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P. FAICIPZJWM CONTAINMENT PROGRAMME
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Z<C MEDICAL CFPICLR
:\LCAi. JTATICi: 7?Ai::iNG
M •.L.-CICLO3Y
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DIRECTOR..TE C~
NATIONAL M\L\RIA ERADICATION PROGRAMME
I
C O IJ T E bl T S
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1.
2.
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T
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objectives uncl mechanics of the course
'’gccI,
a Luc
; a 11 2 r i a c on tr o 1/e >•
• 1 ca t i o n pr og ra •nmc
cycle of hum', n rrr la ria pa
. r itc
3.
Life
4.
Din eno .'’tie featurcs of ma1cria onrarite in
thin ■'•nt tbicb smears
5.
hole of monquito in rrr: 1r is trans mins ion ?.nc
bicno.ai cr> of loo. X vector
6.
C c nc r 2; t of c p if emio 1 og ic■ 1
7.
ibrtalitv anf cl in in-. 1 aspects cf
:iorbiz ity
I'-i-l- 7 io eno sis ;ncl m: narc- ona cf m 1 .ria eases
8.
Cher ■.io th c r a py of ’ a.. 1 a r ia
G
Princip’!oc of m.luria prevention an"1 control
1
Planning unfi organisation of spray operation
11.
ttrengthcninc of malaria control activiti through
Prim-ary lie 11th Cure yr tern
12.
Duties _inG Mesponribiliticr of
1.
JSB s ta ins b 1 oor
u :.'vf i .11 a nee
mcnr pre or. at ion
NEED, OBJECTIVES AND MECHANICS OF THE COURSE
Control of malaria is not an easy task, The different facets
of antimalaria campaign are very complicated, These facets are
required to be not only coordinated but also each one should exihibit
high level of efficiency. Naturally, the persons entrusted with the
responsibility to make the antimalaria campaign effective must be
trained and experienced.
NMEP has undergone changes over the years. It is no longer
a vertical programme. The peripheral activities under the epide
miological surveillance including laboratory services which at one
time was unipurpose under NMEP has been decentralised at PHC level
from 1977 under MPO. Under the MPW scheme epidemiological surveillance
has been integrated at the peripheral level. The planning, implemen
tation and assessment of spray programme are the responsibility of
Malaria Officer from District level although PHC Medical Officer and
MPW Scheme staff are involved.
The integration of malaria services with the Primary Health
Care System has brought into focus the difficulties of malaria
control activities in high risk areas which require undivided attention.
Systematic and well planned intervention measures are the
basic necessity to reduce malaria transmission and sustain efforts
are required towards this high risk areas.
1
SIDa assisted Plasmodium falciparum Containment Programme
(PfCP covers most of the high risk areas where P.falciparum is
predominant infection). It is realised that training to improve the
functioning of the P.falciparum Containment Programme is require at
all levels and more so in the peripheral levels. The Medical Officer
of the PHC has to play an important role in arti-nalaria campaign
particularly in respect of epidemiological suiveillance through
Primary Health Care System. It is, therefore, necessary that the
Medical Officers of the PHC’s located in the districts covered under
PfCP should be imparted a short in service training on malaria.
As such short training course of four working days has been designed
exclusively to expose the Medical Officers of the PHCs to some of
the basic element of Anti-malaria campaign and the part they should
play for control of ,malaria at PHC.
S’/.^UC or I-cAL.\RIA CONTkOL/E’vJjlOA’I j Oil
r
R«?r-}t r? CCU ’- C?
jT-
ah^K
n retion;
rx..e., -.<■ /,< e5raalc It* conticj p? QG • eTtfOe i?? India,
t*.-e C5.i.> .<,*-7 -.-/ej
in tbr. rr^ptr\ sc' j-•cob co th.at Sin ten
I •. d c o g t r v < ? t b a t r e ? a r r r ■':c?
e?l1 -’'i?}^ of life
• z-:
... y G> J
••
.;'....
of
r\ Z J <1 ■: ■
c s: j r-d. I a6. I- ■•.
'/ •
’j.i ion people• ■ '--i- of v r j c;: v r V
c (fc Lojniix) died
r r *. c ■ • ’ ii<s?eriar
r J
W. fh th*? ^ove'?*
^Ynthctio inocctl..-;.kr
EOT and
in;.-ec 11
HTH, pcst 5no
.-. l:;de?l efficacy anc
y? 1? bfl ity of these
ano =•.••ve
I u« .t. c o.T‘ e r'? ■
<'-7'-:;r-y the
< be.ccu'e evident that
rbe pop\ -• c.t m h.-^i.Lr. j.c::ly re31
rureJ areas could be
<-.Uv ;o? v v
j
r* orc_ rroio milcrie k-J. oh t. < or three rounds
o^ te^ * d ).?2 In5 -•<. ■ . 1 c.-: r prey r.
dgtr s 1 p i z c pro j e c to unde rtak'jn, o< •;■ ” i T'T.t--d t»n/• ■; oasibil icy ?f • cn\. rcl of rural malaria
w .<. th 1:
resources of thG r cor.r •••y.
About 30 million
•- - o xotoctio;; ■- > ui.-.r-. e/-d
e.:
of 1951 e
Je;
rrocj
: 3.
a.
. • ; Qt -;.: c :-‘-‘f.-indge ga.-ix^d
bv^.? wide campaign
was j.juok-'- >j> 2^3 in e phased manner ..ith the object cf
afrcrccnc; p'.ohowt j oi-. to 230 mill lor; psopJe living in the
rr/p<r -..-nd r;i-areas e
The \ ei du tick z of sux^ey
s.”^orrer h 1 ^"orre J <.cJcel acliv^Cles.
z
R -; t
I
J
Er vC-xCUtion 1_>r,°^
*
Tno ^srlc- IValvh
/^ccirir.en^^d :’n X95G thau a
gjcJ a)
f.-.rto
launched to craaicate u.alar.i^^
In
vjse-/. . o<. i. {•' v. eii'Gno.Gu^
of rhe r>iCP# and the assurance
r’ ■
'.-ec •..«.. i. r c 2.j’r.GZi*;-txoi.'aj acf iouinroe( the countrv
r t’***-r-:"O'xcrol or^gra-'^. L«
oi - ;<£ar.
hi,Si
xc
.
’ 2ha
:-. .-~r'' seged \.o;.al coverage, c
th^ sc tiro
sp aying opc.rac.lon frcia 1959.
The epi deSji o og^.ceil su " vt: ;■...' 1 rjice
~ was run in er.rJy 3 96G and became fvlPy
cp^racive Izot.
The prograde war run in phases such as
at. t ac;, r ro con^ zic.r.t ;i on...
Aita^ erac'.‘.cation »y6s achieved thepr ccr©jiut\£ could hav^ ito be brought unrer tho General Health
Sor^rj.cG in the = •lainvana-jce phas«*
The main operational u.n?.t haa al>out ? rr t.111 on j'-op:- ? ?■ i cn
end vne.vo were ?bov:. ■;?0
CO suan
SHcn entitle:.*
entl
'.VH-d SIV;a2 J e. t c»l>siX e\t.XC>r.Gr
v;r. t- r;-\r a sect-cd., covering a pop.
pop i ~Cion of about io,. t;do
ptcin ar--p
I f
The impact was easured throve . a number of
epidemiological parameters developed through epidemcloglcal surveillance. The assessments were underreken by Independent Appraisal Teams# The movement
of
programme from one phase to the other was based
on the such evalvat.ton.
By 1966-67, n-ieradicated from
n-.rUioa
populotfon area (233 units) out of 476 million (393 units)
that io 53 p?er cent of the country about 34 per cent of
the population e-iea reached an advanced stage and major
efforts were needed in about 13 per cent of the country.
Total malaria cases registered in 1966 were about 0.1
Fill 15.on and Pt f a 1 ciparum 26? 63 Co. lateral benefits were
disappearance of plague and S? Kale-Azar#
5fc
The programme met a ruujor set back with the stoppage
cf supply of imported insecticides through bilateral
aqancies. At the time many of the areas under maintanance
phase had reverses because of inadequacy of vigilance
service through the health irsfrestructure, which had yet
to develop, Many of the experienced meleriologists and
senior prates?ione.1 staff had retired, or were no longer
available, Meanwhile, there was rapid escalation in
cost of imported insecticides for which funds were not
availuble.
Besides there were otr r constraints.
These resulted in rapid increase in malariasspecially
from s?venticr at an unprecedented rate. The; problem
v;us co.ux'/unded because of less of immunity of many
com.xuoxties in the wake of ccnti'ol/cr£Jication of the
disease, Number of cases went up to 6 million in 1976
from about 0,1 million e deoade ?.gc<
6e
•S t^ps tr,\en^ re combat s itua11 on:
The Go.tremea4 of India reviewed the programme by
setting up two committees. On the recommendation of
these con.nittees the Government of India launched a
‘Modified Plan of Operation* to copc. with the situation
in April >977.
The objectives of which were as under:
(i)
To prevent deaths due to rpalar^a
(i.i) Reduction of morbidity due to malaria
-3/
-Moint-snance
■
oi\ the status of industrial developrneni and green revolution due to freedom from
n ala lie. end retentioi.: o.l Lht; achravehionts made
so lai.
To achieve t! ese objectives a three pronged
ptv. .?.ck '..’as 1c inched.
7e
()
Gove rnme/P-c s efforts - spray and l>v» - ?.■ 13.J.ance
opera Lions.
(b)
Public participation * through voluntary agencies
for collection of blood smear and drug
distribution (riD
DDC)* co-operation in spray
operauioris,
reporting of any out—break to local
authorities etc*
(o)
Itensifying Research undex ivHEP ^nd ICKR *
operational and fundamental*
F.fciparwn Containment Progrsm.mg:
One of the objectives of MC? is prevent ion of
deaths v^hich it mainly due to P<
5'prevent
1.1 s spread F*j. a 1 ci pa rum Con t a 11 im e n 1 'j r o; i ammo w a s
2 “unch-id, in October *977 wit?’ the «’ instance of SIDA
(Swedish International Development authority), PfCP is
a part of the h’4FP w5th special inputs in the hard-core
areas. The necessity for intensification has been
furtner high** lighted due to emergence or dissemination
of the same tc other parts of the country, 81 disticts
rre undei the ambit of P,falciparum Containment Programme
with a population of 98 million*In order to Co-ordinate
and implement the various act'’.v.t.ties < foi’r ^oncs have
been estaollshed with the He a i** Quarters at Chillong,
Bhubanesl.A’ar, Ranchi and. Bhopal in addition to HD Zone
at Delhi, Each Zone in headed by c Senior' Epid-Cum*
Coo i <5.;’net ci -to is assisted by Sp-- iaj Epsd^-nio/^ist.Senior Dist-id.ct/Dlst*«?pidam:■.o 1 cgJst an.J other technleal
and. admin j stvatlve staff *
The teams are to assist in the programme
implementa .ion with particular lefercnce to continuous
epidemiclocrical assessments* PfCP component is «]so
supported by a few entomological tear^s to conduct specific
investigat-ons on vector bionomics* in addition tc
research, training of MecicaJ. uifiacr I/O PHC in th^ area
covered, ifCP is an integral part of the programme*
PfCP cell is located at the KSCP Directorate, with a
Chief Coordinator, tv.ro senior epidemiologist, a training
Co-ordinate r, a reference laboratory and ot'ner ancillary
steff^
e. /.?.i
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LIFE CYCLE OF HUMAN MALARIA PARASITES
The species of human malaria parasites found in India are;1.
2.
3.
Plasmodium vivax
Plasmodium falciparum
Plasmodium malariae
Malaria parasite completes its asexual cycle in man and sexual
cycle in the mosquito and the same are briefly described below:1.
Asexual cycle in man
(a)
Exoerythrocytic tissue phase
When an infective female anopheles mosquito bites a healthy
individual, it introduces a large number of sporozites in the blood
where they circulate for about 50 minutes after their introduction
and then they enter the hepatocyte cells of the liver. Here the
young plasmodia undergo a period of growth and reproduction
(cryptozoic and meta cryptozoic schizonts) which lasts for a time
varying with the species until some of the resulting off spring
spill into the blood stream and enter into erythrocytes. The
erythrocytic cycle has now been worked out for all the human plasmodia.
The duration of this stage in each of the plasmodial species is:
P.vivax 8 days, P.falciparum
to 6 days and P.malariae 14-15 days.
The term tissue phase includes all exoerythrocytic forms.
The exoerythrocytic schizogony represents the development of the
sporozoites in the hepatocytes (cryptozoic schizogony).
t
(b)
Erythrocytic stage
i
The cycle of the parasite in the blood begins with the appearance
of an extremely minute form in the red blood cell. This consists
of a blob of chromatin and a little cytoplasm which generally assumes
a ring shape- (early trophozoite).
The young form grows and especially in case of P.vivax exhibits
a good deal of amoeboid activity (mature trophozoite). But eventually
the parasite tends to round up and becomes less active (pre-schizont).
Stained preparations show that about this time the chromatin begins
to divide, and this process continues until the number of chromatin
masses chracteristic of the mature re-producing form which are the
immediate product of segmentation are called merozoites.
In a fully developed or matured schizont the chromatin has
fully divided, with formation of schizont, the stage is called as
segmenter.
The merozoites attach to and penetrate the red blood
cells, thus initiating a new cycle. The process of asexual multi
plication may continue in the host for several cycles.
contd...2
2
Gametocytes;
/
Kot all the merozoites upon entering erythrocytes proceed
through another cycle of schizogony.
P
Some -develop in the red blood
cell into sexual gametocytes instead of asexual segmenters. Male
gametocytes are called microgametocytes, female
? are macrogametocytes.
Gametocytes are capable of development only in the invertebrate
host and play no part in the pathology of the disease in the vertebrate
the eventual destruction of the host erythrocytes.
