
adversely
that
due
the surveillance activities
affected.
Here,
high
priority
to
it
may
given
also
to
be
family
welfare activities, malaria surveillance has been relegated
to the background
With these developments, it has not been
possible to provide uniform coverage
number
of
of
areas
the community
in
epidemiological
time* and space and
in a
vacuum is observed.
Frequency of home visit has also been
intervals in
reduced to even once a month and even longer
5
some parts.
5.8.2
2
Inadequate spray operations
Insecticide spray is the key malaria control activity.
far from adequate.
However, the spray operations have been
activities could be organised
In 1993, no adequate spray
□
o
•3
63
(
c
<
V
(
(
(
0
(
V
(
(
and so also in 1994 . On going through the reports of spray
operations undertaken during last two years , it was noticed
that often the first round was started but the second round
of spraying was unduly delayed making the whole exercise a
futile one.
(
(
(
Besides shortage and
-
not
officials
(
realising
in
department
health
one major
the
government
by
created
was
dif f iculty
operational
irregular supplies,
labour
organising
by
the
force
for
faced
dif f iculties
the
constituting spraying squads. Insistence for recruiting the
(
(
(
activities
at
contract
basis
the
daily
of
wages
the
sowing
season, which invariably coincide with the spraying
season,
unskilled
(
spraying
for
labour
worker
on
during
the state finance department became the biggest constraint
for the health department. Even delayed sanction to recruit
labour for this purpose on contract basis was fruitless as
-A
would
be
evident
reports of
from the
even
non spraying
after such a sanction.
Insecticide spray has to be done in right time,
-5
concentration ,
right
-5
places.
at
right
intervals
and
at
in
right
Recruitment of such staff and having been given
responsibility of spray operations without much of training
and effective supervision, leads to inadequate coverage and
ultimate failure to check transmission of Malaria.
Public
cooperation
in
spraying
of
houses
was
not
forthcoming and many households visited, were found to be
64
(
(
<
(
V)
Less than 50 percent of houses and
inadequately sprayed.
less than 50 percent rooms and wall space was
(
there too,
(
(
covered with insecticide spray. The spraying was also found
(
to be very patchy and improper.
(
sprayed walls
surface.
found with a
very
(
(
c
There were wide gaps on
even
Lastly,
heavy density
rooms
sprayed
were
of Anopheles mosquitos
resting on the sprayed walls.
(
(
During the current year in the month of October, the
(
t
(
5
(
<
<
(
(
spray
operations
were
got
volunteers,
NSS
through
done
school children, revenue staff and the staff recruited on
the spot, in selected districts. The spraying squads were
supervised
absence
of
by
the
revenue
proper
sta f f
training
of
districts.
the
of
labour
and
In
effective
supervision and monitoring by technical staff, spraying was
15
haphazardly and inadequately done. During discussions with
the officials of NMEP and the MRC,
5
spray
operation
rema i n
wou 1 d
it emerged that such a
ine f f ective
in
checking
malaria transmission.
■5
5.8.3
Over burdened laboratory work.
For the present all malaria slides are to be examined
5
(
3
at the block level by the malaria technicians, this results
5
in accumulation of backlogs of slides and delayed reports
3
due to increased work load. Another draw back is that the
laboratory
technicians
are
working
t
*3
supervision and guidance.
65
3
5
in
isolation without
1
<
V
(
(
*
5.8.4 Inadequate decision making and forecast mechanism
There have been a number of focal outbreaks during
(
V
(
years.
five
last
there
However,
does
be
to
seem
not
adequate capabilities in the health supervisory staff to
*
(
make epidemiological forecast, monitoring and surveillance
(
(
for initiating epidemic control of activities.
(
(
is
Malaria
and
localised
a
a
focal
necessitates collection and analysis of information at the
(
local level,
i. e.
at the PHC and district level. A large
(
*
thus
disease,
(
(
and
3
a
these
the
at
collected
is
information
systemic
it is hardly verified and rarely utilised
levels, however,
t
for decision making.
(
Decision
adequate
for
Ch ie f
and
seem
effective
action
in
be
to
special
As an example, a communication was sent to the
situation.
5
immed iate
not
did
capabilities
making
Secretary
Union
the
by
Health
for
Secretary
initiating immediate action in view of predicted heavy rain
fall
in
June
cognigence
was
taken
Communications were
Rajasthan.
in
1994 ,
of
also
even
sent
It
such
by the
seems
not
much
communication
state medical
and
health directorate and the zonal health officials, warning
t
(
5 ,
the ‘districts for impending outbreak of malaria in these
districts,
but these were treated without much concern or
prompt action at different levels.
ja
There is no early warning system. Though, the health
professionals at the periphery were not fully aware of the
66
f
<
(
focal epidemics,
even
steps to be taken
(
issued late in
clear directions for epidemic control were
(
(
t
A
event of
(
in the
the course of events when the
outbreak had already reached
the peak.
(
<
(
<
(
(
(
(
(
(
J
It
is
to be
appreciated
that the
highest
political
realised the seriousness of
leadership at the state level
to involve the
the problem and initiated effective measures
the health department,
total district administration and
of funds after the matter
and issued sanction for release
in media. However, delayed
had received a wide publicity
of health system
action in the matter at different levels
matter of concern.
and at the local level is a
5
(
(
i
Availability
of
insecticides,
vehicles
there
focal outbreaks. However,
were geared up after the
to meet with such
was gross inadequacy in such arrangements
due
after
even
seems
It
advance.
in
contingency
a
supplies could not be
initiation of the health department,
anti
Requisition for insecticides
arranged in time.
Central
the
to
sent
repeatedly
were
drugs
malarial
Government, but there has been
(
spray pumps,
5.8.5
undue delay in response.
Poor Entomological Support
Support
with
continuing
entomolog ica1
studies
is
The entomological
critical for malaria control activities.
the Regional Office
studies carried out in the State and by
grossly
were
Health
and
Family
(ROHFW)
Welfare
of
• r- r>Aritv rate, human/animal
inadequate. The mosquito species, parity
o
□
67
□
*0
(
(
1
(
(
v
(
were
not
carried
in
out
sufficient
number.
The
(
etc,
(
at the zonal level,
Entomological unit at the state and
i
(
(
*
serological testing of mosquito blood, larval density
bait,
(
(
(
adequate infrastructure
were ill-staffed and did not have
have been vacant
and supervision. Many senior level posts
for years together.
(
(
(
(
(
i
Inaccessibility of area
5.8.6
in tribal and
Realising the difficulties faced
established for
desert area, the PHC and sub-centre are now
3,000, respectively, with
a population of 30,000 and
requisite staff compliment. However, even this arrangement
(a)
does not help in overcoming
difficulties faced by the staff
the sub-centre
(
due to great distances between villages from
(
of clusters of
and spread-out of each village within number
households located at varying distances.
(b)
5
districts
The
levels
in tribal
of
general
development
and desert areas
of
certain
is so low that the
avail the 'existing health care
people are not capable to
gender
level literacy,
low
The
facilities in full.
scheduled tribe
discrimination, large scheduled caste and
and unemployment etc. all
population, low level of income
play important role in this respect.
5.8.7
Inadequate Urban Malaria Scheme
cities
Urban Malaria Units are functional in six major
units has been very
of state. However, the output of these
activities aimed at
limited. These units were to carry out
68
5
(
(
(
V)
(
V)
(
(
(
(
(
(
source
reduction,
biologica1
to be lack of supervision,
laws directed towards preventing/reducing breeding places
of
vector,
distribution
of
<
(
(
(
(
*5
o
69
(.
of
larvicides
extension of urban limits over a period of time.
(
3 1
supplies
and
little or no argumentation of field staff required due to
(
(
(
(
(
(
*5
anti-larval
lack of implementation of bye-
(
3
and
measures. Staff compliment was also provided. There seems
(
V
control
(
(
V
(
CHAPTER 6
(
RECOMMENDATIONS
(
(
The Goal of
(
(
<
(
*'
<
(
(
malaria control is to prevent mortality
For a
and reduce morbidity; and social and economic loses.
there are
planned operation of malaria control programme,
viz; regular satisfactory
some essential prime requisites,
insecticide, a well
spray operations with an effective
organised
surveillance
system,
a
potent
drug
against
at all levels, and
parasite, an adequately trained manpower
with a capability to foresee the coming
above all a system
events and plan strategy to contain it.
O
(
(
1
^5
i
reviewed .the magnitude of
The Expert Committee has
attempted to
malaria and its trends in the State and has
the current resurgence
analyze the factors associated with
formulating the
of malaria in the western districts. While
also considered the
recommendations, the Committee has
Malaria Eradication
opinion of the officials of National
WHO
Centre (ICMR) and the
Programme, Malaria Research
health officials and various
(SEARO), besides the state
The recommendations are
categories of health professionals.
i. e. organisational
mainly confined to four major areas
transmission control and
disease management,
support,
and malaria control
strengthening of health delivery system
activities.
<
i
•XT
0
1.
Constitution of Technical Advisory Group
situation and its past
Keeping in view the malaria
70
<
(
state,
wou Id
it
trends
(
constitute a Technical Advisory Group
in
the
(
•o
The Committee
to
desirable
highly
be
(
at the state
(TAG)
recommends constitution of
strongly
(
level.
(
such a group v/hich could advise the Government on
(
of action.
issues and policy aspects and alternative course
technical
(
(
The group would meet and review at least twice in a year
(
the malaria
(
and
situation
control
of
choice
activities,
insecticides and spray strategy, drug policy and monitoring
(
>0
resistance
of
aspects
technical
other
and
the
(
drug
<
consist of 5-6
programme . The Technical Advisory Group may
b)
(
members
(
have
who
and
health
public
in
expertise
malariology. The representatives from National Institute of
and
(NICD)
Diseases
Communicable
Malaria
National
the
should also be the members of
Eradication Programme (NMEP)
the group.
i
(
3
Developing Early Warning and Forecasting System
(
2.
(
2.1. Review
, present
factors
-5
rain
was
situation
only in
a
building-up
climatic
trends
malaria
of
not
is
the
last
condition
the
factor.
to
3
4
became
that
the
of
the
culmination
current year,
precipitating
for
shows
clearly
though
The
years.
excessive
situation
was
as
the
As
soon
favourable,
malaria
presented in the form of outbreaks.
The
Committee
strongly
recommends
constitution
of
well as district
Epidemiology Division at the state as
malaria,
levels which would . monitor incidence of
disease
transmission,
entomological
□
3
-5 •
71
profile,
vector
drug
(
resistance
and
problem
of
(
Epidemiological
Division
will
(
resistance.
The
identify
the
also
epidemic prone areas and develop a system of epidemic
(
detection. The Epidemiologic Division will also cater
>
to other health programmes.