2.
8
Sexual cycle in the mosquito
contJ^/ E?itable sPecies of mosquito (vector species) takes blood
containing ma-ure gametocytes, these develop rapidly into fullfledred
oZ?::;.,
Th:, ?roten
.ces‘orof fifteen
—
mpleted within
minutes, fertilizationx
ensuing soon
thereafter. The change in the male cell involves leaving the^iost
attached^6eXtrudin8 about eight microgametes. Thfse remain
attached to the parent cell for a few minutes, whipping about activelv
n il they are liberated and seeking the female gamete. There is also
a maturation process which is necessary before the macrogametocyte is
Fertilization involves union of the nuclei of the micro and macro
gametes, and formation of zygote which later on becomes a motile,
longate cell Known as the ookinate or vermicule.
i
The ookinate penetrates th
the mid-gut mucosa. An oocyst then
develops beneath the epitheliumi on the outer surface of the gut.
Maturation of the oocyst takes u
a variable amount of time depending
on ’the temperature, species of mosquito?
Ten days to 15 days is the
usual time required.
From a small body, a few microns in diameter, tne oocyst grows
,
— ------ *, the oocyst
until it rmay '.be 50 to
55 microns in diameter. rThe
"
chromatin divides
repeatedly until there
--- j are hundreds of minute nuclear masses. Then
the cytoplasm follows suit,, t_
so that each bit of chromatin has its
share of cytoplasm, and in- this
--- 5 way a great number of spindle like
sporozoites
into the body
4. enter
m r“
u cavity of the
which
'h
from mosquito,
where theyfrom
„alu
„ Joto
infective form.
1"
---When a female infective anopheles bites a person for
taking a blood meal,, the sprozoites are infected into the body.
Relapses
Previously persistence of malaria jparasite for many years was
thought to be due to relapse cycle in liver.
solely initiated by sporozoite/
The sporozoites of relapsing ®alaria
parasites differentiated into either-hypnozoites
J or developing schizonts,
ihe hypnozoites remain dormant <as single nucleated
intrahepatocytic
round bodies. At the predetermined time
fOr a relaPse <e-g 8-10 months J
in temperate zone,’.i/
—P T11VaX
•-V
’
lnfectl0n
) the hypnozoites start growing
and undergo exoerythrocytic schizogony forming merozoites that
invade blood. 7
“
True relapse
is caused in P.vivax and P.ovale in man.
It is confirmed that persistent hypnozoites^'in liver do not occur in
P.malariae.
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SCHIZOGONY
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5 C H ' 2 C G 0 X Y
LIFE CYCLE OF PLASHODIUH VIVAX
/
DIAGNOSTIC FL/kTbRES OF MA' \R1A PARTITE IN
1.
’IN AND THICK SMEARS
THIN FILM DIAGNOSIS 01 H.^ARIA ; P.V1VAX
Introduction. Th is paras i tc was dis covered r y Gra s s i and Felxtrti in the
The name vlvax j.s. given to thv specie •'<it shows marked arnoebaidicity. It produces e disease
-- in
__i man known as benign terrian malaria. It is
called benign as it is raalv 'a al and tertian because the temperature comes
after every 48 hou* s.
year 1890.
Morthology: 71 parasite as they appear in stained thin films
from peripheral blood are:
1.
Youngest ring fom:
It measures about one third the diameter of a normal rid blood cell, 1L
may be located centrally or peripherally. It consists of a blue margin of
cytoplasm and a rather heavy red dot of chromatin. A vacuole can be seen in the
cytoplasm. After a dew hours, the infected red blood cell is usually enlarged *
and becomes pale. Any stage after this period the stippling known as Schuffner;s
dots may be demonstrated iu may of the parasited cells in a well stained
preparations.
As dccelopment progresses the parasite may continue to show a ling like
appearance in stained film with much thickued cytoplasm and enlarged, chromatin
snass. However, it may very early exhibit pseudopodia, an indication of amcoheicmovement.
ii) Trophozoite:
i
1
It develops in about 5 or 6 hours. It may assume practically any shape
within th' enlarged red blood eel t The growing pa. xslte has pseudopodia. The
chromatin in also increased in some. Vacuoles may be one or tore. Ar this stage
yellowish brown a pigment makes its appearance in the cytoplasm of the parasites.
There are small, iingulsr or red like and increase in nuffiber with the
—
growth of
the parasite. In the ;yot*ng form they frequently cannot be distingushed
1 as
separate granules or fods
- :j. but exihibit their presence by giving a yellowish
tinge to the cytoplasm.
iii) gchizont:
At^ihe end of about 36 to 40 hours the parasite practically f£ij-=
fins t’ne
entire red cell, which ^?.y be twice its normal Eire, liSi'jvr CG.;5; ..scd its
vegetative growth and is preparing for mul t iplicaf'ior*. The motility ceases .and
it assumes a rather compact fora. It has an
. ixregular outline with cytoplasm
motted in apperance as though unevenly massed. It still has single nueeus ’-.'hich
is compact end usually lies Dear the prriphery of the parasite, It would look
smaller than some of the amoeboid from which have proceeded it. It stains much
Eiore on account of its compactness.
Now the division of the chromatin begins. The nuceleus division into 2 to
24 masses but as division proceeds, the segments appear mere regular*ei> F’Zi and
shape, smaller and more compact. The cytoplasm follows suit t-.d breaks up. Each
portion of cytoplasm adheres to each dot of chromatin, Thus f ming xndividua 1
parasites. These are the merozoits. During this process the pigments collect
into one or two loose masses, The complete is a definite sign that segment at wr*
in this species is complete, Frequently there is an uneven number of mexozoits
in the mature schizont. The entire growth from small trophozoite through
2
I
Tt -T
uPIi;“tT
?
tw '
C
*b r- ,-r s tv of pata«it<<
u,e P!'^Sc I.-: r.ot 3nr.irLr-. svr.cn-.cnour.
He X ‘’y” y.-' ',, v
blood
r:„
at i he sar c tic-:.1.
/•
So'pc
tc ■-■
Li -
• - .Zi .. i >
u
st ft
fk-
u.?J
i f..c: ly
early in tnc
?.L- .?.;;
< ?r?L$-.
rn.wv
]>2L5
cu
F ' Miat consf itnIh.-y appear nuite
-'- -
i.» a. «;r2v»- ra;
hrh^
If : a-.: t-.j .'.-j
i cMipo and r.v.rv be cistu—
gui s'u d ^•--. inalt
1 I ' a? e . . n-2
nil. ccftocy • ‘.r vale, garnet^cute is
oftHTi rbovt the
JJ
! ltd ulis. I; s qu?Ticir.y .of pi
;.-«t p,v aeu j.e s *j n
tne matuxt. s0S-XCS xc usual iy greater than is
-- both sexes
scrazonr end thcgranuics 3T--!
? b:i'.td through out the cyt-tln
Ti«e grains and rods
of piijLk'Uts are uS’-cj Iy cat; ' in colour in the
t
lue £21 c?•as'ai.-iutc.i yves .has a d^/.ncly ’ • » u». .‘- /j e •; • ip
gen daily homoge ne* j s
cy ’ op 1 asp. lac n 711 c-j - . 3 usc oni-)ac t and ditp cr;.
Around tl>v nuclei
tices a colour •£’$•? or - 'a- r^ H.'d ih - 7.. ne
i
Li v nucleus is
usudly situated
d.v pc: ;phery d ti,. para?it c.
The fiercetuete-cy; l Ci«Li: ?in7 less c y t =• u»Ins r < c
It Fr^.irx zicre lightly and
ui-iy be gieyish Kl»u. gr
•
duaE pii&lsh blue or .'r:. tii.-s practically odour1
Tbc.f< is
•’ ;< s system with srcl;a*i: and some (imes its extends
in a brc-2<’
;
.cl; .
,.Qd>
-\T acr?ly j lv:r-
is placed centrally
; L
“*
llciSK-.
"'•■-•
”• '’.csLCined rotjert^j rrit •tjl: d rhe nr.es of grains
encounre-ZT'd ir- riciMgaozOCCcyre..
;i’
•“4-—-5~— ’•- rf -r'r
by Urr.^ ir the year 1931,
host .cr .tz g-r,.— -r ^::;-..ric5tion unt5i;r
It is
any
other
animal
Cuej5f£ons>
"‘‘i-* -.r r-.ttvvn as the piiia.^xte of maliguant tertian cr
^-I ^jcacy nf thu o:’ga.n‘5^ is atr^lbvt^ 03 to t^o of ltf=
.v ,
. ***'*,
1Cfc niucI* ftearrr inv^Ucnefs rhau anv of the
oth^'c tfici-i- <'’ '
aue t'b) u, mhc-rert of grew, and niuldplicatioix in thj internal v
of ‘h...
farJ :wi. in -’n. yeripi^r^i r * ^->.1 nfiop)
uni ;ke t •;.
: : -:
>
t'. i.-r'-ir;
t,„. .< ;e3ul? ul the develcu^ent
r- * u *. c an *• ■, 5 u > / .■ ■{ ) ■ -’ t 1 c» f.. \ j ni r?
deposits ever th- suffices: of the infected
c i y z f.,,. t? c.;t '■’? s the t l -.‘.Ils tend to agglumer to ^nd froo ehmps which often oceiude
i- xi ■.. ... u l ■ y2.j.1.21*1 ■; 2 and thereby give rise '
- . c various p^nicious pHtholrt>~cu*.l iiiUsij iL.Statxoiu*. The invasive pmp.~T?v
property
c
.
the
pat-iie iz ._11 the mere
manxytfcLeri by $:.< comparatively celayed^dcve
'opxcnt
cf
lir^unity in the host, than
in
■*■'' cirher
c *r r 7 r 4*‘-.vivay of £>\
1 ££l;tr dP
f c c t i o n :• u
perniciou-5:
vaporCa,-1 •
In
th- commonest of eexual ian.i of the parasite
detectable irTthc
-.
p^riph 'rd circvlation is th- ring ox v. oily i cophe. zo i r c. The
riny in the
■'r / *-<!.- '■*•• of az, cxtreDiely delicnte rextvre and is general]y
about 1/6th to j/5th of the dimeter of the infected red bloj-d
corpuscle. The
cytoplasm is of a f
1;;
su ccnsxstcncy surrounding ;a small clear vacude
end take a purplish blue stain,« The nucieus or ti-e chvoir^tin i
...— is stained ruby
red and implanted c?i one edge of the oytcplaseac
sai.;:: dfrer. /iih a little
bluti cutwaxds giving at a ,‘sguet:-ring,J appearance.
.2otic t i •?. * f ns:. cad <? f one
-««.3
/
*
.. 3 -
ch?’ov.atin dot in a ring, one comes accrof'S cwo chromatins lying side by side on
the "surfaced of the ring, which is a ccrphological characteristic of F«.falcipp•
almost exclusively. Then again.. the rin*! in it sc Id although always endcglovui ..r,
oiivn occupies a pusiiic:: near the sax face of the infected corpuscle thus giving
it an accole or applique form. This is another characteristic of the parasite.
The mult ipficstion of the species of the pcracites is so rapid that more
.'.-a oi.e paicisiti in a red cell frequently occur end this is considered almost
pathognoj'uulc of
' c’’ carvj:; infection-
fhc cytoplasmic rin£ of the perns ice, as it grows in the unfected red cellj
bvcumes sloucer in size and takes a deeper stin. Whc?i it. occupies about 1/3 to
1/2 of the- infected cell, the cell recedes into the intrnal circulation where
further devtlopment of the parasite takes place. The infected corpuscle does
not normally enlarge in volume aloagwith the growth of the harboured parasite
except when cult ip)c infection occurs.
Bccides the ring for-1?; no other a sexual form of parasite is normally
detectable in the perlp'h,.-cal circulation nc-i the infected corpuscle show the
characteristic pigmeat
The pigment (almost blacl and coarsely granular)
appears in the developing forms of the parasite inside th? internal organs of
the host. The infected
cells do not also present the nSchu£fnet’s dots1’ on
their surfaces unlike I-yivax lu/ection but, they may have large irregular
reddish clifts called “maarer’s dots1'.
♦
Wheii th*: infection rf the host is of. an over-whelming nature and especially
3u rhe tei'nina] sragv.c of ^uch infections all kiods cf a sexual developmental
fermt: of this spe:.u. ?f parasite are found in the peripheral circulation. Seme
of rhe gr< 'ing trophozoites in. su i instances are st n to be of an extremely
aT-ucboid uaturevand in multiple are also of red cells the pseudopodia of para
sites are also often seen to anastomose with each other. That is why till about
few yeais age
itologi st s used to think this stage of giov.’th as due to
infection by a differentIn the schizonts of P.falciparum the mvrozoites arc seen to arrange
thcffisclvus in resettle forms with about 8 to 32 nierozoites in each. The
schizonts occupy 2/3 to 3/4 of the RB.C. coarse black pigments are seen
clustered, at the cent res of the schizonts.
GarjetogCiiWi'.i.s In P.falciparum infections under optimum climatic condition
occure about. 10 to 12 days after the sexual parasites become, patient in the
circulation auk the gaitrorocytes take anor.hei* z-4 days to become infection for the
nosquitoesr in F.vivax infections, on the contrary, gametogenesis is almost
simultaneous with the appearance of a sexual parasitaemia and that is vhy the
tine lag between the appearance of infective gametocytes in secondary cases
derived from the same primary case, called the incubation interval, is shorter
nearly a fortnight than ii P.falciparum infections. The difference in the
incubation interval of .infections of the above two species of human plasmodia
has an important bearing on the genesis of epidemics.
The merozoites are the precuresors of gametocytes after a few generations
of schizonts have been produced in the blood. Some of the merozoites have a
different density. They grow more slowly produce more pigment and ultimatclu
develop into large single nucleated organisms having no visible central vacuoles,
which are known as gametocytes or the sexual fonap of the parasite.
, .A
i *
I
I
4
Ti- .-j-j '-t. >cyr.-y > * -S s l-c yarn j , r.nlikt the vtLvx species of humn
pli.SU.‘Jia ti» ji-n..■ _ v i r. ap;;c3rancLi vjIv.,.
nli'.hL cnpvacity cm one. bide.
convaciry is ix:iu r?ork< J : t he L cn:i 1 •■■
~
yice of x:>5-^1 exparuin appear in the
periphera] c. 1 re■ ilac 1 r. xl w<~vc6 ai diffevcnc inter..;• i ~ dependiag upon the strvi n
of the species anJ- ;
; ii.j.t Lcrpuccula’ ■
v.._d-.,z J by the ©pmoranes of>
? ’
• )■ xvit;
:
t ’ 2 fiOSt enr •• ■ •- ■
'• •- c r» < 7 sui f ?o-,r •
The- 1<U'.A«
- j t'* v«
thu m:.c»’•j ■
t».-u y».v and the iem J nscro
w
gazietuc ytc. IiC£
is slight duferanuc m tiiUp'e which is not always Quit
dvsrulij.bl.
'I..-' L.'
■ the mcrogrjtetocyt e~ morphological d;ir< i fro: each
cther Lvt thjj.r fv. - ir-^ three characteriFtic;
*. St ai v.Ing rrscr. i
the cytopl.-sa of the. iaacrogauicuocytc stains u-ore
deeply thau
ox cicrogametocyte•
2, Nucleus - is relatively larger in the riicrcganjetocyte ; h.sn in the macro-'
gaaietocyte but it is more compact .nnd conspicuous in t.?crcgam:.tocytes.
3. Distribution cf pigments — is difius-od over the ent. re cytuplasra mass
in microgametocyte and in conncctrated royud the
nucleus in the
macrogametocyte.
P.MALAEIAE:
Iptrcducr ion; The parasite v’?.s first dir cove ?:<?•: tv Lav» ran in t».e year
1880. this it in fact the earl jest paracjtc discovered.
? produces uB.-trtan
malaria in man in the sense that the attacks cr fever occur every ?2 nours 01
d<xy. The distribution of this species is limited,
MORPHOLOGY:•
stages:
Thin smears made from peripheral b;oud oa atai.cu;;£
the * allowing
1) Rings: rI''he youft^ trophozoites rr_- rinc; foms ai*d a«'c .bout the size of
or slightly smaller than those of P,viva>
They soiiie. times seeni tu h^vc thiekei
circle of cytoplasm than younger vivax rinps.. Double chrowt?ti' dots <-re rate,
The vecvole of the ring stage disappears vciy Goon, .sfr-n the potash.*? begins
its growth
2} Trc-i>:K’Z-- iy <'S
■.
stapes may
band forms st, uv*. b acci^h.-
th* red .blood cell, Tbey may also be corsac:: nonvecac;: red xorv,-.-. r Jugular or even
round to avoid in outline', ihe cUrcuiatX’i ?s a rovndeu mass, ft is luoie freq«i’.vr ;
ly streaked ox semicicular in form even in the rounded parasites- Very liLt/.k.
amoepho zo i t e s. h-2riK.e imgulaixtics in the outline of the cytapl-xsr-. Is a rare
feature. Parasites becoming older m.ny grow into » wide
or have rounded
shapes. The pigtiantc appears early in thx growth and is a characteristic of this
species. Granules are dark brown and the granules are usually r/rrertgad after
along the edges opposite the nucleus.
4
I'sture forms of the parasite .slriosl fill or completely fill
normal sized red cells. They may he rounded cr b~nd shaped vi <h a rounded or t:
elongated chromatin mass. The cells containing them nr. never enlarged. Freque
ntly they even seem tc be smaller then auxinal and sometime dnrker in the early
stages. The curio is completed in 72 hours and hence th?: growth ri the parasito
is rather slow. At this stage the nucleus divided into v tc ■f'> rnrrsse^ (usually
8) and the cytoplasm and fox-ms merozoites. The merozoites pre sx-m-timet, arrang
ed peripherally arouid th^ centrally chir.. eJ piguent (rosette ior^)...
c.S
■•’ V2:7
I\malaria set...at t o h^'v* fetfer g-ipjctocymr. th-sn th- olh/r
or ov . i
Ttu f27ioCocyl:o'' ~ '•■ r’pb'.'...-'r.-.
tvo Spt-.L.IOL.
ar?f4 2L.L lcipcr«.r:
in ^h.xpe. Thez-sexe6 have same niift r■ r.cc in 1 ■. ;ninn q u'llity was I «j T-\Vava>- ; - . J
F\£'\.r..ipjri-j:' The
t is .wrc al •’id
_ • k* f •.- r. e.■7.- and <:c. 11 ■-. cv 11.21i. i; .
F .rna la t i ae c e r I a i'. .- f-t ipj'I ir:g/j h-::v^ be
> Inc-vp as ’’irienic-• S. dot*\
Witr orciinr. *1. ;• tains tn.-j; .ire used t ='>. y er" n i? xy be g iniJiict rat ac <•
to he Ik st
i out Dy iotvniivv scaining wxi n a s tain so 1 u 11 o ' ? ? •: c 1 ri g
FH df
o'
Z.‘r
or malaktZ
Lavuran (ib91) apj-ern to have teen ul,'1 first to use haemo?ys<d blouc as
a mans cf concent rating tl-j parasites for r? cr-._>< c-.-plc
iu’:. Toss in 1903
described firui. thick ioJin method reccv r 1 s."?'»y .vvimiiai to those, usad todny.
/□.though hi*, laetbod had many defects» it war an important advancenc»?L xcr it
showed urmi stahbly that t ?.ick smears of blood could be made trans pa rant by
ucomely bi s end the p2rasi.'tes concentrated and seamed well enough to ’;c ra.co^r fsable. Hock in *907 simplified Rgss's fr/xtuod and adapted it to Romanowsky stamn
the combined haemolysis and staining came into use. Quick eimiltaneous Etainin^
of both th-, thick and thin smears was iy.t.roducod by JSB method*
tub ihiei- rbocn filk:
The thick film is not a thick CropM Xc
It is an suetf wiiich tra^oiits enough
r3scc-pic oxaciiaaticn
oxaiainaticn then
vh^n kjc>jiGgxc«blD is pertly of wholly removed,
X?.gr:t for r--.;.i3uoc-pic
k'tCux-Iyr.'* - fv;V '.v £-y<cv r b-i.
b-b’-’Jj o£
ox the I.b.C
i.t-.ck is thus the tirzt yssential and ctrtir.i.ig
D
../1 V i • £
. b. c • and staining are concurrent with 3
is sscuirj
D..*‘.-;• s
-K/ivij
<; Civ,:
tiu.: r
r.b.c»
Tn e
thick f: .i-x field 3howc. leucocyte , plotelcts aud bi od piotozori on •. Lack g toy os
ox lightly stained renx^r-ts of the rnd ceil.
The r.o:iy31 thick film field contains Jcucocutes and platelets vlth cceaibonal bluish cloud - the renialHS of dissolved reticulocytes. The- cytoplasm is
slw.Tys comewhat scnrVexed# cytoplasmic granules are often lo£t except the
granules of e^Mnopbily vhich have a special resistance ind usually shine c»vt
with gr«&t cl.-rxty. The film, my contain a few degenerated while cells which
are s.'.
e»o.t and recognisable only by thtir
shapes and staining.
Iho t.ioo*'. platelets> single^ in s?all groups ci vccafcionally in clusters
G- s.-2vCX«l ••vi.',rs^c aie utr-med pale purpx»- and. have a wooly texture and o-u.Ifm-:
which ir> urm is taxsole.
euc’t hs
other s- rect.ux’v.-&
in the microsccpic fields are probably exati*aneous
dust.
‘Uxd.s^ yeufters, vegetable spores, bscteria or deposit of stain.
ARTEFACTGi
Struct, uirs vdiich ccnfuec diagnosis from their reseat lance to malaria
parasites eie
x-eea no matter Low carefully rhe film are takon and
stained.
Th«: ccTiTiorcsi caurce.s of error ar.j;
a) toi it ary
sar.ll groups of platelets ?j. he mistaken for quartan
trophosites at the e&rly compact stage5 and <}■iti fox advanced vivax tropho
zoites
thr. stage v'ii.?n cyic-pissm has broken x.ntc a cluster of fragments while
th* chromatin is y/1 ■. j.t --r t, The reser’kI’-ce b&tweeQ vivax at this stage and
6
- 6 -
I
snail platelet groups is extra-ordinarily close, particularly when the magnifi
cation is nor high or the light is not enough to shot- up the colour of the pigeae
b) Blocs _f chron-itined debrts iron intaatGre red cells when associated
with tags of itc cells rroticulir.. These chio!i’&tiod passes* ere coowj-^d in
anaemia. They s’mul^r.e found trophozoites when they arc in chance comiinatioa
with blue st^iriiur materials.
e) Keticuli?! from irmaturr. red cells r.ry stair' deeply
to have a x
vague res-oi. • <-c * > vivex •: rophosoi ter surrounded by thick £i. tn.- equivalent of
Schuifnar1'. ■o’, r..
The e: '-vc arte* iacts cannot be avoiaed auu they nust be learned fren
experience.
Other are facts which are extraneous can be avoided by scrupulous clean
liness in taking the sraear and protection of slide irotu dust etc.
PARASITE MORIAH9LOGY IN THICK S*EAF:
The technique of staining thick-film destroys the host cell and exposes
the parasites to change in shape and size. The parasites appear smaller and
are less regular in outline. Parasites are seen in unfamiliar setting, no lunge
as in the fixed thin films neatly framed by their host red cells, but stripped
and distorted on a mottledgray grounds of red cell resudue. With the disappear
auce of the host veils, raaurer’s dote in falciparum infection are not seen in
thick film, rchyffner’s dots may bo seen in thick smears. In thick film the
red stained r.hromatin with associated nine cytoplasm must be seen before it is
pronounced as a parcsite.
PIGIZET I?-: TEICi; FILM
Firm mt is seen more clearly in thick than in thin filwe^ A trained
observer nay often identify the species and the phase of the parasites by r;-.-th
ing shape size and distribution cf the pigment granules,
THE CONCENTRATION^ACTO?
One great advantage* cf thick film is concentration of the parasites. Thai
more blood nay be examined in a given time or the carae atnount of blood in less x
time is self avid-rat. A film thick enough not to impair microscopic examination
is expected te produce and average concentration of fifteen with a range betv._u
ten and twenty,
25Lin Stained
Lhi ck f11ms from pc ripheral blood Ji res
• J\J2$ forms:
The chromatin consists of only a single bt*ad but somewhat larger than
falciparun> bead. The parasite appear in 'Ring1 ’coma* *swallow wing’
and ’Exclamation mark’ patterns. This etageF it may be difficult to
cist lugursh from F.malarip.c rings oi the same age and P.falciparum order
rings. Cytoplasm appears irregular early, and is an important, distingui
shing
Other stages of the parasite may be present along with
the ring forms.
..•.7
»
7
/
ii) Ecr]y troy-iczoite forci:
Cbronifctin
single dots but fairly isolated trill, cytoplasm is irtegu
lar» It may be cnracteristically stretched cr broken into dedicate wispr.
and strands. Some mdividials forms may, hoover, be compact. Pigment
appears .is small granules. Other stages of parasite will be present.
«
r
ty £;P ho_Z.C i t v fOTO I
7ht-; ryi-c ir^gular. It breaks up into - cluster of fragments
avcuud div: r.uuic..c The chromatin is often SLicted from the cytoplasmic
and granules and disported wderately.
fragments. The pigments are fine ...
-..'-i-A --------- Ghjt'
The parasites may be associated with
typical’ stapled
appearance,
outline of the infected cells may Rcmetimes, bo clear*
iii) H'’Jv <;!
-ar
s ch ijeont s:
Bigger than P?falciparum early schizonts. The cytoplasm is undivided anc
lossely covers completely or incompletely the chromatin pegjuents, Pigmen*
granules are usually discrete and loosely concentrated into ona or tW'.-t
^atu.rg_ gchizonts:
These are large. Individual merozoites are als' large, Merozoites vary
from 12 to 24 (average 16). Each chromatin parti-le may or may not be
clothed with cytoplasm. The merozoites way have well marked vacuole.
rigD.cnt£ appear lightly as a cIosg collect ion or they are sonetiiacfi
slightly scattered . Other stages may be preseuc.»
vi) Gametocyte:
!
T.*ese parasites are rounc or oval* Chromat a ih single ^pkomxnont in
females and diffuse in males). The cytoplasm E^y be fairly uniform or
' ‘
, Pigment scattered
somewhat loose knot and frayed at rhe periphery,
irregularly as small short redlets sometimes tending to a peripheral
distribution. Thry may have su-rounding some of schuffer’s dots.► Sex
different-isa?.ion is not easy, Differentiation from late trophozite
also Avt always easy. There way be associated sexual form in the sarse
smear.
C<v;?’AK\nVE CHARACTERS i-r PEASNODIA Oi; MAN
iarly
•eriod
Phtf>hVlV” vjvpy
(STAINI D THIft SMEARS;
■ *-fl****>?^.-i
-j ac ij>aT tin
ma tri S.ae
Plasmodium
ovale
7—
ar 1 y
r c-ph ezoitc
r ring
lie la live j y
rge
usual 1” orc chro
t?3tin dot. i.oir.e-
Compact; onn chro!T. d t Hi d c t; C c u bl c
ceil •hfectious
Sr-a } 2 j c e ? i c a t. p ; i* l»t e •
times two rheoreatin dots;
Lultiple red cell infec
tion common; applique
f o» Di« frequent
Compact> one
chromatin dot;
double infec
tion uncomwoa.