(
(
the directorate and
A large number of officials from
(
(
(
the medical colleges have been imparted basic training
and NICD, New
in field epidemiology at CDC, Atlanta
i
Delhi. It will be worthwhile to utilize their services
(
in this endeavour.
2.2
that medical officers,
The Committee strongly feels
district level officials and even the state officials,
who
are
(
health
responsible
programmes
for
implementation
malaria,
including
1
Ji
(
health orientation and public health
of
various
lack
public
is not recognised
as an speciality either.
It
is
strongly
management
levels,
personnel
qualifications/ background
may
require
that
recommended
recognition
at
with
the
programme
public
health
should be appointed.
It
as
a
of
public
health
(
2
speciality as was done earlier.
(
3
(
3. Information System and Decision Making
the only
malaria control programme is
Perhaps,
information is uniformly,
programme in which the large
collected. However, this
regularly and scientifically
72
3
I
3
(
(
(
3
3
information is rarely reviewed at the district and block.
level
(
3.1
3
(
*
(
3
programme.
(
(
(
(
3.2
It
is
further
according to revised
(
blocks,
stratification of districts and
suggested
as
information required
recommended that
(
should
13.2,
para
in
be
involved in malaria
collected and the health personnel
(
(
• control activities,
<
should be trained in information
management and decision making.
5
J
Committee strongly recommends de-centra1ised decision
as to enable
making at the district and block level so
accordance to
local specif ic control measures in
the
under
activities
control
malaria
identified
*
1
malaria
plan
and
<
(
3
trends
control activities accordingly.
<
1
disease
the
monitor
(.
3
3
to
(
3.3
also
Committee
recommends
computer isation
of
the
and speedy
information system for collection, storage
.3
retrieval
of
information
for monitoring,
review and
decision making.
4.
Training
4.1
Training
i
in
malaria
control
activities
accorded a high priority. The key
responsible
for
programme,
should
control
implementation
be
adequately
be
health professionals
of
malaria
control
in
malaria
trained
operations.
The
contents
should
include
basic
curriculum
should
of
training
epidemiological
73
•I
<
(
malaria
of
management
program:
control
(
concepts,
(
operational aspects such as spray of insecticides, use
(
of
larvicides
distribution,
drug
and
(
and
surve i1lance
disease
outbreak
management,
(
management,
<
management information system and decision making, and
V
IEC in malaria control.
i
i
4.2
should
Similarly short orientation training programmes
health officials
be organised for all categories of
and
¥
functionaries
for
effective
malaria control activities
implementation
of
This should be done before
the malaria season in 1995.
2
4.3
also be developed
A suitable training programme should
for
3
teachers,
functionaries
panchayat members,
for
their
of
other
departments,
NGOs and other volunteers groups
effective
participation
in
health
care
delivery including malaria control.
i
4.4
i
and vaidyas should also be
The private practitioners
activities
control
malaria
and oriented
trained
and reporting of
especially in diagnosis, treatment
cases to the health system.
MOHFW and MRC, may
Training modules developed by the
various
for training of
be reviewed and utilised
categories of personnel.
74
0
Strengthening of Entomological Units
Entomological
X
units
are
staffed
adequately
not
and
equipped. These need to be strengthened by filling up
(
vacant
the
providing
and
positions
necessary
t
equipments for conducting entomological studies with
c
adequate facilities for mobility of the staff in the
(
t
This
field.
is
extremely
of
malaria
recent
important with
the
potential
increase
(
resurgence
c
a
and
resistance
insecticide
ecological
wide
besides
in
(
changes.
(
(
/
?
There
need
immediate
is an
to conduct entomological
(
t
studies on a wider scale to develop a vector profile
(
and status of insecticide resistance in all districts
(
with
adequate
sample.
s i zed
This
crucial
is
in
(
^3
planning malaria control activities which are specific
(
to local areas.
□
(
6.
Technical Appraisal of Insecticide Resistance
•5
There
is
immediate
an
need
vector resistance to the
to
review the
status
Of
Resistance of
insecticides.
. malaria vectors to commonly used insecticides namely
i
DDT/BHC
is
varying
degree.
reported
The
in
various
Committee
level Technical Advisory Group,
may
prepare
insecticide
•w
□
□
3
O
parts
recommends
resistance,
choice
the
of
for
state
declaring
insecticides
alternatives to currently used insecticides.
75
in
as proposed earlier,
guidelines
revised
state
of
and
(
'O
{
The Committee also recommends to consider the use of
(
(
alternative insecticides where the vector resistance
(
to
currently
insecticides
used
has
well
been
(
established.
(
V
i
7.
Disease Management
<
Disease management is a critical component in malaria
(
objective
of
control
malaria
the
control.
The
programme
is to prevent mortality and reduce morbidity.
main
<
i
!
i
This
enta iIs
ear 1y
case
detection
treatment
prompt
and
(EDPT) at the village level through PHCs, sub-centres, FTDs
and DDCs;
and strengthening of hospital services at the
districts
and
CHC
the
In
level.
light
of
above,
the
(
following recommendations are made:
(
7.1
*
(
7.1.1
Early Case Detection and Prompt Treatment
To enable early detection and prompt treatment of
(Fever’ protocol)
a11
with
■
panchayat
health
operat iona1
diagnosis
be worked out
and shared
for
criteria
malaria,
may
functionaries,
DDCs,
FTDs and
This operational diagnosis
members
may be based on history and clinical findings.
7.1.2
All
in
vi1lages/hamlets
the
dif f icult/problem
i
areas should be equipped with DDCs with adequate
drugs,
keeping
information
and
of
reporting
doses
schedule,
record
The
local
procedure.
panchayat must be fully kept informed of the same
(
for ensuring supportive supervision. However, the
76
<
(
<
be clearly oriented about
DDCs and FTDs should
(
(
tasks,
(
malarial drugs.
treatment
and
schedule
doses
of
anti-
(
o
(
<
Mobile malaria clinics should be set up in the
7.1.3
(
problem districts to treat, examine and follow up
(
For
the cases of malaria.
r
other districts,
the
usual practice of case detection and treatment
may be continued as is done under MPO.
(
(
(
(
7.2.
Strengthening of hospital Facilities
level hospitals
should be
/
All the districts and CHC
(
fully equipped to deal with severe malaria cases and
<
5
its complications.
(
pregnant
women
and
ch iIdren.
additiona1
beds
and
anti-malarial
(
3
Provision must be made for care of
<
Besides,
drugs,
providing
a
special
<
orientation ot physician, paediatrician, obstetricians
3
3
• and other specialists should be conducted.
(
3
The
3
working
in
the
district
hospitals
should be advised to keep a record of suspected drug
3
3
specialists
resistant cases and report the
(
same to the district
health officials.
(
The hospital records may be very useful in developing
an
early warning
system and therefore proper record
maintenance and regular analysis should be undertaken.
77
□
\
(
8.
(
3
Drug Policy
P.
chloroquine
to
resistance
Falciparum
has
boon
reported in several districts of Rajasthan. Currently R-III
"4
(
3
level resistance
is the criteria used for declaring drug
But
it has to be realised that R-I and R-li
resistance.
level resistance ultimately lead to R-III level resistance.
3
there was about 23 percent.
the reports,
On the basis of
combined R-II and R-III level resistance.
v.'
In this context,
it is recommended that:
3
8.1
3
•3
(
NMEP should bn
The Central Technical Advisory Group,
status
the
requested
to
review
resistance
to
P.Falciparum
earliest,
and
to
declaring
drug
resistance
out
work
revised
and
at
th<«
criteria
1 or
state
the
in
chloroquine
of
starting
alternative
(
drug regime.
(
(
8.2
studies
(
3
steps
Immediate
in
must
all
be
drug
taken
for
and
desert
triba1
resistance
districts
1n
or more
Rajasthan, especially those having 30 percent
p.- Falciparum infection. This has to done on priority
0
basis so as to introduce revised schedule of treatment.
(
in such districts.
It
is also suggested to consider
clinical experience by
reports of resistance based on
i
the specialists in the hospitals.
i
(
I
8.3
Meanwhile,
in the wake of
reported drug resistance,
of* alternative drugs
the Committee recommends the use
already prescribed under National Malaria Eradication
78
•1
'»
(
I
(
&
(NMEP)-Drug Policy
Programme
(
policy,
this
Under
cases.
resistant
P.Falciparum
for treatment of
1982,
(
■a
Suphalene
(
(1000
combination and Primaquine (45 mg)
may
treatment
radical
be
in single dose for
institutional
the
at
used
mg)
(50
Pyrimethamine
+
mg)
level only.
drug
also
and
cases,
complicated
and
severe
For
resistant cases, cases coming with multiple episodes,
i
should be hospitalised and treated with a prescribed
course of quinine hydrochloride as per recommendations
(
of the NMEP.
J
(
(
J
8.4' The group
further recommends,
(
chloroquine
(
J
J
J
mg,
(
and
resistance
cases
3
in
suf f icient
and
45
course
full
given
l?e
Pr imaquine,
mg
all
1500
is
of
evidence
number of districts,
shou1d
Chloroqui nu
a
is
there
resistance studies
in drug
used
that as the amount of
partial
p.Falciparum
of
mg
1500
henceforth
till
therapy
under
further decision i s taken.
3
8.5
(
The
group
certain
also
recommends
cond it ions
like
mass
drug
aggregations
of
labour
in
connection with construction projects, development of
• water
systems,
mining
etc.
A
single dose
of
600
mg
i
(
chloroquine
with 45 mg primaquine
per the guidelines under NMEP.
(
□
□
3
1
79
is recommended as
J
t
f
insecticides Spray operations
9.
(
In
the
covered
districts
malaria
intensive
under
areas/sections with API 2
control programme all sub-centre
cases are
where p.Falciparum
Sub-centres
all
and above,
with reported malaria deaths
and
all
Sub-centres
reported
with Indoor
shouId be covered
preceding
year,
in the
with
operations
(IRS)
Spray
Insecticides
Residual
other
the
or
DDT/BHC
of
concentration
recommended
and
For successful
be.
may
case
the
insecticides as
be
following aspects may
operations
,
effective spray
f
1
considered:
9.1
3
(
1
5
3
3
5
<
!
held in the
for spray should be
schedule
the zones and spray
in
all
month of March
of de-centralisation, the
the
process
In
finalised.
decisions
authorised to take
should
be
zonal officers
schedule, requirement
for execution and send the spray
funding to
' of insecticides, equipments, man-power and
Preparatory meeting
the Directorate.
I
I
I
I
9.2
of
and
timely
supply
arranged
the
state
Full
by
(Additional
health
leve 1
Malaria)
Director
to
all
districts with
with priority to the
started
o
be
□
schedule
from
should
be
• (Malaria)
will
ensure
I
(
the
districts
recommended
The
Chief
availability of
80
authorities
operations should
Chief Medical &
I
□
and the
adhered to.