Large; markeuij
cmvt-boj 1; promiuent v<>( uni
p’niDcnt in :i-<i
rod!ets.
Sme/l 1 <• fl ten bundslsycri; not r.moeboid; vaoujle
f rxoi.spicuous;
pigment coarse.
liO • J J U Ui £. I 7 v ;
Small; compar:
n.?t arriocbotd;
vxcurlr* iucorspicuous; pi^hi er.: coarst*..
Large; soi»?what
amoeboid, <hromatlr res ns: i t
numerous, p pr-eut in j 1 at
rodlet. .
Small; compact;
chromatin’ masses
lev; pigment
coarse.
Medium size; compact;
chromattn masses numerour: pigment g_an»ilar;
rare in peripheral blood.
Med turn r.: st. ;
compact; chiomatin masses
few; plgs&ent
coar se.
t>-•<_,
.■Lien
tze iJrgn 5:, or:.fvll.
4
rop »7.oa ti-
chizont
i
Mature
schiron?
largev than normal
I cd cells
Smaller th a
normal red
cells: single
rurntte.
Smaller i an noirir.al red
cells; single rosette.
larger than
P. malarias
Number ci
merozol:cs
b- ..., usually
i ?-18
6-12, usually 8
8-36, UbvpHy 8-18
6-16, usual]’.'
M tr**'-' “
cM.^vicai; com
pact; no vacuole:
•.i\'gl-.x 1 rrf? nuel
diffuse 03rse pigaent;
cytopiasm suafns
’ight blue
SlmjJ^r to
P. vivax but smslj er and less
• hurntrous
•Crescents usually sausspe-shaped; chromatin
diffuse; pigment scat
tered.- Jsrgc grains;
nucleus rather large;
cytoplasm stalus darker
blue.
Similar to
F, vV/a? b»’t
Spherical; coiipact; larger than
u: 1 g rcf\ame toe. v t e;
stk-ller nucleus.
Similar to
t vivax but
smaller and
less njiuercus
Orescent often larger
and more sienoer? chroratie central; pigmeat
more 4:i?’.Qpact *. nuclei?
compacl.
Similar to
t-_, vivas but
suniewhat
small €‘1;
never
abundant.
11
tocytes
(usualJy
smallci
and less
numerous
than Macrgameto
cytes)
.
u 3. L1 y
C C’Eipact, 1 ai c 1 y awoeboi d
vacuole inconspicuous;
rare in peripheral blood
after half grown;
pigment gr«nuk?r.
Macrogametocytf.s
S'<-J^W>io .
SiO’t •
ler; never
;• bundant.
(continue
(conclude.'!)
Early
period
Pies mod 11 iru viva x
Flasmodium
malariae
Plasmodium falciparum
Plasmodium
oval e
i
Pigment
Short., rather
delicate rodlets
irregularly scat
tered, not much
tendency to
coalescc.
Seen in very young
rings; granules
rather than rods;
tendency !owards
per i phcral
sc.it ter.
Pigment granular; early
tendency to coalesce;
typical single solid mass
in mature trophozoite;
course scattered ’rice
grains* in crescents.
Similar to but
somewhat coar
ser than
P. vivax.
»
AlteratJ ons
in the
infected
red celi
Enlarged arid de
colourized ;
Schaffner’s dots
usually seen.
Cell may seem
smaller; fine
stippling occa
sionally seen.
Normal size but may have
’brassy* appearance;
Maurer’s dots (or clefts)
may be seen; host cell of
crescent barely seen.
Enlarged and
decolourlced:
Schaffner * s
dots (or
James’s stip
pling) early
and prominent
at all stages;
numerous oval
shaped red
cells or crenated margins.
Length of
asexual
phase
48 hours or a
little less
72 hours
36-48 hours
48 hours or a
little longer.
repatent
•eriod
Usually 13-17
days
Usually 28-?'’
days
Usually 8-’7. days
Usually 14-16
days
Minimal
8 days
14 days
5 days
8 days
sual
ncubation
8~17 days, average
14 or longer
18-40 days,
average 28
9-14 days, average 12
16-18 days,
average 17.
nterval
etween
arasite
atency
nd gameocyte
ppearauce.
3-5 days
7-14 days, appear^-anee 'irregular and
numbers few
7-12 days
12-14 days;
appearance
irregular and
numbers few.
From
WHO Regional Publications, South East Asia
series No,9 (1986)
I
Role of Mosquitoes in Malaria transmission and bionomics
Qi Local vectors:
1.
B
Tntroduction; Malaria
s transmitted from an infected man to
healthy one by the bite of an infective mosquito.
Among different
types of mosquitoes viz. Culex, Aedes, Mansonia and Anopheles, the
anopheles mosquito is responsible for transimission of Malaria.
There are 365 Anopheline species found in the world.
53 species have been recorded.
transmit malaria.
In India
All Anopheline species do not
Only a few are responsible for transmission of
The species which transmit malaria are called as vectors
Malaria.
of malaria.
2.
Vectors of Malaria in India; In India there are 10 Anopheles
species regarded as vectors of malaria of which 6 are regarded as
principle vectors. These are An.culicifacies , An.fluviatilis,
An.minimus, An. etophepsi, An.philippinensis and An.sundaicus.
The rest 4 species are regarded as vectors of local importance.
These are An.balabacensis, An.annularis, and An.varuna and
An.jeyporiensis.
3.
Essential requirements of good vector
(i)
Receptivity of pathogens
(ii)
I
About 80% relative humidity
(iii) Should survive 12-14 days
(iv)
Temparature around 30°C.
(v)
Good anthropophilic index (human blood preference)
Reservoir of infection with good number of gametocyte
(vi)
carriers.
(vii) High density and efficient ’biting species.
In general, An.culicifacies, An.annularis, and An.philippinensis
are malaria vectors in the plain area and An.sundaicus in the coastal
areas of West Bengal, Orissa, Andhra Pradesh, and Andaman and Nicobar
Islands.
In the foothill regions An.fluviatilis
important vectors.
In the hilly forested region
and An.minimus are
An.balabacensis
plays an important role in transmission of malaria.
I
a -
A.
Aitopheles and Ct*lex
«>
itoes
Anopheles
Egg/
Boat shaped, laid separately forms fSpindlu
*
shaped attached to each other
a pattern, tiangular of star shape, forming raft pntterji.
b) Larva;
Plat^hoirirontally on the surface
of water no eiphon tube but
spiracle openings.
c) Pupa:
Range down wards with long siphon tube
upwards
Breathing trumpet or spiracle
traingular with wide opening
(funnel shaped).
Narrower with small opening longer
d) Adult:
i) Resting position:
Head, thorax, abdomen in a
straight line, rest at a 45*
angle with the surface.
Hunch back appearance thorax and abdomen
are parallel to the resting surface.
ii) Wings:
Spotted-dark and white.
iii) Palpi and proboscis equal
in length.
Unspotted.
Palpi much shorter than proboscis.
iv) Scute 1 Imi;
Convex or curved with regular
one row of hair.
Triiobed » each with one bunch of hair
v) Abdouen:
Without scales or with few
scattered scales.
with uniform rows of overlapping white
and dark scales.
vi) Hale;
Antennae Bushy
' 4
Pulp! - Equal in length to th«t
of proboscis.
Bushy»
Longer than proboscis and bent upwards
e.c3
I
i
•'. >. •'
> ' -. F ; .
\.:;y <
L t i ■• - s
’ V,?f '
~L*
'x'rZ-V.'?*?* - 7*-
>-
:
Z<
I-?
-
I
,_^j’ h iz.'-Wx'-’F
’ -J.
Jk3
• i >'
LEAP- Gr MALE
a
RfSTiNG
P ? 3 E*
f EMAI E
> >$. 53
CULEX MOSQUMO
ECGS
PUPA
LARVA
■ - -W7
<% I'
J... .t .
,aX';
J?
I
§
4‘
■
J
5:’:
.V
•
fcv'
w
I
I
i
s^£V!
FEMALE
\'-
RESTING
POSE
I
1.
CONCEPT 0? ^HD&niVLOGICAL SURVEILLANCE
2.
COblPOxNENTS;
CASE DETECTION PROCEDURE
DIAGNOSTIC SERVICES
EPIDH*'!” • - TCAHUNS
REM1AL
3.
->....Rl:
CASb DETECT}ON PHXJEDURE:
CONCEFI CT TOTAL COVERAGE IK SPACE .AND TIME
GEOGRAFHICAL RLCONKAISSANCE
ACTIVE C/kSE DETECTION <ACD)
PASSIVE CASE DETECTION (PCD) OR INSTITUTIONAL
VOLUNTARY /COLLABORATORS:
TOTA1. COLLECTION/ LAMINATION:
ABER: FRUFORTICN ACD; PCD: FTD:
4.
DLAGEOST1C: LABORATORY SERVICES:
BLOOD SMEAR EIjLMI^TION? OUT PUT
CONFIDENCE IK THE SERVICES *, QUALITY
CROSS CHECKING ACTIVITIES? DTSCREPENCY RATE
TIME LAG BE1'WE;: ?r CCLUXTION AND DESPATCH
DESPATCH /.:vD RECEIPT
RECEIPT AKO EXAMINATION
EXAMINATION AND REPORTING
BACK WG GF ViiEX^MiNED SLIDES: FACTORS IirVOLVED
REPORTING SYSTEM
PROBLEMS: vOKNEOIED WITH LAEORATORi SERVICES UNDER PhC
5,
6.
EP1^1CWI£^2\-.Y£^/
PRELIMINARY
INTENSIVE
NOTIFICATION
:
classification
REMEDIAL PEACUR^:-;
RADIQiL TREATED?
INSECTICIDAL SFkAYINC
CThlb*\
7.
PARAMETERS;
THOUCK LPIDEMIQLOGICAL SURVEILLANCE
ABER
TOTAaL M44AR1A CASES
SPR
P.FALCIPARUM
SfR
API
SUF7STtXA?'CL •??r.r.ATr^S TH NATION^.- ^rH- MAI.A?IA PR(X?^m4e
IfsTP.ChbCTJCM.
The t c.. • •. e.' i d - ■ i c '■ og ic a 1 cu rve ill pace was f ii s t ercp loved in. Gr e c ce
in 1951 to picv....
•. ..f rrgcTics of H' tlaria from areas whore it had apparently
disappeared. I’-.
t-v? fact that the infant parasite rate was zero
in must vil •.or Greece, the epidemiological surveillance discovered 400
nsI aria eases.
V'.l Gv-.r’
vjs czv-c/teo and adopted in N.M.E.P.
Although* in
ths bcgiv.ning cniy oui ?'-xl *ance th*cvo.i Active Caso Detection was introduced
in Greece, this ccuxitry dli not find 1-. enough and in 1957 Passive Case Detection
vas added tiirc----- ejc c- liabrra^icn of hospitals and rural dispensaries.
CO?^Cr?T C-r LF-II’.
•PT CPT.CAL F‘Tvi'FiJ APC-1
u;surveillance in National anti -“malaria
i-'C ?-Cr:cC;.L
'272 J
< 9‘
of the population in Space and Timeprogr <r.r:^ i t> w. • .. «:■•'.■
*. ■Criteria cor rcr.iO-: tr.7 ' r- ,. wl.-ofc L‘I -•. t L’>n rdght be severa 1 such as history
SX'Spici.nrc
^.', -. cg er..’..'*r iu spleen? or fever. The last has been chosen
so ^hr.c C'i.^ ?<-; A
.■• .•'«$ med.n’;’ rests on detecting, first the persons to
have fever n" h:.iv--; -eccf'* ly hnd it, Thiu criterion har to great advantage that
it cm al>< •.,.. •
prefescional porsons.
/ j icr ; avr
j •' carriers without fever3 the great Etajority of them
’•T if thcit tnno the surveillance was ope rating they would
have r.sa uv -r I ' fcr
have b^on c.^taci
.?u.l cured»
(1)
Th;:re are different approaches to search for cases:
rossite Car e Z ?.lru-J.on (2) Active Cases Detection (3) Mass Blood Surveys
ani i-.vc?f p?.7-;:nn« in the neighbourhood of confirmed cases.
r
Hr a ceurVcfy develop a very effective network of passive detection
covering -'ll tuL r-alarious area there will always be a number of fever cases that
would not report to the detection agency. They any be too ill to go there or
so s 1 £gh11 y i 11 th•>t thc-y do not th 1rik they had any fever at all. To till
such gaps in the passive detection system. Active case detection through
periodical house to house visits for screening of fever cases is required for
providing a total geographical^ coverage of the entire community.
t
I
/
COMPGnENTS;
c-
p. Trf i jO>’:
notificatiou of
FIRST LSvTk 07 PASS.-V ^.TeCTIOg. is of cocrpulsory
by all the nodical profession-'
^nfirr^ed or suspicicus C '£> s of feiaria
This nroccdure r.ay detect
hospitnlo, Valth
cl disocnsarras. -sicr; prreiats and are Hable
, ex
--‘t- -•■ •-iHf’os Vh-re traut,
to be^v.:.-; ’: robli--.', arcc'?'r
**
,
, «•?»Ff i r iput: co1• cra^e
respite tcral cc..:?l.:lc .^u.ar and sufficient ^..1 .
UwetitU^.
» k-
th“ ” "2! a«l SS op’~t^> -a/or
ere as paraistenco of ua-.tsrsisr.ion was asso^iatvc wit
ac-inratraitva saort-eoni^ga.
tn
i»ith lesidnnl
«ProblCIS
v
.™p u.it« ^.»<™ »
„, ■»
cs«
toc“;S.=«- «"«o
Cl L.al.xi*. 1-Jt
pj. - - - /;cn.fi_rnxd Claris cases appropriate treatment as
to all I-cor acasos
ir d i ct-- k j
‘ • i* • r €
jcycl of ponsivv: cas'’ detection is through voluntary eollaboxat.
» rrllpbovate with hTTP iu case
* < .'.vtG
Th-y belong
cud live in a c'-rj.auity
errj^l;?.v.y a">d
<v>.u can
v<»d c< >
blood fakirj’ and vi.----- •- •
t
They
j. - reti'’ed civil c
f’*
— c c. - - * i-.
guidec»
(2)
AuTIVr. CAS1..
.t t„.
it«« u
-z5'’;,
crxl i’as.i3v«. ss tikcl/ to
c.u-. ■. •■. coverage bv ineccticliU
To ratorrupt tra^iraion t7 ensurang n per feel ;ot.l tcra
<?) .^..^ "a:T^S"“p?X^<nr^enin'do;JK the tv^typc-3 of
detucH^n wirh iiabo-iiU^ exa^natwns in ^5^— --the xrdncrJ.stion sor-ror.,
Frequency and system of dc^iciV^rv_yiL?—±
i
i
^e-aver^ ..«£r £
X
oi8K h. P^ueod by a typical .P^ “ «r
«»"«il.ry
visits Of curveillanee worker is high
Xks of their
visici; jheuld discover s«cor.d-.-ry ca?-^
rov.'des for fortnightly visits,
occurrence. Therefore the Indian Programme provides lor
I
me eyrev o*
ri’s mwpM
ueb thru on airxi 18
-ig in
i?’ » village
Oc^worLtir tl .-Jr - i/-t pay tec visit to the he- -’ man or the most
inf Jucr.t • -.I pcr.:-^. . . tj. i where he nr// g/sthcr ir.fonnMt ion of people
I aviuj; X?Ve
• ec 'hl: frv.i ,• . ■;
3.
- /-/kt tut. dotectiri; p.jb'L
p ji;L ;i
ii lucre is one,
and then pToceed to bi B VIpit.
LL-3rThe5” cccisiitt
concmin i ty ■
he £■> di?i-.>t‘ of bjoor tFcrn evt.-ry persons in a
The wsr usual rr-aF-s blend survey is made during the epidemiological
investigation of tl.p pvx^ons in the neighbourhood of a positive case.
LriQ t her re a r- c r. for btRFs Mood examination ie
to detect all the parasite
carrier when transinis®i
—--- si on it persisting to
suppleutinl ACD
and/or PCD.,
I
!
-
-
/
- E PIDEMTOLOG
S URVEILLAKCE OPEIu\TIO>;
operation is an unique Programme whixch
Tr.e rvrveiUance 1
-------...
, Preventive
cove? s - Diagnostic Services along uihn <’'.na,.jve,
The Epidemiological Services in
ai.a Epidemiologiccil serviceseludes two scoots: invest1
(e )
t-
kb)
rn<~.j i..j
’j ..., ci HCsitivo ccses/fcci Jn to facilitate appropriy^
fDo< ‘. surr- s .
c to. tv a of
!•>--remvlit-‘ii~ for assessing the
of
ongoing
ci the progress
Zji <’ -rS• xi uisi< - -valuation
•
c on tr g J r kj a s u r s •
The basic hk thod for assessing
Eradications
programmes are:or
2
ftelarioi.ieti ic surveys
2.
Epidemiclog leal Survt- i Hance
malaria status in a control
PaT-arTietc-r s o f mea s ur e n ie n. t:.
• ; ezami
nation of
r K^-rO-.v-ir-Jc Survey is theezamination
or the
one population
/y
.......... "
- in ,localities
, . , .
seiected at random m
by selected ai e grout..
’Y^*’a'-i'' present at a given moment
order to measure the amoun t oi mxaiii prr.^u<
(Irevalence)*
i
'
The commonly vaed method are expressed assPositive spleen x.iOQ..,
Chile
spleen
rate
Child;
in examined.
1.
2.
Child pai-o.. itc raix- - Positive x ) Dp...
B eS - exam! ned f r om Ch - - Id r en
3o
Infant
ra r:e
itdye , x. 2 00______ __ _ —
. s
B*s". examined from infants (^-12 mJio)
lone; with Hosprotal/Dispcnsary statistics
Spleen so..’ Vt y
rrlrici'^os for n^surm-nt of malaria ter
const y.-rnter ene '
on the basH of spleen rates system
,■ cerit.u-r^
. a.-; ol endemic Ity was developed.
When both, the spleen rata and parasite survey retults,
.-hilcr’en are combined, the findings on the malario
^55
inf—
“r*iJ3S£
ance because it provides xnforn-tior. ol-. inira6'‘31cipr^b Parasite
cal happenings". Xf done in a systematic way
tim= Shen
rates furnish informations not only aoouv tnc pou-nt o-. t.
.^Kil transmissim has been interrvpced but also snout the
Qua r fedk; of transmif sion«.
Ttalariometric surveys were the principal classic^1 tool f°r
rcasui-ement
of malaria and for the institution_ o <m<.. i«_
the
— and early part:
c o n tr o 1 me- a s- ■ i r---.
c s < During the control programme
Isc gave • dequate
Programme these surveys also
of the Eradication
t.. ...----information on malr.: ia status.
Contdv<... 2
I
v
- 24Hoyevr yc daring Jat.c r stages of
the l.rao io:, v jen Frocranrno
- --’.c hulciiiu cases •Ji.cxeased ra'
are not sr native c^cwh to
u. Kh
,jrc' the pz tne nvlariometj Jc rates
nh s
sure
ciiang^s in the a?: --‘urit ./
l lujia.cia ?'> ■'.1 e?»f. in th' '
por-ti aticn, In the iritr r stages of
-uEcidacaf -oh _• t. :ntjccso;.r
’( •o 'teat lit.
-I
in •-: ccr-iifiutv
jr, Yle■ulat-’ or. w
lij 4 ar j.onx-. tr 1 <: surveys do net. i uj f i j 1
those > f.-r .3.1 er,-. v ?L> ti ■~y- are isualiy Corr:.cd
out ones cr at the
mosu t\-Lc a (e.:r r - 7 c corrJ ucteJ
in
a samp.u
lhc loos J r.i,?r " .. ; ,.1< • ,
gr o u. p sf pop\ > j a 15 •'r •.
t:
• /
.
IS
CX/S..' .'..’■■J1-
"■ '
F
1.1 •-
'
r-~ '
tflC
- ^Y. .• 2 s e o t a b I i s n cd
si u ia l ion Jr.' term.'; cT
1 or j
Vi.Gvalance" as
,s.;i-. . trough
rt-.-j.'j is-
I.t Joe. icb' eg: g..:.
rnslcr Lor7K;ti ic surveys 1
Malaria inc^denr-? means n The Number
ci Cases or Malaria
Occur 1 ng d •. .r 5 ,-?g r.
Lime (Usually per year). Malaria case
deteetjo'j iri the
p- puiatlon through out tr»e
the basis fcr tne measuremcEt of malaria incidence. year giveel
The pirem^ters comonly usc-d are?
(1)
^koocL, eyaMnat jog rates
ABExl
wpuiauion
'■>•• • Ji ti
tne tra:• smisc jr»:
'
vear x 100
~—
ex auiiuclly wirh at dgost I.% montH}y quring
,
-ir. highly malarious areas these rates may go
Hovever, in
to i L'% more
up
_ ATr;E£ represents the index ol’ operational cfficienoy and the
adequacy of scare'n for ma laris cases.
of this only the
yy» snerirs collootea through ACD and Because
FCD and
_ —1 v o 1 un ta x y o r ga n i Su.Lioi;r cere to be taken into account. The slides collected i*'
through
the m£SS survoyo 3 r. not to be t-aXcJ into
account
during
calcui-"
aciea of AUER.
If. A’EER is cpnT.tk-x3.1.ly bdov ..10%
’ ' it is most likely
that the
poyjuladieu covcraoc is net roguJsr in time an
----e? S|iFce«
‘ ; t -
APT ■
/
"r-r j./r -.r •
.•:jetecced_iu one ,ye?r x 10n0
y ‘c pu 1 c t i .on
cc^runit-/3 p’i — d'' yy
to the amount of malaria in tehe
vai-^' J _•■•■ .71’be oauc-.onn m interpreting API
Pk' —-t ■■•Ji.r .fbe oased erdv or, the re^ujts of
fully aueguate o.-..;., deletion. .Althou.Q, thL- -JA-l Jhn-X
5r
Contd
•n
i
i
I
1
/
z\J. I playc-u o siQuiirole during the E•.ad teation Programme
foi ckau?,trig areas fr rto corso) idetion ani thoii to
laainucn-n-jc phoec uwclcr ; h'_ MP*.--AfSfe API has been taker, as the
guid-.J irjr f.:w iiiciushri g
1.-; icn under sr^ayJng programme.
Buch opjj'ations arc virici tj.ha in
with API 2 or above.
(3 ) 3 j
.? yas 1^
i
-AQ£
‘ .1 IX.d
SFR is direct.l yz though usually not proper tic nat£l y related
to the amount or mlarA s Eeeices amount of rialaria .'a Inversely
c o r r e 1 a t€-d to th e a me. u t o f n u g a t iv c b j ood s 1 id c s col 1 ec ted .
Therefore/ when an c»ttempc is nacie to increase Z^BER by indiscrminute screening of healthy people there is an artificial decrease
ci SPR. There ferp/ SPR is meaning full only when ABER or API
a r o a v a i I a }> 1 c .
In situaticas when APT is lew and ABER is also below i«0/ am
should be taken into cons id era t ion in decision rraking regard inh
spraying activities* In such areas spraying should be undertaken
if SFR is 2 and above.
BEK
for March
SER
for j ar Qua r ter (Janua r y to Ma rch)
Pl
y-’T
2h.r July
2nd Quarter (April uo Uune)
In such calculations cases are grouped by the- date of
collection c id not by the date •>. - examinat.iOri.
ZkPI and SPR r<ay also be broken down species wise.
The corresponding rotes acres
Zinrroo 1. fa 1 o iporvrn Jnc jd ence
An n ua .1 v iv -i x 1 n s r ? ei iC e
Slide f a 1: _ i r ui;. r j tc
S1 id e v iv •? x r aJ c.
~ ZiFI
=- 7iVI
SfR
= EVR
r.
‘-•o ‘err. o •-■/•••■ cfiic^onoy
tn*i f ■ f foi
<. .nt agencies of the
case aGt.ectb'-n procedar<b it io nLce:.'-ary to calculate the above
Indices agency-wise viz. z\CT)z PCD vcJuntary agencies etc*
Another parameter used sumotimes is the P.falciparum Ratio (Pf%)
Pf%
~ Number of Pi cases d etection x_. 1^00
Number of total positive
Pi ratio is not only direct.’y proportional to the incidence
of falciparum malaria but also negatively correlated to the
incide nco f othcr s pec its.
Percentage of jA_fa_lciij2orum depends on incidence of both
P«fa. 1stipcrum and P.yjycx;, If the incidence'’ of P. talcirum
is increasing faster than the incidence cf £»yJ/vaXf Pf% will increase,
but the same will napi^n if the incidence of P.faleiparum is
Con to • .
I
.jg s.lov-c-i tian the . K2i3 _r
is
. • ?■• Jb } _ .Vy- >v._. >
Exc-n’r?} £.;
t j • :■ tten f i 10009, 300 cases c£ PJ^Jcimrum
.-■ ’•/•
v'
j 93* .
In 3985
■?v .r 5. ng 393*^
vzei fc detect/'!j erring
-* ■ .;•
ri-.c- \ri:~ -IvO -ato. l.!. ■
b?Lh viLit
r»"v
a rd l?0 c^.;-Hr. c,
th I CBBCi jat'C
more or }esb t.
Yeai
1\ s
Ly«:Pi
1983
(\
(~6L /, 5;0
Pv
300
j. 00
J f"0
zo
(-S6t67%)
»**»-•»*•-•
-^tr. <••v-r*-
/ i !* -'
3 9;-.
J c%
89%
( - 7 3X ; (- ZC. 3?y) ( -6,67% )
Tn tbit cy, IE spite ,of decrease in a:n-incidence of
faXciparunt ly 613,6'//.’ the Pf% hoc increaseci, on.iy because the
r-.j/jd (75%)
decrease in th*/- iir'iConce of Vive>: •••?.•_.•■'
Because of ito c-'riguity.
s pre
n
Pf% h-s or4jy i .1;: r. it t ed va 1v c
’ >,-'LaJiP4 \ ?C"
■. e ■• s
r tw'1 successive
t^l?y
:.’■•■ /f-ru a ring tr <
di
Ju
yC-i.
<■
«
v x; ic r- »av h.-- cm-ed rt yc r 1
c’r
~r-/ Tn’V v for tb*:
r’crccrit.aoa of chance' (/'ch) < Index for tht
rl ^-AOO___ _ _____________
Index tor year - X
it
t.c’
’..’
Th:~ xesvjt.: n'^y lx-
(5. nc ?ea 5 e} or Ne Ge v. i v f-
i
t>i£ 3^
0 3^3^
■9 -<ZLIBR ARY^
and
documentation
UNIT
yA
>
J ?-l
(decrease)
HMBIDtrc DI .GNOSIS ^ND
.
“
The micro organisms causing ntalarie.
jcted'to Plasmodium
Malaria Parasites. This •> erm s u-^
throuqh the anopheles
which cause the diseat-a xr. men -n~ uxan-.mmesquite host.
is the w^ertior. c£ the number of cases
Via lar la ^Plux bidity
the population in which the/ occur.
Of malaria irTa unit tiT-e.- in
or attendances at h>..spxtaA^
This rate is. based on recorded admis.n_on hi oh endemicity with large
-r> dispensaries. Naturally m areas the
of
morbidity rate records only
proportion of Asymptomatic
carrier-,
Resent
only a small proportion of total amount
to clinical cause and pros
of.malaria.