Health Officer and Dy
□
May
be
Intensive Malaria
Activities. The first round of spray
15th
should
insecticides
spray
Medical
&
Health Officer
insecticides,
(
f
0
(
spray pumps and squads.
(
9.3
The mobility of the staff and spray squads requires
serious
Either,
consideration.
the
State
Government
should make additional funds available for mobility on
local hire basis. Or alternatively until the regular
vehicle position is strengthened,
Collector
District
Zila
and
the support of the
should
Parishad
be
obtained. The Health Secretary may write letter to the
i
district Collectors to provide support in this regard.
i
9.4
*
Panchayat Samiti members to obtain
*
in
their support
organising effective coverage.
(
(
4
(
4
(
9.5
*
will
outbreaks/epidemics
Focal
specia1
receive
attention and immediate steps will be taken for early
(
i
detection
case
*
*
Medical Officer of PHC should organise meetings with
and
surveys
(
prompt
and
treatment
through
mass
malaria
clinics;
and
of
establishment
initiating anti-larval measures and insecticide spray.
a
9.6
The contract system for executing spray work has not
worked
thus
should
be
it
may
abandoned.
be
Spray
operations
(
(
restricted
time
to
and
the
spray
squads
should be adequately trained. Additional squads should
be created for difficult areas as per the requirement.
For
the daily wages
should
be
district
worked
out
Collector,
of
hiring
by
Zila
81
a
the
labour,
committee
Pramukh,
the
rate
consisting
of
Medical
&
Chief
(
V
(
Of f icer
Deputy
and
(
Health
(
Officer (Malaria).
Chief
Medical
Health
(
<
0
9.7
A
monitoring
schedule
for
spray
should
also
be
prepared. The monitoring of spray should be conducted
The
by Malaria Inspector, DPHS and Dy. CM & HO(M).
Entomological monitoring should be carried out which
I
include adult and larval studies,
■J
vector bio-nomics
and resistance to insecticides and quality of spray.
i
9.8
The
ROHFW
should
be
requested
to
organise regular
studies in the priority districts.
9.9
J
3
i
all
Medical & Health Officer (Malaria) should provide
and
equipments
necessary
and
help
technica1
(
(
supervision of spray operations.
10
(
is willing to take over
In case the panchayat system
Chief
the respons ibi1ity of insecticide spray, Dy.
' Surveillance: .
be the corner stone
10.1 Passive Case Detection (PCD) may
slides collected at
in surveillance and all blood
should be examined
CMC,PHC, hospitals and dispensaries
preference may be given to
on priority basis. The
FTD and mass
sub-centres,
slide collected from
be effectively
surveys. The passive case detection may
disease trends, out
used as the proxy measure for
breaks and effectiveness of the programme.
J
82
□
(
1
(
>
(
10.2. Wherever
>
(
(ACD)
work
load
permits,
detection
case
active
be carried out through MPWs.
(
)
(
)
(
10.3 There should be no time-lag
(
blood
examination.
The
results
same/next
day
at
<
available
i
3
in reporting of results of
the
be
made
institutions
where
should
(
laboratory facilities are available, and within a week
<
to
where such facilities are not available,
initiate
(
action.
(
[
5
(
A
(
3
10.4 In all institutional P.
be
(
3
(
a week
examined again after
of
complete
rad ica1
treatment. This will help in detecting early evidence
(
3
Falciparum cases, blood slides
towards drug resistance.
(
(
5
(
(
10.5 A
sample
check
of
blood
slides
should
be
by
done
verify the
senior technicians and health officials to
results and check the quality of work.
5
(
(
11.
Bio-environmental measures
11.1 Greater
emphasis
should
now
given
be
environmental control measures especia1ly
(
(
(
bio-
where vector
either emerged
resistance to chemical insecticides has
future. Further, the
or likely to emerge in the near
prohibitive
cost of chemical insecticides has become
and these are not free from toxicity.
For
adoption
detailed
of
studies
bio-environmental
of
water
3ar
83
<4
to
control measures,
bodies,
feasibility
of
I
V
(
engineering measures, vector bio-nomics and community
<
(
awareness and there participation are essential.
(
many
(
(
i
Y
(
studies,
experimental
this
a
requires
control
collaboration
with
other
agricultural,
irrigation, public health
sectors
close
education ,
namely;
(
(
Further,
found to be cost effective and acceptable.
bio-environmenta1
been
has
approach
In
engineering,
(
local bodies, panchayats and NGOs and people at large.
(
This should require a high level coordination at the
(
(
*
state and intermediate levels.
leve 1 Coordination Committee
A state
i
be constituted
state
with the Health Secretary as chairman and the
•«
obtain effective
malariolcgist as member secretary to
(
J
participation of all related sectors.
<
(
11.2 The household
need specific mention as they
' tankas'
of breeding
have been found to be an important source
(
and
availability
premises. To
of
vector
within
the
household
prevent mosquito breeding, the Committee
! clean and dry-up these 'tankas' atleast
recommends to
once in a
seem
(
<
which
to
is
week by the people themselves, though it may
be
impracticable.
being
Alternatively,
successfully
used
for
Temophos,
guinea
worm
control, may be used as a larvicide in these 'tankas'
in recommended doses.
• As a long term measure,
it is suggested to encourage
people to make these 'tankas' mosquito proof by fixing
suitable lid and fine wire mesh at the water inlet.- It
84
i
(
(
considered
to
subsidy
provide
through
(
may
(
Rural Development department which is also engaged in
also
be
(
rural sanitation.
(
(
(
12 .
Administrative and Logistics Support
<
The
(
state
>
facilitating
>
providing
government
programme
smooth
seriously
consider
implementation
through
should
administrative
requisite
flexibility
(
Directorate of Medical &
(
(
the
(
J
(
area
of
f inance.
Health Services,
The
Government
to
the
particularly in
should
reconsider
Medical & Health
restore financial powers to the Dy Chief
however, they should work
Officers at the district level,
district Chief
under direct supervision and control of the
(
J
(
Medical & Health Officer.
(
(
(
of health
The vacant positions of various categories
and additional staff
personnel should be immediately filled
should be provided.
at the zonal and district level
-5
*
for
effective
implementation and su pervision of the programme
. Government
Mobility
4
<
(
of
staff
is
for the purchase of vehicles
must initiate immediate steps
&
of Medical
(Jeeps and Trucks) for which the Directorate
A review of
Health has already submitted the proposals.
be carried out so as
district-wise requirements of vehicles
different districts keeping in
to reallocate vehicles to
operations,
view the population to be covered by spray
and
supply
insecticide
travelled,
be
to
distances
supervision to be provided.
I
□
□
3
crucial
85
c
3
(
(
(
(
(
0
(
(
-!v
(
13. Revision of Malaria Control Strategy
The
set an example by making
State Government has
special
provision of
recent
epidemic
selected
in
situation
in
the
districts
of
control
for malaria
funds
Rajasthan. This is very much to be appreciated. The cost
incurred because of morbidity and mortality due to malaria
malaria
on
Investment
heavy.
very
is
(direct/indirect)
control is an investment on human resource development on
which
(
service
sector
productivity
malaria
control
programme
sustained
political
government,
<
(
industrial
and
State.
Hence,
the
high
priority
and
of
the
agricultural,
total
the
depends
the
in
a
requires
sectors
commitment
in
all
because
of
fast
specially
situation in the state and at the national
deteriorating
level during
last few years.
(
(
13.1 Government initiatives
Malaria control
worker.
health
*7
c
isolated concern of the
of
partnership
requires
It
the
involvement of those engaged in
community members and
education,
the
is not
environment in general; and water supply,
sanitation and community development in particular.
(
i
Malaria control must be an integral part of national
development
health
development.
well
as
national
overall
as
Keeping in view the above observations
made in the Global strategy for malaria control, it is
imperative
steps
to
control
3 t
that
the
develop
and
strategy
at
Government
adopt
the
86
an
of
India
initiates
alternative
national
level.
malaria
The group
(
(
(
(
that
alternative
strategy
in
(
(
(
to
addition
recommends
an
level,
the
state
the
at
developing
government may request the Ministry of Health & Family
to
India
of
Government
Welfare,
necessary
take
immediate actions in the matter. This is all the
(
more
essential as a need has now emerged for review of drug
i
and insecticidal policy urgently.
(
i
<
13.2
Stratification for Providing Guidance for Selecting
Malaria Control Measures
based
strategy
control
for
need
urgent
an
is
There
local
on
of
malaria
specific
malario-
revision
metric indices, climatic, topographic characteristics
J
(
(
J
3
3
J
and
such
resources
of
availabi1ity
manpower,
as
logistics and financial. This has become all the more
essential because of changing epidemiology of disease,
<
rising
bionomics,
vector
cost
of
insecticides
and
emerging insecticide and drug resistance.
1
The Committee recommends following stratification and
•5
3
undertaken
be
for
ef f ective
malaria
actions
to
control.
The stratification considers endemicity of
malaria, P. Falciparum proportion-, epidemic proneness,
3
drug
(
vector
resistance,
strati f ied
specific
in
three
malaria
proposed. However,
malaria
being
a
strata
control'
the districts have been
and
for
each
activities
s cratum,
have
been
the Committee strongly feels that
f oca 1
and
87
I
population
characteristics, climatic and topographic conditions.
• Based on above parameters,
3
resistance,
loca1ised
disease,
each
(
V
(
(
(
district should develop its own
parameters indicated above,
information on the
for all the PHCs in its
(
to stratify them and take appropriate malaria
(
area
(
control activities.
The suggested stratification and respective actions
(
have been presented in tabular form below:
c
(
(
0
I
(
(
(
1
15
(
(
3
3
88
□
1 I
U U <J (J O
u
C'
U (> <j
G
i
ACTIONS
STRATUM
parameters
DISTRICTS
Strengthen surveillance and case
management
■k
I A
Tribal
Districts
High scheduled tribe
population, scattered
settlements, hilly/arid
area, high endemicity of
malaria, high P.F- rayo'
unstable malaria,. epidemic
proneness, reports of some
resistance to chloroquine
and vector resistance,
poor communication.
Banswara,
Dungarpur,
Udaipur,
Pajsamand, Sirohi,
Chittorgarh and
Bhilwara
* Effective referral services
Effective supervised indoor
residual spray
*
★ Capacity development for
forecasting and"controlling
epidemics
Developing a management
information and epidemic
monitoring system
k
* To
Desert
districts
Extreme climatic
conditions, varying
rainfall, low population
density, high endemicity
of malaria, high P.F.