_; ■ difficult to determine
is
true
Mor ^axiv
y_ ii.-Jhi frc«n malariawhen
The v,_______
__
the diagnosis and re~ia
i.. conditions
---,
for similar rear:cnsii except
_1
is r.;„ ried oat to perfection.. Therefore, the
•porting of each case
raxaria (1%) is not more
*'.?ften quoted average mo:utality rate due to i------than an estimate ,
1.
CLIHICaL iiSFECI &.
from mild to severe and
The^ClinicaXf^ti^S. of malaria vary
"s^ciirof^asite Pre*e J'
cc— plicated according
isity of the infection and c.^o iLu
.zcate of immunityf tn^
itioM such as malnutrition and
presence of tconccriitant
cwWi. to «■ particularly severe in chxloren and
Z
pregnant women.
b.
bite and. the onset o-
sssrsgs
c.
-^4time of the infective
p^^auring it ore-erythrocytic forms are
s' '^ioJ of the Incubation period xs
S’^SntSiS - was.
A typical attack oi .wlaria has
‘’jZsZirZtZlZed’by
cold Stage, the hot stage ana toe sweat sta^
relieved
afebrile period on whx^h th- patxen
Afttr tne Primary
iebrile herpes is common -n all maxar
P
of <58-'.'2 hours
attack of fever, there follows an ’g^^^IZed by similar afeand then other attacks similar -o tne
brile period.
so.tyEical
J5
However, the.M.str
Tr, P.falciparum.ixifcct ions
associated with marked
irregularly or regularly spaced pt^oxy
follows a rapid
nrostrat-xon^ aua ci.uv.--r > ’
1 nn associated witn shocx ana
deterioration in the parier.ts
A result of inother complications and xn lne fler several weeks or months of subadequate or no treatment m_y fGhrile enisodes, malarial anaemia
opt?™,! health intersperse with fXetioS t£ dlse.se is rarely
4
^Z^rSerZ
the patient's ro^ed
• • .2
'
■■
■■
-
'
-~2-
'
immunity increases, and the attacks, even in the absence of treatment,
become less severe. They are followed by short term relapses or a
period of sub-optimal health before a natural cure takes places.
e ..
Complications^ of P. falciparum infections
Cerebral, Malar;a « This occurs particularly when non-immune per
sons have remained untreated for 7-10 days after development of the
primary fever.. At this time patients condition deteriorates rapidly
. ..cji increasing head-ruche-, drowisness‘which merge into confusion and
light coma. This may deteriorate further into deep coma with stert
orous breathing. In very heavy infection, delirium and cone may
develop suddenly and may even occur early during the course of febrile,
illness. Hyperpyrexia is not unusual. Signs of meningeal irritation
are rare except in young children.
;J e Acute Renal failure;: The shock like mechanism associated with
severe malaria, particularly when there are no cerebral features may
lead to oliguria or anuria and histologically in such cases tubular
necrosis will be present. A watch should therefore, be kept on the
urinary output in severely ill malarial patients. Except in very hot
weather, a drop to 4 00 ml. or less urine per day indicates renal
failure.
iii. Liver damage J Haemolytic Jaundice, more than usually enlarged
liver and tender, '/ery rarely occurs.
intestinal
syuptoms : Diarrhoea in severe, infections due
iv « Gastr
J______c___
___
to necrosis or damage to the intestinal wall,t Dysentery or even
cholera may be simulated.
v. De hy dr at ion ? Caused by vomiting, sweating and diarrhoea.
Dehydration by increasing blood viscosity, impairs its oxygen carry
ing capacity and may lead to renal and cardiac failure.
vi . Collapse^
pse ? The patient may suddenly collapse, possibly when the
temperature is sub-normsl. Peripheral circulatory failure due
in
part to dehydration and in part, in some cases, to lesions in the
adrenal glands is thought to be responsible for this coirollcation
which was formerely referred to as the Algid type of the infection.
vii . Ana pm j a i In. PrVf a ic; par up infection greater number of erythro
cytes become parasitized than other types of infections and there is
release of more malaria antigen with consequent more marked ImmunoHaemolytic anaemia. Sometimes in pregnant women a sudden and cata
strophic fall in haemoglobin may occur.
viii< Black water fever : Classical Black water fever consists of a
sudden massive haemolytic episode in which the patient who has felt
unwell for some time takes a dose of Quinine and within an hour or
two has ’ an attack of shivering, feels weak and collapses and the
urine, which till then had been normal in colour is almost .alack when
next passed. Marked anaemia, recurrent r goes and. irregular fever
follow / There is almost always history of having taken small doses of
Quinine, inadequate to simpress the existing P<faiciparum infection.
' 4,?
I
—3™
IX .
Other complications?
a.
Petechial haemorrhages in the skin, mucus membranes and the
retina.
b.
Rupture of enlarged spleen from trauma, sometimes slight.
C e
Pigment. containing gallstones in chronic malar la case--.
d.
Malaria In Pregnancy :
Malaria of any form may precipitate miscarriages or abortion
and may complicate pregnancy by causing severe anaemia. Pregnancy
also appears to impair immunity to malaria and thus relapse may
develop during pregnancy. Fever during puerperium should always be
considered as possibily resulting from malaria*
e a
Malaria in,Children
Children commonly develop high fever even from relatively mild
infections. They may develop convulsions during the malarial attack
and. dehydration in them develop with greater rapidity as a. result of
vomitting or sweating than it does in adults.
2.
DIAGNOSIS
Certainty in the diagnosis of malaria depends on demonstration
of the parasite i; the blood, but sus icion of the d ignosis is caused
/ epidemiological and-clinical evidence.
a.
2J inico epidemic,, ogica 1 diagnosis ;
In evu.rv case of unexplained fever in person in areas where
malaria is or has been endemic, or those coming from endemic areas.
laria should be considered alongwith other diagnosis^ Under the
MMEF, all fever cases are presumed to be due to malaria.
b.
Laboratory diagnosis s
The finding of malaria parasites in the bleed and their
identification is essential for confirmation of the diagnosis of
acute malaria. An initially negative result does not necessarily
mean the absence of malaria, specially in persons who have received
anr.i-malarial drugs prior to reporting. Several examinations by well
^ained technicians or microscopist are sometimes required in these
cusesT The malarial flourescent antibody test, usually becomes posi
tive two weeks or more aft er primary infection, by which time the in
fection may have been cured. A positive test is, therefore, not
necessarily an indication of current infection. The test is of
greatest value in epidemiological studies and in determining whether
a person has had malaria ia the past.
• .v.4
' ex
3#
tV^AGEMENT Q?1 MALAR
«r.
Q
G\SE
Management of malaria case may be discussed under the follow
ing headings:
a •
Treatment of a presumed chloroquine sensitive case.
b.
Treatment, of a case in chloroquine resistant areas.
c.
Tr e atmo nt
a.
Treatent of a presumed chloroquine sensitive case.
jf
c omp 11 c at J on r .
____ t : To all fever cases chloroquine 600 mg.
Presumptive treatment
This
treatment will suppress the acute attack.
base snougivenAfter the diagnosis is confirmed by a blood film/ radical
treatment should be given.
Radical Treatv.ent : Pf cases - Chloroquine 600 mg. with primequine 45 mg. in a single dose.
Pv cases - Chloroquine 600 mg. on 1st day
x
and Primaquine 15 mg. daily for 5 days.
7 re a -.az t in areas of known eh ? or
fc i no recista nee
Z.s per the present drug schedule under M.F.O.
Pre sunpt iye tre n.trae nt : Amodiaquine 60^ mg. by field workers
Sulfadoxine/Sulfalene = 1000 mg.
Plus Pyrimethamine 50 mg. in single
dose by PCD centre .
Radical treatment *
Pf Cases
Sulfadoxine/Sulfalene 1000 mg. plus
pyrimethamine 50 mg. with Primaquine
45 mg (Single dose)
... -
PV Cases
Chloroquine/Amodiaqaine 600 mg. on 1st
day, and Primaquine 15 mg. daily for
5 days.
In addition/ the PIICs v.’hile treating malaria cases with the
' i schedules need to assess the condition of the
above chemotherapeutice
patient and other medical care may be employed when the patients
condition so indicates. Thus hydrotherapy of fever, adequate
rehydration, antipyretics, analyesics and attention to nutrition
should be given. All pat. ents with malaria should be treated urgently
in view of the possibility that, their condition may seriously and
speedly deteriorate f If nti-i^alarials are to be administered
parenterally/ the intravenous route has considerable advantages over
5
f
--- 5--the intramuscular • More-over most patients requiring parenteral
administration are dehydrated requiring intravenous infusion which
forms an ideal vehicle for the drug.
c>
Treatment of complications
When a patient suffering from malaria develops high fever (above
•40 C), vomitting, diarrhoea, pain in the abdomen, smoky urine, severe
hypotension, oliguria, delirium disturbances of sensorium, convulsions
jaundice or a bleeding tendency, that patient must be transferred to
the nearest hospital as quickly as possible •
CERBERAL I4A1ARIA
For diagnosis and management of cerebral malaria cases we may
refer to the booklet issued by the Directorate, NMEF, Delhi (Contents
enclosed)B
ii.
ACUTE RENAL FAILURE
Treatment should be aimed at preventing is-chacmia by electro
lyte and water replacement as needed.
iii*. BLACK WATER FEVER
The profound degree of haemolysis may be associated with gross
anaemia and shock. Attention to fluid balance in such patients is
of critical importance and for anaemia, blood transfusion is necessary
as an emergency measure.
Prednisolone phosphate in doses of 40-60 mg. daily IM may be
given during the period of haemolysis or until the haemoglobin con
centration is maintained at over 7 gm. per 100 ml*
ivR
ANAEMIA
Treatment of anaemia following single acute attack of malaria is
seldom necessary, for iron and other requirement for haemoglobin pro
duction are liberated intravascularly as a result Of haemolysis.
These then bee erne mostly available for resynthesis of haemoglobin. .•
Pregnancy and
During severe acute infection particularly in^child-hood, blood
transfusion or preferably transfusion of packed red blood cells may be
required to combat anaemia .
v.
DEHYDRATION A?4D SHOCK :
1
«
■1 ■1
11
—1'
■
" ■ ■
ii
Fluid balance is important in dehydrated patients with renal or
gastro-intestinal involvement or metablic disturbances. Fluid should
be replaced judiciously to avoid over hydration which may cause
pulmonary oedema and probably also cerebral oodema and coma. Shock
. “Sically non-specific and when it appears, requires immediate
infusion of fluid, to restore the blood volume, isotonic saline is
commonly used and 500 ml. of it or a plasma should be given rapidly
^in about
to one hour) followed by IL of Isotonic saline or Isotonic
glucose more slowly administered (at a rate of about 500 ml.. every 4
-.6
/
hours).
vi.
—6—
The total volume of fluid needed is assessed clinically .
LIVER, DAM/\GE
Management of the hepatic failure which occurs very rarely
should be carried out in the same general lines as those for liver
insufficiency. Diet in the form of sips of glucose solution and
vegetable soups should be substituted for solid food.
d,
MALi-iRIA IN PREGNANCY
Malaria in a pregnant woman must be regarded seriously and
treated accordingly.
1.
Administration of commonly used anti-malarial drugs in pregnancy
is not contra-indicated. Only Primaquine should not be used for
Radical Cure.
’ '
Folic
acid at a dosage of 5 mg. daily to prevent folate defi
ciency (which may be aggravated by Pyrimethamine).
2.
7“
le on preparations are indicated (oral or injectable forms).
4.7In severe anaemia
’ blood
"
transfusion may be needed as a life
saving measure before the onset of labour •
*
Proper nutrition* with green leafy vegetables and protein is of
are at imp ort a nee .
I
I
DIAGNOSIS AND MANAGEMENT OF CERf^BR^L MALARIA
CLIffICAL PROFILE:
'
A patient of cerebral malaria with P falciparum infection presents
ipay bu
be
with fever and varying grades of disturbances of sensorium., There 935
In
early
states,
sometimes
there
disorientation, delirium and even coma,
may be changes in behaviour, excitement and mania. Occasionally there is neck
rigidity, focal weakness and epileptiform convulsions. Hyperpyrexia and shock
may develop.
DIFFERENTIAL DIAGNOSIS:
The condition has to be differentiated from mjningitis, encephalitis,
heat stroke, typhoid encephalopathy, gram negative septicsamia, uraemia with
pyelonephritis, brain abscess, cerebro-vascular accident and hepatic encephalo
pathy. Other cause of some e.g. diabetes and narcotic poisoning when associated
with fever due to secondary infection,have to be distinguished from cerebral
malaria.
In cerebral malaria, the coma has a rapid on”set> is accompanied with hyper
pyrexia or mental changes.
In cerebro*,vascular accidents, the on-set is sudden and there are sings
of focal cerebral lesions such as hemi,legia and meningi a if subarachnoid
haemorrhage has occured. There may also be evidence of the cause as hypertension.
atherosclerosis and cardiac disorder.
In meaningitis coma is of gradual on-set in most types preceded by sign
of meaningeal irritation and fever. The cerebrospinal fluid is turbid and
contains polymorphonuclear leucocytes. Viral encephalitis as a cause of coma
is not cotnmon. In heat stroke, there is a history of exposure to heat, a high
body temperature and striking absence of sweating.
In uraemic and hepatic coma the history is more chronic and there are
signs of the underlying disease.
In dicbetic and hypoglycaemia, coma, there is no rise of temperature and
there is a history of diabetes and/or taking some drug for diabetes. Urine
examination in the fomer^will' show sugar and ketone bodies, while there will
be no sugar in the latter.
In epilepsy in children there.will be previous history of such
attacks.
»
LABORATORY
INVESTIGATIONS:
The following investigations should be carried out to confirm the diagnosis
of cerebral malaria and excludes other clinical possibilities. (a) Thick and thin
Contd.«.
)
i
~ 2
smears for n^latia parasites,
negativc 9 noga tivc srr^arr> /fox
Sometimes peripheral blcou smears nuy be
malaria parasites do not exclude cerebral malaria.
count&.
(b)
Ictal and different5^>1 leucocyt
(c)
Blood culture
(d)
C. S .F e e'xa’Li u t i or..
GO
LI. i re < x?rr<.tr
(f)
y~i .y «;> 7.11 should b? done to exclude o.ther condirions which eimulste
cei ct ul 17^.1 aria
TREA’P-iENT GF CL?J BK/X 1-LL Ar.LA AI-) T’-’S CGHPTTCATlOWr:
SPECIFIC yREATffiKI CF CERLER/X
tf
i
and quinine are used for the. treatment of
Cci j . an . - *f chic.
Cor.:- ’unds of quinine should
uaed if parasite
c c. ..Lt ! ,•? '’ric'-.
.
u
L
c
’
cq
’
-ir?
i&
suspected
or
if
the
patient
is sensitive
.-•ec
:
> u chioruq1. -.-7G.
KI
cl
-juin:
iphosphate^
.’j i'g
hue !'• ?C i i. f. pyrogen free i ter is injected
fr*‘ra\ 'c.urx
ing a 20 ml, syringe ansmall bore neddle.
h
- v.-rs
in jcctic-ri of (hloroquine diphosphate should be given
or'
< d jvj ba romDleted^in^jess^thavi 15 minutes.
i
K 1.1
Tf tbu pa ient is in a state of scbock- the first dose should be
^dcinistex cd lx an iiiiiavenous drip. The total dose of chloroquine
d iph 2 a p j. te 2 C C Hig. should be added to 5 per cent glucose saline.
hl.2
If there is no v.proveTT.er.t in 8 hours, a second dose should be given.
Third de ?;
required only in exceptional circuiastances.
1.1.3
irtrarrMScul
r injecLioa
irtraTru^cul -r
ir»je«"i_ioa is
is alternative
alternative tc
tc intravenous
intravenous route.
router This
route choeld not be used if the patient is deeply eonatof* cr in a stage
of shocks
Chloroquiue dispVosphafce, 200 rsg. of the base, Should be used in 9 ml.
of sterile pyrogen free normal saline or distilled water and injected
slowly and aseptically into gluteal muscle. It isay be repeated at
8 hourly interva’£ during the first 24 hours.
1/i.4
In children, the dose of chloroquine diphosphate should not exceed
5 tig per i.gc body vaight.
i
9
4
»
o
/
Quinine-dihydrochloride 650 nig. dissolved in 20 ml. of sterile pyregen
free physiological saline or water to injected slowly intravenously
in 15 minatus.
1.2. »
Lose may te repeeted after 8 hours and then again 8 hours later.
Total dose should not exceed 1950 mg in 24 hours.
1.2.2
First dose may be. given by syringe, subsequent doses in intravenuous
saline drip. It ir seldom necessary to continue this more than 24
hours. If it is considered essential; subsequent doses should not exceed
1300 mg. ic 24 hours.
1.2.3
Intrai-dscujar injection: Quinine hydrochloride 600 mg made in
of physjologieai saline or distilled water is injected deep into
the gluteal muscles.
f ml
1.2.4
Abscess ’ is more conroon with quinine dihydrochloride as conapared
to quinine hydrochlcroride. .
1.2.5
In child enfl the drug is given intramuscularly, the dose of quinine
hydrochloride is 10 mg per kg body weight. In. children up to one year,
th^ dose cf
i «.inc- Lydrcehloridc should be one-tenth of the adult dose
and between 1 .o 15 years lt should be age/20 y. adult dose.
2.
GEKEIVlL 7 £/.TMF”T 0? C2RTERAL KA-. A1A IS AS FOLLOW! .
** "
2.1
'
*"
'
— •—^<«r- . .. —
— -
_ __ r- -
I ----r- 1~
» 1-
LT -H
Treatmrn*: of phc :k
This Trust be treated as quickly as possible.
2.1.1
Raise the foot eerd of the bed.
2.1.2
Cortisone Lemiscuccinate 300 mge first dose and 100 rsg. 8 hourly
bhould ba administered intravenously, or dexamethasone accetate 8 mg.
first dose and 4
8 hourly intravenously should be administered.
Dose should be gradually tapered after 24 hours If there is
srrkcd dehydration, adequate fluid and electrolyte replacement
should be ensured.
2.1.3
Flasraa expander# Tike low molecular weight dextran 6-12 per cent
solution 250*^00 mi. should be administered intravenously.
l-i
2.1,4
Mt phen.eranine sulphate 30 -60 mg. intravenously 6 hourly
and if this d>es not bring up the blood pressure, 600 mg in 500 ml. of
5 per cent rl rcote should he administered by intravenous drip, the rate
of adTiiiuiptrution being regulated by the response of blood pressure,
’"i\ ;?Xruv.iU of ccayyflsion / c>.ci tcl«int:
£5 ..n_/ r a;r ear as costplications of cerebral malaria treatment
G^h.inistrcticn cf injection Dizapani W tng. intravenously or
1 cxiinc t 2 mg. iatratnusci’lrrly.
2.3
re-J '
’’
;■ iec:
th.
..k«.
C’Ct j- coiza:
>»
*■
i
patient becomes deeply comatose., the following line of
to be adopted.
7.3. \
scji.c cccetate 4 ’rig 6 hourly intravenously.
C<-'$v£ C’
1 tnJ.axx wlIL Lr useful5 it is also helpful in excluding other
like mcanlngitis end encephalitis.
COE
z .of 1 ^erpvretfiax
-:
:t of cerebral malaria develop hyperpyrexia.
> llcws:
.1 er
'JC f .
t.
2.Cz
i
c
2./.4
9 r
It should
be gapped in Wet sheet inmersed in cold Fater
fan. If possible patient should be moved to an air
■n’ ent.
” 'C' ac e t anso 1 G, 5
Tig. intrenascularly to be injected
-Uic shcuId be recorded. Surface coding should be
temperature cotjus down to 30° C.
If toripiiatur ic not controlled by the above measures then
injection of cblotv. romazine hydrochloride 50 mg. may be given intramuscul
arly or ?« plow ii ravencuo drip. Half hourly record cf blood presere
•jpuuiC t-?. w.lntainc.
This should be administered with utmost caution
a5
bicod •.,cssure is likely to fall.
*
2-> nii jvascular clotting*
to; . hr rccogni _on of intravascular clotting one should watch for
lug
o:t2
iiiepuncture^ haematuria or bruise;.
This may be
lur-zher supnevtad b"« oing the laboratory investigations as determination of
f71 r 1 ^ogeu Gegr&G.at 1 i products , platelet count and fibrinogen.
lr .? pGr.i.rni. o- eiebrai malaria develop this clotting problem
?: o 11 g ’ ii»» t r e a t • •. t should be administered.
t
I
s
2.5.1
Injection dexamethasone acetate 8 Eg. first dose and
A cig» 6 hourly intravenously.
2.5./
reparin 50 units per kg. body weight in 5 per cent glucose
solution every 6 hours.
: .5.3
4
I
i
1
Fresh an^ cnrefully matched blood transfusion.
/
CHEMOTHERAPY O> MALARIA
1.
II *
Available drugs and their application according to selective action
on the different stages of the malaria parasite.
No single drug available acts on all,the stages of malaria parasite.
In different stages different drugs have been found usefull.
(*) Causal Prophylactics: Drugs having action on the Primary tissue
phase egT pyrimethamine, primaquine.
(k) Tissue Schizonticidal drugs : Drugs acting on the tissue Schizonts
eg. Primaquine, pyrimethamine and sulfonamides (possibly some action)
Blood Schiaionticidal drugs : Drugs acting on the asexual parasites
Amodiaquinei :Chloroquine Sulfonamides,
in the blood eg. Quinine Amodiaquinei
Mefloquine.
^d) Garnetocidal drugs ; Drugs acting oh the gametocytes in blood
•
destroying them eg. Primaquine.
Quinine, Chloroquine, Aaodiaquine and Mefloquine are active
against P.vlvax and P.malariae but not in ^.falciparum
(e) Sporontocidal drugs :Drugs acting on the gametocytes in blood
but prevent development of the gametocytes in mosquitoes eg.
Pyrimethamine, Primaquine.
Recrudescence : Infection comes back due to survival of the
Erythrocytic forms (upto 8 weeks).
R^currance : Infection comes back due to reactivation (Relapse)
of dormant parasites in the tissue (Hypnozoites).
fleet ion of available drugs as per their cheglcal const i tution
1.
2.
4 - Amingquinelines
8 * Amingquinolines
5. Dyamino Pyrimidines
4. Cinchona Alkalods
5< Sulfones & Sulfonamides
6.. Quinoline Methanols ~
•
I
- Chloroquine/Aaodiaquine
• Primaquine
• Pyrimethamine (Daraprim)
- Quinine
(Short and long acting)
• Mefloquine
Properties of available drugs
Chloroquine : Rapidly absorbed, stored in tissues of organ and
persist for long time• Therefore, to achieve an effective
concentratibn in plasma quickly a ,,loding dose” at the begining
is advisable. Slowly metabolised. Its elimination is very
^l^h dose it is toxic (deaths occurred within 2 hours
of injection of 2.5 gm of Chloroquine).
Contd...2..
- 2 /
—Syffiptores : Headachest dizziness^ nausea, anorexia
s p. - c g as t r o i n it st i n a 1 symptoms and ditvrbances of visual
accomodation•
Severe Sy^ptons
.... • Heart and nervous symptoms and death by respiratory
Tai’lure • Cnlorcquine acts on the blood schizonts possibly inhibiting
the respitatory enzymes of the parasites.
2.
• Sarae &s Chloroquine. Dosage also fame for single dose
or • ..oses treatment. However, for suppresive therapy 400 mgm. of
Amodiaquine weekly as against 500 rogm. of chloroquine should be
given. It seems that in some localities Amodiaquine is more rapidiv
effective than chloroquine.
3.
Primaquine : Primaquine diphosphate most commonly used. It is very
quickly absorbed, but also rapidly eliminated within 24 hrs. Very
small amounts are fixed in the tissues.
This drug shows that in some individual and particularly in
Negroes, doses that were harmless for other people could cause
haemolytic anaemia and Kethaemoglobinamia. In a daily dose of
30 Ego. it was found to cause acute haemolytic anaemia in about
lC-15% of adult American Negro njales. This individual suscepti
bility has been shown to be a genetic characteristic, corelated
with ar intrinsic defect in the deficiency of an enzyme Glucose 6
Phosphete - Dihydrogenase {G6PD) which influences various functions
viz Glucose Oxidation.
Methaemoglobin is formed and its reduction into haemoglobin is
impaired hence methaemoglobinaemia which is recognised by the
development of cyanosis in the subject and the clinical picture of
8-AQ intoxxation i.e. nausea, abdominal and • epigastric! painst
..vomiting, daikurine that in servers cases suggest blackwater fever.
Haemolysis is self limiting as only the older PEC’s are
destroyed;
Priwaquine sensitivity is accompanied by a sensitivity to a number
of other drugs e.g. Sulphonamides, sulphenes etc.
The S-AO distinguish as the only drug capable of destroying
P.falciparum Gametocytes^ They also have action on the Secondary
<xoerytHrocytic forms. Thirdly they have sporontocidal activities
as well. Fourthly Primaquine can be used as casuaj Prophvi^rfs
for Radical cure of P-viyax cases - 1? mgm. daily for 5 d^ found
adequate with only uoouF^S^ relapses. Primaquine can be given in
higher doses if the interval between them is long enough.
Primaquine inhibits parasite mitochondrial resdxatior? and this is
, probably the basis of its action against the tissue schizonts and
the gametocytes.
CoDid,.♦J..
-34.
Pyrimethamine : Daraprim is an extremely valuable drug in taalaria
Tradication and completes the action of the 4~aQ by acting on the
•’sporogony and on the exoerythrocytic forms of come strains,.
Absorption is rapid. Moderately stored in the offeane but loading
dose is not necessary. Elimination of the drug is slpw after the
. ;^first ;?2; hours. . Toxicity is. v.exy .low but whejqat higher doses
- — or-iirTonger courses it may inhibit neucleoprotein synthesis in
man and give rise to macrocytic aneamia. So use folic acid and
folinic acid in such cases.
Daraprim acts on the malaria parasites by inhibiting nuclear divison.
The sporontocidal activities of Daraprim is seen after J-4 hours
ingestion and may keep the person harmless for 3-6 weeks.
5.
Quinine: vTth the discovery of resistant strains of P.falciparum
malaria to Chloroquine, Quinine has .again becbme .useful drug*
Fortunately Quinine is second to no”"other drug ih saving the life of
a severe malaria patient and.in giving quick clinical relief.
Quinine is eliminated very quickly and it appears in the urine a few
minituesafter ingestion. Hence the need to give.daily’amount in
practical doses 5 or 4 times. Quinirie acts on the asexual form of
all species in blood and on gametocytes of P.vivax,' ovale and
malariae. It is inactive against exoerythrbcylfc’ forms. Radical
cure can be achieved in P.falciparum cases with quinine alone at
dosage of ^.g. daily for 7-10 days.
In severe cases Quinine should be injected- ini-ravenously/intramaccularly.
Sulfonamides: Sulfonamides and sulfones are highly effective against
'Hie asexual blood forms of P.faleiparum but legs effective against
those of the other species. Wey produce clinical cure of falciparum
malaria, but their action is too slow for them_to be used alone.
They-are^also effective suppressive agents but-should not be used
for this purpose alone because of rapidity with which drugs resistance
can develop.