Ratio, reports of some
chloroquine and vector
resistance, ep idemic
proneness, development
projects of new water
Jaisalmer, Barmer,
Bikaner, Jalore,
Jodhpur and Pali
89
investigate deaths
To monitor population movement
k
I B
1
•k
Introduce bio-environmental
measures for vector control
k
promote and organise training
programmes for all categories
k
Hold periodic review
k
Organise effective TEC
activities
k
Organise Mobile Malaria Clinics
in selected areas
11
L
U
II
Desert
and semiarid
Districts
<
J
Better health
infrastructure, extreme to
moderate climate, low
endemicity, low P.F.ratio,
low epidemic proneness, no
reported vector
resistance, no reported
resistance to chloroquine,
better communication
J .
if
Ganganagar,
Hanumangarh,
Churu, Jhunjhunu,
Sikar, Nagaur,
Jaipur, Dausa,
Alwar, Ajmer,
Sawa imadhopur
★ Activise private sector for
disease management and
reporting of malaria cases
★ Focal spray in areas with API 2
and above
★ Introduce bio-environmental
measures
* Anti-larval measures through
panchayat system
A
Effective 1 EC measures for
community participation and
awareness
★ Personal protection
90
i u Ou u u a tj
m
Hilly and
Semi-arid
Districts
<3
Better health
infrastructure, low/
moderate endemicity, high
P.F. ratio, infrequent
epidemic situation, new
development projects, high
to moderate rainfall
c
G
Bhcratpur, Kota,
Jhalawar, Baran,
Dholpur, Bundi,
Ajmer and Tonk
• *>
* Detection and treatment of
malaria cases by peripheral
health services and
pract i t ioners
★ Selective vector control
Monitor population movement
A
* Introduce bio-environmental
and water management measures
■k
To hold periodic meetings
k
To organise training
k
Monitor drug and insecticide
res i stance
k
Personal protection measures
k
Investigate deaths
★ Legislative measures for project
areas
* Organise IEC activities
91
13.3
Special Containment Programme for P. Falciparum
wake
(
In
(
infection
preponderance
of
high
and
potential
of
resistance
drug
Falciparum
P.
several
in
(
desert and tribal districts, P. Falciparum containment
activities
should
identif ication
management,
of
be
intensified.
P.
Falciparum
monitor
follow
and
include;
These
cases
up
of
and
their
the
cases,
investigate all P. Falciparum deaths, and focal spray
in the affected populations.
J
In such areas,
v
and
regular studies
resistance
drug
and
resistance
for vector bionomics
should
be
conducted.
(
13.4
(
100 % Central Assistance for tribal and desert
districts
The Committee strongly feels that tribal,
border
d i strlets
incidence
of
Falciparum with
the
in
malaria,
state
which
desert and
preponderance
high
potential drug
high
have
of
P.
resistance and other
J
operational constraints should be considered for 100%
assistance by the Government of India as
north-eastern
states.
The
state
in case of
government
may
consider taking up on this issue with the Ministry of
Health & Family Welfare,
Government of India and the
NMEP.
13.5
□
It
□
3
£
Assistance from International Agencies
is
understood
the
that
92
(
state
government
makes
(
(
(
efforts to seek cooperation to funding from bilateral
(
and international agencies for setting up industries,
(
power projects, health infrastructure development and
(
hospitals.
(
(
(
' may also consider funding of public health programmes
assistance
such as malaria control through similar
(
priority basis.
from similar bilateral agencies on a
(
'V
(
i
(
i
‘W
<
3
(
(
<
5
It is suggested that the state government
14 . Strengthening of Urban Malaria Scheme
The Committee felt that the malaria control activities
in the urban areas should be streamlined.
The larvicidal
in the municipal
operations and bio-environmental control
municipal administration
areas should be implemented by the
of fever cases
and the surveillance and medical management
municipa1
The
department.
health
the
by
done
be
administration should enforce the implementation of bye
<
<
(
(
*
breeding places
laws directed towards preventing/reducing
Scheme the
of vectors. Under the existing Urban Malaria
in view the
f ield staff should be augmented keeping
Further it
expansion of urban limits over a period of time.
of the urban
may be considered to transfer implementation
to the municipal
including funding,
malaria scheme,
bodies/corporations, keeping medical management with the
health department as suggested earlier.
3
1
i
15. IEC Support
, No
programme
effective IEC support.
for
□
increasing
succeed
can
without
adequate
and
Immediate steps must be initiated
awareness
at
93
the
ind iv idua 1,
family
and
>)
■>)
(
(
community level, to enhance utilisation of services and to
(
encourage community participation. Rajasthan is privileged
(
to have an independent and fully functional IEC Bureau in
(
r
<
r
the health sector. The Committee recommends to develop and
implement effective IEC strategy for increasing awareness,
health
utilization
services
and
to
ensure
people's
participation in malaria control activities especially drug
(
insecticide spray, environmental measures and
distribution
personal protection.
in
0
J
Additional funds under the NMEP/MPO must be allocated
for
IEC
organising
activities
Mass
effectively.
should provide adequate coverage with messages
The
Chetna
Jan
Campaign,
as
on malaria.
the
in
organised
media
Barmer
other affected areas
district, should be organised in the
inter-personal
and
approach
on group
focusing
with
such as UNICEF,
communication. Even, international agencies
could be approached tor special assistance, as was done for
5
guinea worm control programme through the
involvement of
NGOs (SWACH) for bio-environmental control measures against
vector
borne
malaria
is
a
diseases
rea 1
including
killer
and
malaria.
Incidentally,
debilitating
disease
in
children and pregnant women.
V!
16.
0
Legislative Measures
New development projects are now being undertaken in
the state. Some of the project areas in which investments
are being made include: hydro and thermal power, irrigation
1
projects,
cement,
mining
and
94
□
medium
and
large
scale
(
in view
industries.
Keeping
(
protection,
the state government may consider adoption of
(
(
(
r
legislative measures regarding
control
of
borne
mosquito
collaboration.
sectora1
(
rapidly
deteriorated
the
under
potential
activities.
due
Under such
environmental management for
inter-
to
The
situation
of
malaria
to
creation
of
mosquitogenic
developmenta1
of
impact
has
proj ect
situations malaria is generated by
human/project activities and the
'V
ensure
and
diseases
<
v
policy of environmental
the
(
primary responsibility for
control should
prevention and control of malaria and vector
for generat i ng
respons i ble
therefore lie with sector
malatiogenic conditions at their cost.
17.
of
Involvement
J
*
Role of Panchayats
malaria
control
seriously considered keeping in view the
activities may be
recent
in
panchayats
Panchayati Raj Act which provides more autonomy and
be involved in
decentralisation ot power. The panchayat may
*
as
malaria control activities such
drug distribution, spray
of insecticides and mobilisation of people.
A
Inter- sectora1 Coordination
18 .
. Malaria
is
a
mu 11 i
factorial
involvement of many sectors
Public
Health
Engineering,
Local
Education and Medical &
such,
must
be
thus
requires
including; Rural Development,
Irrigation,
steps
disease
initiated
to
Bodies,
Agricultural,
Health Department.
ensure
As
inter-sectoral
ia control activities from
coordination for integrated malaria state level to the grassroots leve1.
95
X10
(
(
(
19. Involvement of Voluntary Organisations
(
The Non-Governmental Organisations have an important
(
x
(
0
(
x
<
in general and malaria
role to play in the health sector
control
organisations
These
pa rt icu lar.
in
been
have
involved in various population programme activities by the
i
medical
and
health
programmes
health
but
their
1 imited.
The
Committee
is
in
recommends
Non-Governmental
the
of
participation
increased
involvement
department,
The activities that can
Organisations in malaria control.
be undertaken by these organisations may include:
IEC and
and
disease
insecticide
spray,
0
management,
mobi1ise
monitoring,
and
distribution
drug
mobi1isat ion,
social
for
people
especially
research
operations
in
bio
environmental control measures.
^7
20.
5
Operations Research
operations
5
resea rch
recommends
strong 1y
comm i t tee
The
in
ma lar ia
control.
The
initiating
operations
research may be conducted in developing alternative malaria
control strategies, bio-environmental control measures, use
of impregnated mosquito nets,
drug
distribution
med ica 1
practitioners
insecticides,
indigenous
alternative drug therapy and
and
and
involvement
of
systems
of
other
medicines such as Ayurved and Homeopathy. It is recommended
that
all
the Ayurvedic dispensaries
be
treated
as
fever
treatment depots (FTDs).
The
(ICMR)
organisat ions
such -as
Research
Centre
be requested to undertake experimental projects in
96
k
Malaria
(
<
(
(
bio-environmental measure on pilot basis, studies on drug
and vector resistance, alternative surveillance strategies
(
(
and their effectiveness in monitoring malaria situation,
(
etc.
(
Effectiveness of edible oil,
mosquito breeding in the Barmer and Jaisalner districts,
should
V’
as was done to prevent
also
be
evaluated
as
it
may
have
long
implications for malaria control activities.
■e
v)
•o
•o
:!
3
3
3
3
3
3
5
3
3
3 ,
(
2 ,
□ ,
97
(
.
term
5
(
(
)
CHAPTER 7
(
RECOMMENDATIONS FOR IMMEDIATE ACTIONS
(
J
(
>
<
J
-
(
Keeping in view the impending resurgence
J
0
and perpetuating problem of
the month of March and April
malaria, the group recommends
of malaria in
following short-term measures
for immediate actions:
1.
The
Committee
endorses
the
appropriateness
control
programme
and
recommends
adequacy
of
the
crash
malaria
launched
by
the
State
Government
continuation of this programme
and
in Jaisalmer and Barmer
districts.
i
5
2.
Government
State
to
Technica1
Group
malaria
s 1 tuat ion
should
appoint
rev i ew
and
the
ongoing
necessary
control
monitor
suggest
and
departmental
a
measures.
4
3.
After
serious consideration
4
inadequacy of
persistent
insecticide
transmission,
4
additional round of Indoor
and keeping
spray
the
in view the
1994
and
recommends
an
in October
group
Residual Insecticide spray
in Jaisalmer and Barmer districts.
However it should
systematically and
be ensured that the spray is done
to
prior
trained
adequately
is
man-power
the
pproval from the
undertaking the spray operations. An a
obtained. However, pending
NMEP, New Delh i may be
provide
should
government
state
the
approva1,
□
98
(
■o
4.
(
disease
The
The
strengthened.
be
must
management
District Hospitals, CHCs, PHCs must be fully equipped
(
'V
(
with necessary drugs and equipments. Indoor facilities
(
for
of
admission
cases
of
should
be
of Chloroquine and 45 mg.
of
Those
not
and
severe
complicated
(
malaria must be kept in readiness.
i
<
i
5.
The
patients
P.Falciparum
of
treated with 1500 mg.
as
a
responding
of
this
combination of
t
i
drug
action.
therapy,
Sulphalene and
institutions only.
J
J
of
line
f irst
. Primaquine
infection
should
be
Pyrimethamine
given
in
the
In view of persistent gametocyte
presence in blood films in afebrile cases even after
three or more completed radical treatment cycles, all
3
P.
Falciparum
infections
in
Jaisalmer
and
Barmer
districts should be treated with 75 mg Primaquine to
be given over a period of five days as is done in P.
4
Vivax cases. An approval from the NMEP, Delhi may be
3
obtained
, under
tor changes in the drug policy recommended
special
such
circumstances.
However,
pending
government
should
provide
approva1,
the
state
necessary
funds
for
the
is proposed
that
mobile
additional requirements
of
clinics may
be
(
drugs.
(
6.
It
established
to
diagnose
villages itself.
99
■
a
and
malaria
treat
patient
in
the
7.
The surveillance, including blood slides examination
in
developed under the crash malaria control programme
these two districts must be maintained.
I
*
8.
cases must be
A follow up mechanism for p.Falciparum
followed up until
developed and the cases should be
the parasite clearance.
9.
There
is an urgent
campaign
need to mount an
in
the
Jaisalmer
IEC
The Jan Chetna Shivir
in these districts.
organised in Barmer district may be
initiated
intensive
continued and also
district.
Besides this,
exploited to communicate
mass media should be fully
increase awareness and adopt
the IEC messages to
requisite malaria control measures.
3
10.
break the man-mosquito
There is an immediate need to
villages. Households
cycle in the households and
dried up regularly.
tankas should be cleaned and
larvicidal in the
Alternative, Temophos may be used as
recommended doses.
5
11.
Keeping
in view anaemia
and malnutrition caused by
should be given
malaria, the young children
solution in addition to iron folic acid.
12 .
I
The
informat ion
system
programme must be maintained.
0
0
developed
100
■ in
vitamin A
the
crash
■,d
(
(
IMPORTANT REFERENCE MATERIAL USED FOR
PREPARATION OF THE REPORT
<
(
<
(
2.
A Global Strategy for Malaria Control.
Organisation, Geneva, 1993.
4 .
5
6
J
7
5
8.
5
9.
3
11.
Centre,
V/orld Health
Development of Strategies and Approaches to Malaria
Control in South-East
Asia. A
A Report
Report of Regional
Technioafcommittee, SEARO, World Health Organization,
1987.
Malaria and its Control in India. Vol I, Vol II and
National Malaria Eradication
Vol III. Directorate of
Services,
General
of
Health
Director
Programme.
Government of
Ministry of Health & Family Welfare,
India, 1986.
Chemotherapy
Practica1
Series
No. 805.
Report
Geneva, 1990 .
WHO Technical
of Malaria.
Health
Organisation,
World
al.
p.
Falciparum
p.
Ray AP,
Narsimhan MVVL,
et
of
Operation
in India
Containment Programme- Ten Years
Malaria
of
national
1.
—---(1978-1988).
PfCP/Directorate .
Eradication/WHO/SIDA, New Delhi, 1988 .
Epidemiological Consideration for Planning Malaria
Control in South East Asia Region. (Eds) Kondrashim AV
and'"Rashid IT.'"world Health Organisation, SEARO,
SEARO, New
Delhi,
10.
Strategy.
Cyan Prakash. Training Heeds Assessment of Health
. Workers and Community Participation and Behaviour-• in
Malaria Control Programme in State of Rajasthan.
Directorate of Medical & Health Services, Rajasthan,
Jaipur, 1988.
New Delhi,
■3
Research
Malaria Contro1
Delhi, 1994 .
(
'V
Malaria
1.
1987.
for
for Environmenta1 Management
Manua1
Control With Special Emphasis on Malaria
World Health Organization, Geneva, 1982 .
Mosquito
Vectors.
Implementation of the Global Malaria Control Strategy.
Report of a WHO
Group on the implementation of
WHO Study
Study Group
the Global Plan
of Action
Plan of
Action for Malaria Control (
Geneva r usi.
2000), World Health Organization, Geneva,
Malaria
Control
the
Revised
of
Implementation
Working
Group
Meeting.
Strategy. Report of a Reg iona 1 1
SEARO, New
SEA/MAL/178. World Health Organization,
Delhi, 1993.
Malaria
Sharma VP. New Technologies in Vector Control.
13 .
' Research Centre, New Delhi, 19
12 .
u\s sn
a
-o
f7
LIBRARY
and
> O'*
>
l*\ DOCUMENTATION ) ’-n
X s. -'—Air
(
(
■k
(
14 .
f
(
(
15
(
(
16 .
of National Malaria
Harar xa EradlC®yi°]n
Records Level),
Directorate
of
Medical
Di
rectorate
(State
Services , Government of Rajasthan.
Records of National Malaria
(District Level), Directora
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Programme
&
Health
Programme
& Health
Profile of Indira Gandhi IJahar Project. Indira Gandhi
.
Nahar Board, Government of Rajastha , Jaipur
,
___ ' , Office of the
Monsoon 1994. Irrigation Department^,
Government of Rajasthan.
Deputy Director, Hydrology. -- - .
■ t office of the
Monsoon
Monsoon 1993. Irrigation Department,
18 .
Government of Rajasthan.
Deputy Director, Hydrology. -Research
Medicine
Desert
Report
1992-93.
Annua 1
19 .
, Centre, ICMR, Jodhpur.
in
three
Investigations
Entomolog ica1
of
Report
Rajasthan
.
20 .
in Jaisalmer,
villages of PHC Pokaran
Research Centre, New Delhi, 1994 .
Malaria
17 .
8eport O„ water
21.
' -eaS
' —; ^Irr^ated
in Irrigated —
•
of Irrigation. <
Irrigation,
Snr^ln^rSl^n^Xn-ent of Rathan,
Jaipur.
in
Malaria
in
2_ g
Resistance
Drug
Brief
Report
on
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Welfare,
Rajasthan. Regional Office of Health &
Rajasthan, Jaipur.
Insecticide
and
Malaria
Vector
Report
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23 .
Rajja sthan. Regional
Status i n —
ResistanceFamily
Welfare, Rajasthan, Jaipur.
Health & 1
■ ) of Population in Rajasthan,
District-wise Migration
24 .
and Wool, Rajasthan, Government o
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' An Analysis of
[^Xures^'olmlnd/clnsumption of
25.
in Plant Protection
Ranasthan. Department of
Technical Grade Material
P
Agriculture, Government of Rajastha .
22 .
3
J
J
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JODHPUR ZONE
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o
a
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84
85
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YEARS
0
Barni
e
Jaisalmer
JodhpU|
Sirohi
Figure : 1
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Jalore
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t
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20
15
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86
87
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89
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Figure : 2
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Figure : 5
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92
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Dungarpur
YEARS
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93
91
94
0 C;'
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40 rI
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l-h ...
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20
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10
I
I I
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o4—
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1991
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Figure : 9 A
1993
”Q
Roopwas
1994
;l
■:
‘i
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20
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10
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Sewar
I
~--n
—--KJ-7
oL—
1991
1992
4— Kumbher
De eg
1994
1993
e
Jurhera
Bhusawar
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(
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L
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I k
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r
G
o
c
Jaipur API (PHO Wise)
40
30
20
• 10
i >
0*—
1990
—
=4^
—4^
1991
1992
1993
-
--e- B h i c h o o n
Amarsar
Bassi
BhanpurKala
Jahota
Kaladera
Kishangarh Renwal
Figure : 10 A
1994
U V <J L'C U (J o u u u u
U
G
U
G
G
U
C
J-
G
F
Jaipur API (PHC Wise)
40
30
20
•10
0*=
1990
e-
—6i—
—*—
1991
1992
1993
Kotkhawda
Med
—Na re da
Faagi
Sirsi
Vatika
Figure( : 10 B
1994
' 1
<
A I
r
i L
. 1
i II
i 1
u
I
*' C-
■
Ganganagar API (PHC Wise)
I
il
ar /
r
.
40
30 -
20 I
i
10
0®—
=*=
1990
1991
Shivpur
a
Anoopgarh
___ rk----
1992
—I—
Shr iKaranpur
Raisingh Nagar
Figure : 11 A
1993
Ghumad Wall
J
1994
Q V L! (J
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40
30
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1991
1990
Bichiwada
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1992
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Semal wada
Figure : 12
1993
Punjpur
1994
i
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40
30 -
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1990
Rawatsur
1993
1992
1991
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1994
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(
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(
Page 1
(
Annexure- I
(
I
District-wise Malario Metric Inciice
1984-94, RAJASTHAN
(
(
5
f
Year
Popu 1 a t i-on Rainfall
o
3
£
API
ABER
SPR
7305
4239
2476
2849
5170
3954
2432
898
890
977
1966
1571
726
100
59
575
277
154
66
161
96
396
21.51
17.13
4.04
2.07
11.12
7.01
6.33
7.35
18.09
9.83
20.14
4.50
2.61
1.53
1.44
2.61
1.99
1.23
0.39
0.39
0.43
0.86
6.81
6.51
5.59
5.69
7.70
7.47
9.17
7.29
9.32
8.78
8.55
6.62
4.02
2.73
2.52
3.39
2.67
1.34
0.54
0.42
0.49
1.00
1.42
0.69
0.11
0.05
0.38
0.19
0.08
0.04
0.08
0.05
0.20
182200
134547
84757
83206
113702
81640
110400
105284
185852
134604
154851
6900
7609
2486
484
1112
808
1814
2808
13763
12293
8989
185
2792
415
75
197
130
724
369
3590
4002
1227
2.68
36.69
16.69
15.50
17.72
16.09
39.91
13.14
26.08
5.36
13.65
1.31
1.71
8.36
7.47
5.44
14.16
10.25
6.45
6.01
8.21
5.90
7.97
6.39
11.29
8.18
9.38
3.79
5.66
2.93
0.58
0.98
0.99
1.64
2.67
7.41
9.13
5.80
0.10
2.08
0.49
0.09
0.17
0.16
0.66
0.35
1.93
2.97
0.79
700.00
985.00
665.00
621.00
0
0
0
0
0
0
0
46101
86256
76279
79349
0
0
0
0
0
0
0
172
867
420
288
0
0
0
0
0
0
0
22
113
26
68
0.00
0.00
0.00
0.00
0.00
0.00
0.00
12.79
13.03
6.19
23.61
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.20
0.99
0.48
0.28
0.00
0.00
0.00
0.00
0.00
0.00
0.00
5.27
9.86
8.72
7.85
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.37
1.01
0.55
0.36
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.05
0.13
0.03
0.09
4 . DISTRICT - DHOLPUR
585059
1984
585059
1985
585059
1986
585059
1987
585059
1988
585059
1989
836.10
585059
199 0
360.80
748326
1991
992.70
748326t
1992
429.70
748326
1993
571.00
749479
1994
69884
66206
60840
48687
55649
58493
63601
67868
87311
64525
71077
5793
2717
1189
256
328
546
598
422
515
648
663
1376
486
111
29
63
’83
176
150
474
100
237
23.75
17.89
9.34
11.33
19.21
15.20
29.43
35.55
92.04
15.43
35.75
9.90
4.64
2.03
0.44
0.56
0.93
1.02
0.56
0.69
0.87
0.88
11.94
11.32
10.40
8.32
9.51
10.00
10.87
9.07
11.67
8.62
9.48
8.29
4.10
1.95
0.53
0.59
0.93
0.94
0.62
0.59
1.00
0.93
1.97
0.73
0.18
0.06
0.11
0.14
0.28
0.22
0.54
0.15
0.33
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
3
%PF
Sr R
Pr
110421
105529
90.667
112897
152637
148242
181976
166701
213011
200812
196441
ALWAR
1621987
1621987
1621987
1983496'
1983496
1983496
1983496
2286701
2286701
2286701
2296580
1. district
3
BSE MALARIA
CASES
767.60
319.00
675.00
665.00
454.00
bharatpur
2. DISTRICT
1287120
1984
1313214
1985
1313214
1986
1384329
1987
1384329
1988
1384329
1989
671.30
1384329
1990
447.40
1646501
1991
736.30
1646501
19j2
558.20
1646501
199 3
546.00
1651584
1994
DAUEA
3 . DISTRICT
0
1984
0
1985
0
19 8 6
0
1987
0
1988
0
1989
0
1990
874393
1991
874393
199 2
874393
1993
1010883
1994
32.56
5.79
1.89
0.35
0.80
0.58
I
f
Page 2
(
(
Year
Popu1acion Rainfall
(
(
(
‘O
(
I
I
*
(
a
BSE MALARIA
CASES
PF
tPF
API
ABER
SPR
SER
JAIPUR
5. DI STR I CT
3188330
1984
3459300
1985
3459300
1986
3459300
1987
3505210
1988
3505290
1989
694.50
3505290
1990
561.00
3844864
1991
442.00
3844864
1992
493.00
3844864
1993
661.00
3871445
1994
221672
252562
211320
220092
227807
198024
221553
158967
186737
181266
246336
3425
3840
1482
1100
764
889
785
589
1166
526
4068
211
245
454
40
68
91
94
35
251
72
1482
6.16
6.38
30.63
3.64
8.90
10.24
11.97
5.94
21.53
13.69
36.43
1.07
1.11
0.43
0.32
0.22
0.25
0.22
0.15
0.30
0.14
1.05
6.95
7.30
6.11
6.36
6.50
5.65
6.32
4.13
4.86
4.71
6.36
1.55
1.52
0.70
0.50
0.34
0.45
0.35
0.37
0.62
0.29
1.65
0.10
0.10
0.21
0.02
0.03
0.05
0.04
0.02
0.13
0.04
0.60
JHUNJHUNU
6. DISTRICT
1264000
1984
1264000
1985
1264000*
1986
1264000
1987
1264000
1988
1264000
1989
381.00
1264000
1990
337.00
1565488
1991
509.00
1565488
1992
401.00
1565488
1993
450.00
1582421
1994
81840
86453
67986
50650
65962
57040
80775
73572
84406
87278
122694
4884
3611
1516
1032
686
827
800
674
662
761
3100
516
310
45
13
18
28
75
40
128
57
843
10.57
8.58
2.97
1.26
2.62
3.39
9.38
5.93
19.34
7.49
27.19
3.86
2.86
1.20
0.82
0.54
0.65
0.63
0.43
0.42
0.49
1.96
6.47
6.84
5.38
4.01
5.22
4.51
6.39
4.70
5.39
5.58
7.75
5.97
4.18
2.23
2.04
1.04
1.45
0.99
0.92
0.78
0.87
2.53
0.63
0.36
0.07
0.03
0.03
0.05
0.09
0.05
0.15
0.07
0.69
SIKAR
7 . DISTRICT
1445501
1984
1445501
1985
1445501
1986
1540877
1987
1540877
1988
1540877
1989
1540877
1990
1836572
1991
1992
1835572
1836572
199 3
1842514
1994
468.00
344.00
464.00
296.00
525.00
3532
77577
95410
119832
130482
101345
112436
106479
116110
127652
177851
1183
702
300
875
139
127
141
89
82
78
648
95
47
17
0
15
15
12
11
16
8
457
8.03
6.70
5.67
0.00
•10.79
11.81
8.51
12.36
19.51
10.26
70.52
0.82
0.49
0.21
0.57
0.09
0.08
0.09
0.05
0.04
0.04
0.35
0.24 33.49
0.90
5.37
6.60 0.31
7.78 0.73
8.47 0.11
6.58 0.13
7.30 0.13
5.80 0.08
6.32 0.07
6.95 0.06
0.36
9-. 6 5
2.69
0.06
0.02
0.00
0.01
0.01
0.01
0.01
0.01
0.01
0.26
8. DISTRICT - BIKANER
1984
840059
1985
840059
1986
840059
198 7
840059
1988
840059
1989
840059
1990
278.00
840059
1991
1209107
159.00
1992
1209107
336.00
1993
1209107
227.00
1994
1211140
350.00
80551
75850
67837
70210
67488
74206
76015
64729
95455
83980
46187
1887
1344
1277
799
565
1114
2043
1120
7237
3675
1309
112
70
75
17
28
134
525
129
3704
458
175
5.94
5.21
5.87
2.13
4.96
12.03
25.70
11.52
51.18
12.46
13.37
2.25
1.60
1.52
0.95
0.67
1.33
2.43
0.93
5.99
3.04
1.08
9.59
9.03
8.08
8.36
8.03
8.83
9.05
5.35
7.89
6.95
3.81
2.34
1.77
1.88
1.14
0.84
1.50
2.69
1.73
7.58
4.38
2.83
0.14
0.09
0.11
0.02
0.04
0.18
0.69
0.20
3.88
0.55
0.38
9. DISTRICT - SRI GANGANAGAR
1984
220812
1984514
1985
280408
1984514
1986
191814
1984514
1987
191194
1984514
1988
170250
1984514
10838
9000
4240
1270
238
2810
1463
290
32
15
25.93
16.26
6.84
2.52
6.30
5.46
4.54
2.14
0.64
0.12
11.13
14.13
9.67
9.63
8.58
4.91
3.21
2.21
0.66
0.14
1.27
0.52
0.15
0.02
0.01
6
35
.57
i.48
Page 3
(
(
5
(
.1
(
BSE MALARIA
CASES
PF
%PF
API
ABER
SPR
SFR
266.00
230.00
354.00
223.00
301.00
143115
150175
158710
162823
151977
164938
376
223
218
984
559
4889
15
12
12
291
35
338
3.99
5.38
5.50
29.57
6.26
6.91
0.19
0.11
0.08
0.38
0.21
1.86
7.21
7.57
6.06
6.22
5.80
6.29
0.26
0.15
0.14
0.60
0.37
2.96
0.01
0.01
0.01
0.18
0.02
0.20
368.00
305.00
394.00
511.00
376.00
86325
90715
80400
73934
77662
68766
67632
59922
67675
69980
89581
2861
3815
1710
577
644
1097
1556
1211
1483
1707
5457
203
101
43
7
36
55
137
32
292
59
1249
7 . 10
2.65
2.51
1.21
5.59
5.01
8.80
2.64
19.69
3.46
22.89
2.43
3.24
1.45
0.49
0.55
0.93
1.32
0.79
0.96
1.11
3.54
7.34
7.70
6.83
6.28
6.59
5.84
5.75
3.89
4.40
4.55
5.80
3.31
4.21
2.13
0.78
0.83
1.60
2.30
2.02
2.19
2.44
6.09
0.24
0.11
0.05
0.01
0.05
0.08
0.20
0.05
0.43
0.08
1.39
11 . DISTRICT - BARMER
1118892
1984
1118892
1985
1118892
1986
1118892
19 87
1118892
1988
1118892
1989
739.80
1118892
1990
49.00
1433351
1991
413.00
1433351
19 92
386.00
1433351
1993
653.00
1994
1435222
76843
88879
77317
91600
90345
110781
159242
103042
162377
133791
339615
101
1040
308
1752
57
566
34
207
194
1710
2303
8133
6571
19322
1221
11033
4182
12218
836
5508
34941 17172
9.71
17.58
10.07
16.43
11.35
28.32
34.01
11.07
34.23
15.18
49.15
0.93
1.57
0.51
0.19
1.53
7.27
17.27
7.70
8.52
3.84
24.35
1.35
6.87
1.97
7.94
6.91 0.73
8.19 0.23
1.89
8.07
9.90 7.34
14.23 12.13
7.19 10.71
7.52
11.33
9.33 4.12
23.66 10.29
0.13
0.35
0.07
0.04
0.21
2.08
4.13
1.18
2.58
0.62
5.06
12 . DISTRICT - JAISALMER
166667
1984
198 5
231869
1986
231069
1987
231069
1988
241069
1989
241069
1990
107.10
241069
1991
343618
129.50
1992
343618
232.60
1993
343618
370.70
1994
343517
192.00
15325
13666
14300
18321
19579
19608
29647
21579
20000
36233
81963
370
152
100
335
557
2007
301
3695
3131
18129
31
21
3
16
15
128
416
89
1567
1602
12261
5.02
5.68
1.97
16.00
4.48
22.98
20.73
29.57
42.41
51.17
67.63
3.71
1.60
0.66
0.43
1.39
2.31
8.33
0.88
10.75
9.11
52.77
4.03 0.20
9.19
2.71 0.15
5.89
1.06 0.02
6.19
7.93 0.55 0.09
1.71 0.08
8.12
2.84 0.65
8.13
1.40
12.30 6.77
0.41
1.39
6.28
5.82 18.48 7.83
4.42
8.64
10.54
23.86 22.12 14.96
13 . DISTRICT
JALORE
1984
905688
1985
905688
1986
905688
1987
905688
1988
905688
1989
905688
1990
905688
1039.40
1991
1141604
164.00
1992
1141604.
745.00
1993
1141604
394.60
1994
1142563
717.00
33827
39360
38843
55000
87889
82117
123629
74632
106672
86201
156171
244
412
319
370
7131
4949
7058
2407
2103
1536
5364
17
30
37
41
2230
710
2122
316
1009
469
2646
6.97
7.28
11.60
11.08
31.27
14.35
30.07
13.13
47.98
30.53
49.33
0.27
0.45
0.35
0.41
7.87
5.46
7.79
2.11
1.84
1.35
4.69
3.73
4.35
4.29
6.07
9.70
9.07
13.65
6.54
9.34
7.55
13.67
Year
Popu1at ion Rainfall
(
(
(
1989
1990
1991
1992
1993
1994
1984514
1984514
2618914
2618914
2618914
2622777
10. DISTRICT - CHORD
1176471
1984
1177821
1985
1177821
19 66
1177821*
1987
v>
K)
o
0
0
□
0
0
o
o
0
1988
1989
1990
1991
1992
1993
1994
1177821
1177022
1177022
1539470
1539470
1539470
1543211
■
618
0.72
1.05
0.82
0.67
8.11
6.03
5.71
3.23
1.97
1.78
3.43
0.05
0.08
0.10
0.07
2.54
0.86
1.72
0.42
0.95
0.54
1.69
3
...
R §
■
(
Page 4
(
(
o
Year
Population Rainfall
(
o
O
L
(
BSE MALARIA
CASES
PF
%PF
API
ABER
SPR
SFR
JODHPUR
14. DISTRICT
1695712
1984
1695712
1985
1695712
1986
1695712
1987
1695712
1988
1695712
1989
821.00
1695712
1990
232.50
2127552
1991
526.00
2127552
1992
232.00
2127552
1993
470.00
2153483
1994
118219
120199
102314
100019
103346
97645
125399
110099
656940
595567
222697
456
4883
315
1901
117
1834
29
399
277
2887
1417
6011
3022
10462
1031
6374
38864 14628
5771
24219
7282
11961
9.34
16.57
6.38
7.27
9.59
23.57
28.89
16.18
37.64
23.83
60.88
2.88
1.12
1.08
0.24
1.70
3.54
6.17
3.00
18.27
11.38
5.55
6.97
7.09
6.03
5.90
6.09
5.76
7.40
5.17
30.88
27.99
10.34
4.13
1.58
1.79
0.40
2.79
6.16
8.34
5.79
5.92
4.07
5.37
0.39
0.26
0.11
0.03
0.27
1.45
2.41
0.94
2.23
0.97
3.27
PALI
15. DISTRICT
1379141
1984
1390745
1985
1390745.
1986
1390745
1987
1390745
1988
1390745
1989
1047.00
1390745
1990
304.60
1484691
1991
685.80
1484691
1992
291.40
1484691
1993
649.00
1486432
1994
124020
115856
122940
146377
194630
160239
189542
134850
156494
146679
195116
5163
2869
1989
3217
10706
12097
14608
9746
7957
7339
12264
287
259
267
466
2583
1975
4023
1220
1849
1122
3592
5.56
9.03
13.42
14.49
24.13
16.33
27.54
12.52
23.24
15.29
29.29
3.74
2.06
1.43
2.31
7.70
8.70
10.50
6.56
5.36
4.94
8.25
8.99
8.33
8.84
10.53
13.99
11.52
13.63
9.08
10.54
9.88
13.13
4 . 16
2.48
1.62
2.20
5.50
7.55
7.71
7.23
5.08
5.00
6.29
0.23
0.22
0.22
0.32
1.33
1.23
2.12
0.90
1.18
0.76
1.84
SI ROH I'
16. DISTRICT
1984
569504
1985
569504
1986
569504
1987
569504
1988
569504
1989
569504
1990
1415.40
569504
1991
953324
206.80
1992
653324
931.80
1993
542.20
653324
1994
654029
.691.00
39507
38425
35152
55097
76571
66621
81557
48768
55778
59260
67113
453
397
260
640
4556
7670
5449
3540
3214
3609
3928
33
33
32
35
1412
2141
1547
591
1307
922
767
7.28
8.31
12.31
5.47
30.99
27.91
28.39
16.69
40.67
25.55
19.53
0.80
0.70
0.46
1.12
8.00
13.47
9.57
3.71
4.92
5.52
6.01
1.15
6.94
1.03
6.75
6.17 0.74
1.16
9.67
13.45 5.95
11.70 11.51
6.68
14.32
5.12 7.26
5.76
8.54
6.09
9.07
10.26 5.85
0.08
0.09
0.09
0.06
1.84
3.21
1.90
1.21
2.34
1.56
1.14
17 . DISTRICT
BANSWARA
1984
914180
1985
914180
1986
914180
1987
914180
1988
914181
1989
914180
1990
914180
141.00
1991
1154964
410.00
1992
1154964
1203.00
1993
1154964
1204.00
1994
1155600
1397.00
91871
110164
136539
131420
118628
75429
112117
121594
156339
154151
137504
1377
2829
6971
6183
4200
2315
2381
3085
3026
3884
2863
499
876
4274
3717
2255
1155
1160
1594
1345
2143
1429
36.24
30.97
61.31
60.12
53.69
49.89
48.72
51.67
44.45
55.18
49.91
1.51
3.09
7.63
6.76
4.59
2.53
2.60
2.67
2.62
3.36
2.48
10.05
12.05
14.94
14.38
12.98
8.25
12.26
10.53
13.54
13.35
11.90
1.50
2.57
5.11
4.70
3.54
3.07
2.12
2.54
1.94
2.52
2.08
0.54
0.80
3.13
2.83
1.90
1.53
1.03
18. DISTRICT
CHITTORGARH
1984
1235800
1985
1235800
1986
1235800
1987
1235800
1988
1235800
1989
1235800
99569
118811
126520
165333
182693
157623
2318
1974
7889
8263
15535
13677
211
268
705
1402
4695
2328
9.10
13.58
8.94
16.97
30.22
17.02
1.88
1.60
6.38
6.69
12.57
11.07
8.06
9.61
2.33
1.66
6.24
5.00
8.50
8.68
0.21
0.23
0.56
0.85
2.57
1.48
10.24
13.38
14.78
12.75
1.31
0.86
1.39
1.04
<
Page 5
<
%PF
API
SPR
SFR
PF
ABER
BSE MALARIA
CASES
152337
124921
138383
142128
128377
5838
4096
4864
4362
5002
2180
1144
846
900
170
37.34
27.93
17.39
20.63
3.40
4.72
2.76
3.28
2.94
3.37
12.33
8.43
9.34
9.59
8.65
3.83
3.28
3-. 51
3.07
3.90
1.43
0.92
0.61
0.63
0.13
93231
63974
87680
82081
93451
59362
73187
70249
72374
84158
91680
965
456
2799
7191
8041
7085
5357
4099
6050
7605
7127
266
158
1667
2683
5183
4202
2859
1971
3927
4223
3714
27.56
34.65
59.56
37.31 •
64.46
59.31
53.37
48.08
64.91
55.53
52.11
1.41
0.67
4 . 10
10.53
11.72
10.33
7.85
4.69
6.92
8.70
8.15
1.04
13.65
9.37 0.71
12.84 3.19
12.02 8.76
13.63 8.60
8.66 11.94
7.32
10.72
8.03 5.83
8.28 8.36
9.62 9.04
10.48 7.77
0.29
0.25
1.90
3.27
5.55
7.08
3.91
2.81
5.43
5.02
4.05
0
0
0
0
0
0
0
79599
87774
78375
90158
0
0
0
0
0
0
0
1642
1521
1765
2693
0
0
0
0
0
0
0
159
213
209
449
0.00
0.00
0.00
0.00
0.00
0.00
0.00
9.68
14.00
11.84
16.67
0.00
0.00
0.00
0.00
0.00
0.00
0.00
1.93
1.79
2.07
2.81
UDAIPUR
21. DISTRICT
2351988
1984
2356959
1985
2356959
1986
2356959
1987
2356959
1988
2775418
1989
855.00
2775418
1990
513.00
2034246
1991
858.00
2034246
J992
486.00
2034246
1993
958.00
2093544
1994
192904
191875
246143
349886
336613
2777834
318180
174679
194482
211019
200869
8850
3430
7109
19866
18746
18528
12580
6105
9700
13040
13034
974
610
1941
2880
4199
4231
3201
2181
3751
4193
3944
11.01
17.78
27.30
14.50
22.40
22.84
25.45
35.72
38.67
32.15
30.26
0.50
8.20 4.59
3.76
1.79 0.32
8.14
1.46
2.89 0.79
10.44
3.02
5.68 0.82
14.84
8.43
1.25
5.57
14.28
7.95
0.15
0.67
6.68 100.10
1.01
3.95
11.46
4.53
1.25
3.49
8.59
3.00
1.93
4.
99
9.56
4.77
1.99
6.18
10.37
6.41
1.96
6.49
9.59
6.23
BUNDI
22. DISTRICT
570217
1984
570217
1985
570217
1986
608104
1987
608104
1988
608104
1989
860.40
608104*
1990
479.20
768150
1991
502.50
768150
1992
662.60
768150
1993
812.00
770243
1994
4 4 6 62
50198
44199
40396
55024
67257
57692
58582
67006
534 38
66780
1140
1373
1892
727
766
958
1040
1363
3244
2398
2838
516
519
390
76
102
153
217
688
1344
563
963
45.26
37.80
20.61
10.45
13.32
15.97
20.87
50.48
41.43
23.48
33.93
2.00
2.41
3.32
1.20
1.26
1.58
1.71
1.77
4.22
3.12
3.68
M
Year
1990
1991
1992
1993
1994
<
(
0
<
1235800
1482267
1482267
1482267
1484190
1116.00
952.50
819.70
529.40
939.00
dungarpur
19. district 682845,
1984
682845
1985
682845
1986
682845
1987
685845
1988
685845
1989
682845
1990
874329
1991
874529
1992
874529
1993
874549
1994
(
(
(
c
(
t-
o
popu1 atxon Rainfall
1024.20
583.80
654.80
692.00
1205.00
20. DISTRICT - RAJSAMAND
0
1984
0
1985
0
1986
0
19o7
0
1988
0
19 89
0
1990
446.00
850793
1991
679.00
850793
1992
461.00
850793
1993
548.00
957557
1994
i
(
c
o
o
o
$
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
9.36 2.06 0.20
1.73 0.24
10.32
0.27
9.21 2.25
9.42 2.99 0.50
7.83
8.80
7.75
6.64
9.05
11.06
9.49
7.63
8.72
6.96
8.67
2.55
2.74
4.28
1.80
1.39
1.42
1.80
2.33
4.84
4.49
4.25
1.16
1.03
0.88
0.19
0.19
0.23
0.33
1.17
2.01
1.05
1.44
<
J
Page 6
<
(
' (
Year
population Rainfall
(
BSE MALARIA
CASES
PF
%PF
API
ABER
SPR
SFR
(
(
(
(
(
I(
I(
!<
*
23. DISTRICT - BARAN
0
1984
0
1985
0
1986
0
1987
0
1988
0
1989
0
1990
1046.80
841484
1991
605.40
814484
1992
631.00
814484
1993
1079.00
810326
1994
0
0
0
0
0
0
0
76332
89666
101252
111522
0
0
0
0
0
0
0
905
1091
1824
3523
0
0
0
0
0
0
0
298
346
664
1843
0.00
0.00
0.00
0.00
0.00
0.00
0.00
32.93
31.71
36.40
52.31
0.00
0.00
0.00
0.00
0.00
0.00
0.00
1.08
1.34
2.24
4.35
0.00
0.00
0.00
0.00
0.00
0.00
0.00
9.07
11.01
12.43
13.76
0.00
0.00
0.00
0.00
0.00
0.00
0.00
1.19
1.22
1.80
3.16
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.39
0.39
0.66
1.65
JHALAWAR
24. DISTRICT
820709
1984
832162
1985
832102
1986
832102
1987
832162*
1988
832182
1989
1027.30
832182
1990
714.80
955510
1991
836.00
955510
1992
1113.60
955510
1993
974.00
956971
1994
112649
129700
118909
106996
122823
106141
106190
99739
113838
105667
103160
2539
1902
1796
2395
2454
1266
815
648
471
1317
1427
748
663
776
900
1184
519
356
201
210
521
581
29.46
34.86
43.21
37.58
48.25
41.00
43.68
31.02
44.59
39.56
40.71
3.09
2.29
2.16
2.88
2.95
1.52
0.98
0.68
0.49
1.38
1.49
13.73
15.59
14.29
12.86
14.76
12.75
12.76
10.44
11.91
11.06
10.78
2.25
1.47
1.51
2.24
2.00
1 . 19
0.77
0.65
0.41
1.25
1.38
0.66
0.51
0.65
0.84
0.96
0.49
0.34
0.20
0.18
0.49
0.56
S. MADHOPUR
25. DISTRICT
1611762
1984
1650205
1985
1650205
1986
1987
1650205
1988
1650205
1650205
1989
663.00
1990
1650205
773.00
1991
1953807
1953807
807.00
1992
713.00
1993
1953807
1994
1803471
90625
88950
181429
137760
138295
117691
139921
167925
190897
175637
130119
1239
1210
502
540
817
1009
2828
1847
2851
2730
2275
111
129
60
33
101
36
135
180
279
1^9
3 54
8.96
10.66
11.95
6.11
12.36
3.57
4.77
9.75
9.79
6.92
15.56
0.77
0.73
0.30
0.33
0.50
0.61
1.71
0.95'
1.46
1.40
1.26
5.62
5.39
10.99
8.35
8.38
7.13
8.48
8.59
9.77
8.99
7.21
1.37
1.36
0.28
0.39
0.59
0.86
2.02
1.10
1.49
1.55
1.75
0.12
0.15
0.03
0.02
0.07
0.03
0.10
0.11
0.15
0.11
0.27
182953
153613
171385
109736
206441
181630
219642
112154
125960
118817
117670
3602
2692
2958
4534
6103
5076
3187
1673
2554
3656
4813
1578
1127
1865
1854
2000
1387
1025
831
1151
1572
1674
43.81
41.86
63.05
40.89
32.77
27.32
32.16
49.67
45.07
43.00
34.78
2.26
1.68
1.76
2.71
3.60
2.98
1.87
1.38
2.11
3.01
3.94
11.49
9.59
10.19
6.56
12.17
10.65
12.87
9.25
10.39
9.80
9.64
1.97
1.75
1.73
4.13
2.96
2.79
1.45
1.49
2.03
3.08
4.09
0.86
0.73
1.09
1.69
0.97
0.76
0.47
0.74
0.91
1.32
1.42
120199
129517
186487
125971
135417
139216
121109
6270
2909
2120
1298
3696
3370
4196
635
417
460
215
532
64 6
264
10.13
14.33
21.70
16.56
14.39
19.17
6.29
4.53
1.98
1.44
0.87
2.48
2.26
2.81
8.69
8.80
12.67
8.45
9.08
9.34
8.12
5.22
2.25
1.14
1.03
2.73
2.42
3.46
0.53
0.32
0.25
0.17
0.39
0.46
0.22
(
(
3
*
(
W
(
(
(
i
i
t
<
(
I
i
!
0
(
i
(
26. DISTRICT - KOTA
1984
1591588.
1985
1601372
1986
1681372
1987
1673330
1988
1696961
1989
1706152
1990
660.80
1706152
1991
1212891
829.20
1992
1212891
698.40
1993
1212891
759.60
1994
1220505
777.00
27. DISTRICT
AJMER
1984
1382885
1985
1472197
1986
1472197
1987
1491270
1988
1491270
1989
1491270
1990
1491270
840.70
>3
\3
o
o
o
v)
Page 7
-J
API
SFR
popu1 atioR Rainfall
%PF
SPR
PF
ABER
BSE MALARIA
CASES
468.60
656.80
562.10
525.00
124400
137354
138639
179195
3416
4940
4434
11084
381
1281
426
2972
11.15
25.93
9.61
26.81
1.98
2.87
2.57
6.41
7.22
7.97
8.05
10.36
2.75
3.60
3.20
6.19
0.31
0.93
0.31
1.66
BHILWARA
"'8. DISTRICT 1308500
1984
1308500
1985
1308800
1986
1338600
. 1987
1308500'
1988
1308500
■ 1989
894.70
1308500
1990
856.00
1591236
1991
796.00
1591236
1992
338.10
1591236
199 3
1022.00
1593128
1994
1144830
1188450
199500
186890
191738
183151
155238
172993
203815
212636
238795
300
3446
3268
4146
6114
6140
7450
5116
10046
10800
24916
306 102.00
18.25
629
25.12
821
13.05
541
20.38
1246
17.51
1075
15.91
1185
18.30
936
19.98
2007
19.09
2062
25.42
6334
0.23
2.63
2.50
3.10
4.67
4.69
5.69
3.22
6.31
6.79
15.64
0.03
87.49
0.29
90.83
1.64
15.24
2.22
13.96
3.19
14.65
3.35
14.00
11.86 4.80
2.96
10.87
4.93
12.81
5.08
13.36
10.43
14.99
0.03
0.05
0.41
0.29
0.65
0.59
0.76
0.54
0.98
0.97
2.65
NAGAUR
DISTRICT
1686185
1984
1696207
1985
1696207
1986
1718108
1987
1710103
1988
1710106
1989
473.00
1710106
1990
275.00
2137258
1991
443.00
2137258
1992
323.00
2137258
1993
255.00
2144810
1994
179846
204277
281161
108456
202488
192047
174332
197198
202586
190717
199903
1365
699
269
190
308
426
500
360
1330
1465
5000
34
22
4
4
24
38
81
62
332
83
1291
2.49
3.15
1.49
2.11
7.79
8.92
16.20
17.22
24.96
5.67
25.82
0.81
0.41
0.16
0.11
0.18
0.25
0.29
0.17
0.62
0.69
2.33
10.67
12.04
16.58
6.31
11.84
11.23
10.19
9.23
9.48
8.92
9.32
84988
87360
68481
90852
94777
95024
106895
97313
110217
97690
88443
967
781
5 66
491
979
1145
1284
1013
3298
2654
4313
116
115
77
40
132
175
305
224
1244
878
1633
12.00
14.72
13.60
8.15
13.48
15.28
23.75
22.11
37.72
33.08
37.86
1.29
1.04
0.76
0.62
1.23
1.46
1.64
1.04
3.39
2.73
4.42
11.38
11.68
9.16
11.52
11.94
12.13
13.64
10.00
11.33
10.04
9.07
1.14
0.89
0.83
0.54
1.03
1.20
1.20
1.04
2.99
2.72
4.88
0.14
0.13
0.11
0.04
0.14
0.18
0.29
0.23
1.13
0.90
1.85
0.00
0.00
0.00
0.00
0
0
0.00
0
--^Year
1723081
1723081
1723081
2729207
1991
>1992
1993
1994
129.
0
o
o
o
o
0
0
TONE
30. DISTRICT
747089'
1984
747889
1985
747889
1986
788635
1987
793635
1988
783635
1989
783635
1990
973118
1991
973118
1992
973118
1993
975004
1994
31 .
DISTRICT
1994
609.50
435.20
605.20
601.90
522.00
0.76 0.02
0.01
0.34
0.10 0.00
0.18 0.00
0.01
0.15
0.02
0.22
0.05
0.29
0.18 0.03
0.16
0.66
0.04
0.77
0.65
2.50
HANUMANGARH
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AHNEXURE III
3
POSITION OF KEY HEALTH PERSONNEL THE STATE AND IN THE
SELECTED DISTRICTS (PRIOR TO SEPTEMBER 1994)
’i
CATEGORY
SANCTIONED
VACANT
VACANT
STATE LEVEL
0
326
4
1
5
224
102
4 00
32 3
661
7.9
7.4
11.1
2.5
23.6
7.8
3.8
5.9
32.9
18
3
26
35
178
30
43
2 0.0
37.5
56.5
65.0
44.6
15.2
71.6
25
3
7
3
1
6
Q
c
76
53
16
10
27
10
12.0
33.3
8 5.7
62.5
13.1
5 0.9
62.5
4130
Medical Officers
54
DPHS
9
Sr DPHS
203
Malaria Inspectors
Sector Supervisors (male) 948
1308
Lady Health Visitors
10483
A. N.M.
5487
M. P.W.
2010
Lab. Technicians
BARMER
Medical Officers
Malaria Inspectors
Sector Supervisors (male)
Lady Health Visitors
A.N.M.
M . P . W.
Lab. Technicians
90
8
46
54
399
197
60
JAISALMER
Medical Officers
Malaria Inspectors
Sector Supervisors (male)
Lady Health Visitors
A.N.M.
M . P . W.
Lab. Technicians
5a.-
__ jaK.'LBL
-
5
Annexure
(
(
3
IV
SUPPLIES RECEIVED FROM THE GOI
(
(
Chloriquin
Received
Demand
Item
Date
Qty
Date
Qty
28.12.92
150.0 lac
10.3.93
12.5.93
19.1.94
50.00 lac
4 0.56 lac
50.00 lac
140.56 lac
Primaquine
DDT
BHC
28.12.92
20.0 lac
29.7.93
16.9.93
21.10.93
29.10.93
21.1.94
31.3.93
12.3.93
22.3.93
23.3.93
1000 MT
99 2 MT
] . 00
3 . 34
7.00
7.00
0.10
lac
lac
lac
lac
lac
18.44
lac
918
22 0
102
60 0
MT
MT
MT
MT
1840 MT
1994
Choloroquin
1.3.94
175.0 lac
o
D
3
3
26.05.94
04.10.94
14.10.94
25.10.94
25.10.94
28.10.94
01.11.94
03.11.94
10.11.94
1,94,40,570
TOTAL
J
Primaquine
11.77
lac
15.04.94
09.05.94
12.05.94
22.06.94
04.10.94
08.10.94
18.10.94
02.11.94
10.11.94
TOTAL
o
36.00 lac
20.00 lac
15.00 lac
0.5 0 lac
25.00 lac
10.00 lac
50.00 lac
1.35 lac
36,55,570
0.40
1 . 70
0.64
1.50
3.20
9.54
16.00
3.50
10.00
lac
lac
lac
lac
lac
lac
lac
lac
lac
46.48 lac
!
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