I
Malaria parasites like cany bacteria are unable to utilize proformed
folic apid and require para arcinobenzoic acid as a substrate in order
to synthesise it. Sulfonamides and Sulfones act as competitive
antagonists of this substrate^ . r •. .. J i.i...
'■
•
-i ■
"**
.
I
1 •
♦
•
•i*
•
•.
*”
-
_ ______ —.—-w • •
,
■■
•
. • 0 When' adrainis t e red t o^e t he r wi th Pyr ime th amine 9 sulf onami des may
potentiate the action o^f this drug. The potentiation aay be of such
a degree that the combination can be effective against strains of
microorganisms that are resistant to either component used alone.
Mefloquine: This is a new anti malarial drug still being used on trial
basis. Mefloquine has marked action against asexual blood forms.
Against gametocytes , the drug is active against P.vivax and P.iaalariae
but no direct action against P,falciparum.
™
Contde . - .e
9
J~^uine it feher,Bn
wcl2 1tolej-^ted, p e^tivity
; - and ha® a potent blood
•— ’
of
s
u
c
Ji
—
parasites r€sir!.
t,
..
SUC* - chloro<iuint
and Fyrifcethaoi n^’.^
^2£ilX^L.in Holeri. Er H.
A «
blood tSSV~A77^"--Ti-i.- Gito r
e!2.‘ fever c«eec.
the
Claris by theDA^0" P^euHing that
’ •-‘J * ewi" riyc
aEenciec.
e surv
Are&c wh.-rc
££_
A CD - Al-Odig.-.y,..,
(b)
- >
-, ..
.
, ._
■' ' iC’’2Phr>’te'fit c? ^lphsdoxt-.< .. -rr.,-.^
^"■d >0 SgK ,-i
(c)
• ^.ynetSfiRji^tr )
nDo/n-p, vjfj? ~ Attodi *'.■< i' • -• h
- I ,,^
-—• .
tr.pp, J., ;; ,.
.
. .
Artao where
TW7BSM-ii
-r
■■.
;.-
■......................
B.
P^ThsilesnrSrcuS’»\ aSa found positive j- ..
,
radical t^saisis^ yy^r®“®sr exaEiRatiSa
to be^;tr
w.rn
I.
(a7 P f,Xc~-----*■ *ipsrurr,
-0c<; .
Cbi ler or.
■"
h-
-.^
A'A: '"•
'"
£-
r>-r' Sui^hedoxiaa i;Ux^KU a^e}
Ko pric;ft(5uinR_
r^)
—iofgetieg
C^loroqui^^ ~ &.o
"
Pri^i^
....
"‘
dsiiy for 5 d.
a.
(b) P.vivsk
,.^2^ ,2'^222 y-r * a
c
*-'’1- - ^lorcquiRt 60G
* ^i’wqvine
45
XKt dc.y .. t^r. r_ ....
2T2' Prjj>raQt
•<■
rrt.raaq;.iEie
o'^y i> E5?p
t.-A,-s* <la\ly p.-jr J d5yc.,
JlEilL. f::'*i-'.’?lst '-st-; {-■;• ■ 5?-.felt?ng viffs
HDA e h£-: j c:
c4.rfc £: ,
SSSleltjT Chi;A3Ar" -o:;‘
b
E.eop
h-ey^ be;
' 3.
‘>:
.
■‘■?!:' ai‘ug. e<i«if,jatrat-;crA»-Z’- i
■'■ui!iai f*PrK? i'. ti-or tvo rntrthly
to co-‘A”Zu '? Lf ’ tPsatftd «t .r.-c, iT 1 •-''
/ _5_
D . Drug Bhcedule for labour population in PfCP ^rqas.
/=ri,,n+ dose''
(a) Labourere on entry PfCP (Zone-I) areas.
MDA with 600 mgm Chloroquine and
mgm Frimaqu^.n ■■
must be given within 10 days of their arrival.
(b)
Labourers before leaving PfCP, x„1+.x Sln„ie
MDA with bOO'mg’m Chloroquine anTT^PrisEaquine (adult) - - ..
dose.
General
2 j will be given in the doses
Use of raracetaniol - This drug
(i)
(adult) by^ACD/PCDlnd FID only in current
of 500 mgm (
fever cases. DDC will not distribute this drug at all.
salts are-• life saving in cases where other drugs
(it) Quinine For
acute cerebral or other serious typea of malaria
fail. L-- intravenous Preparations should be used#
E.
Injectable: Special precaution should be taken
(ill) Chloroquine oT" thi~Tn children, as shock may be produces.
Tor the use
resistant
arum cases shou^a
In Chloroouine i
---------- areas F.falcip
---- —.,~.™
—.
treated with Chloroquine injectione.-
dot be
■"V. ■ Drug •resistance to
laria Parasite£_;
"availability cf
Drag resistance in malaria has b<-n defined as tne
> the administration
a parasite strain to survive and or multiply deep, .e
higher
than those
and absorption of a drug given in <t>ses equal to or
of
tolerance
of
subject.*
’
usually recommended but within the limits c_ -----------
1
all aspects of malaria parasites
Although drag resistance embraces
tissue schizontocides, gaweand all acceptable dosages of blood or
it is most commonly related
tocytcides and sporontocides, in practice
falciparum
”* +Drug
to the effect of blood nchizontocides on
------malaria
,
o refer
resistant malaria" at the present time customarily understood to
to the 4 aminoquinolines particularly chloroquine.
t/•’
I
Bros failure - is ab.aae. of drug aotloa du.^o.detielent sbsorptios,
’■unusuaTraTe of metabolism or excess excretion ox the dr g.
’F
.
2 ncrCciS^Li
..
C’
r..,
„ d„U(, can be seen when the psrasitesv-xo-mF.
disappears
vO a Qa.ug vau
4.
usagel 6ay from 600 rngm to 900 mgm when
persist even on increasing the dosage, the strain is resistant to
k
the drag.
Gradation of response to drugs:
-SSSS'jS--..
'\ -
grading the . resistance of asexual P.Taiciparum to
ri
doses of Chloroquine (1500 mgm) has been proposed and has proved
practical and useful# Ab per this grading#
I
I
••
' .:T-
-6/________ _
.•
*• -itM—.iv
Evidetiv*--
RecoaiT.eno'ed Syrnbcl
Response
Sensitivity
Clearance of asexua 1 ps? ss51• a .1 c within
cc t d/xj-- cX JrJ. via-ion -i ter tr-.5. - •
w.i thout subsequent recrudescence
S '
WI» *■-—»- .- «■—
^^rn01V»M>-.M*
Gle aranc e of as ex an 1
j I- s i i ae r..< a
as in sensitivity followed /
recrudescence early or dr lay<
Resistance
Marked r edn-'t? or. r *' ■ ( ■ '. '
paruoitaemia but no clearance
RTT
I —IM
fC
B I r»— Cl
,
w- w
> ■ «->. ------- M-
— rl-
r
.i"',-
-.
_ 1.1-,; ..■-
- - —• • -•-* ■ —.*
*- **••- -v-.
• w-r- *-«. -•
.MT*"'*
— lif^
No warktd reduction of
pa r a.s i t a c 7;i a
I<I u
-
-r
yr -i iliiui j ~ -,
■ - r"-Q - U-~~n~
•—<>•**»’*• ‘'Hry*.-'wv«'
*—iy
i<i»
Machf. rtisffi of drug r-eE-ist-^cc
Resistance by J, ihlc. p.\r u:? tc .Chloroquine
w&Jj ;u. by all species to
Pyrimeth&mixM' T&^aTT.rTuV-ft^r j e to ss'iecticn unde; drug, pressi-r^ of
resistant mutaxvl;.. which ourv-jve by vtflisSrig
tex-nativc ?ur t&volic
pathways to thosr; j r-? f-|i: r^rtionlar drug. In rv-5p^< t of
Ch 1 o r c qu i n e f rs- s: t <•:, n c < 1 r r h r: ctor 1 r e o b y a decree e i v: h; gi 4
affinity bindiag
for ite cxtup.. Once selected :\n‘ provided th.^t
thvy f\->napc- the drrtru s iv-‘ action of host i: iy
resistant
paTASitec vnay b- • ;
-i it
1 y Igo^.I ruGSuc-itco> ’ o other people in
tht? is-raediat ar.•-, cr
> be carri i by a migrant h c^: to otherpiacese
Distribution of drry. r:.". 1st ant malaria*
■»—C»»V?H —• 'WOWO "
I
- —r
ytz—■ —wt• ' v>«^ •—m««
Drug resistr:pt
all over the world.
***
—"V» ^•*T**W**^ « --
r>as been confirmed fro& G i f f e r e nt c ou n t r i e f?
In south and centra- A^i'^cs, h«f&i’-iparu& j
to Cuioi oquxnv
was fir^t observed in
Since tb.<?n this har-- been
reported frohs Brazil, Guyana. Surinam, Venexual^? B^lvia
me
re^G'itly Equad or ai/i Ere neb Guyana.
In south east Asxsx re sistance was first suspected in 'Thafland in 1957*
Since then'At
:c-tr* confirmed
Thailand, Wesv
republic (G^bQdici)* L \.>5, Vietnam, philiipines > Buraia* E&st hulay,- eie ?
Ir df s , Benp 1 r dsh , Papua Nsw rvi ne& nr» r? Ir.don
In Africa Resistance has now been reported fro& the eastern coast vis.,.
Ta n ss ni a t Ke ni a 5 Madagaskar, 0ga nda, Zambia and Sudan«
The resistant strain have- been continually spreading from the criginal
focus in Thailand in jra eastern south eastern direction reaching a^l
countrieso
West ward the spread has engulfed Burna, crossed into the Cnitt&gong
Hill tracts of Bangladesh and reached the North Eastern Str tes cf
India. At this point there has been an onward spread down into the
plains of India mainly through imported labourers fror: Orissa to the
North Eastern State fee construction projectsr Resistant strains
hav-e now been confirmed from Maharashtra, Andhra Pradesh; l.F. , M.P. ,
and Karnataka.
In the north Basteru region resistant Pȣalei paruro, ronlaria was first
detactediin K.S. districts of assart during 19?3* Subsequently the
resistant strain was detected in.JNowgongj Ka^rup, Sibsagar, Kokrajhar
districts of Assam, East Khnsi tfills, East Garo Hills and West Garo Hills
districts of Bcghalaya, Jalpaiguri and Purulia districts of West Bengal•
Kohima district cf Nagaland, South district of Tripura, Central District
of Manipur, Aizwal and Lunglei districts of Mizoram, Tir^p diotrxct of
Arunachal Pradesh and Andar-ar. arrd Nicobar Island»
i
*
I
I
V^’T^ALAFOA DittxG pOl iX'Y FOR. 1981 - ^ECj.^ION
/V^ )^Rtv ANT- FILAR^ WC^RS
cX-iX.i .iLi AT CilANDKJAkH FROM 25TH APRJ-L,
.^1/------ -------------------------------------------------dorerlcd in
.... lie rc^i^c-4-iC!- 2;r r-rV'l
•■ - -v • -■*->7-■ r^'^< Y 3 C' first
di s c c- vc r c din
the year 19,3 in Assam. Tn 1974 .r.c r-.-.- focus waapp ] i : cj
j. XT?^' Directorate N'^EP had texon up
tho sanic state • r
Qy, > 4- - .y 3 pq t he chi or o.qu i nt r c s i n i x- <- 0t<:tu3
r e s e u r c 11 c cl xerr.e jn” drill, en-.-.
parts of India.
India. At present, there, are H’/deratad,
cl hjJiLlc
y
p
•
j
rerti
'
x? Ehuhoncsv/ar
Dhuha nesv/ar, Ljck^-.
.
-.^vsr^ -.r
' Ilona,
s
a
ci
•
sSy'lnd Danga^e?' Presently
n^r of teams
^^y^/ha^'
presently the number
Perino the last two years several xMatio ond ilLu^Kg^:,
__
b.e.,
Phon^enon
- have been <-----of Chloroquine resistance exist•
rf- chovld b- n’enti'-ned here that in some areas Pj^^ciparum
eonstXutJhK L/i L.ii.tlec 1"
iL eo-o«l=ts .-1U. SUBHffiU
iy-^
wh^-^-0 P - foieip?rum is found to be resx.>tai.u to
‘.-^h-swa ro»^»
totallY
am. in th-"’
lenree ox rexx.^^e to chloroxine is
scxr.o arc
rtoX
. ^+-o^ i w: iif --rc fvllv
to calor
oqu-n^/
,
fu 1 ly
susceptiLle
,t.....susceptible
?6slston=e.
M.
with P.J,I typo
of
or RT1I type of resistance,
r e s i st a nc c- a r c- f ■ - tunately sti 11 very f-v v
It is vorth ^tion3ngj chat so far
tar there is no authentic pport
, , . .,.o rr,«-‘e>3r.^ r>< P-vivax
ro
chloroquine
•. Triers d~*cfc. ne^
.vivax
chloroquine
p
Report feitetiag th/- chloroqu.ne susceptibility
s ta c us of „ P^rno lpi rac, i n Iaula?
In this content ft appears that our policy should be clearly
defined for the following four types of situation.-.
_ 1
..
1
2
A e
A.
. .
-. .f
T”.
T*' -.•.?“> >
■■
r» <■
•»
Tn ar-a- wh'-re chloroquine resistant f^loi^arum has been
Xo-wS. Tno Xl.,. retains
trewmert, raoxeax
triatment an-3 policy for cl» Inccmxng ana outgoing labourer,
dt’e to be defined;S .•: n-1 j ar p: / i-e?y“ '<'e ci'icn ere required in respect of areas where
i
ccrr- iases to be susceptible to chloroquine.
Th.e policy regarding the treatment'- {presumptive and radical) for
areaT/where
<3ar.inar.es and liiHialari^ -1-0 co-exist.
Tl^ drug polio-' for the project areas where there is a frequent
inf hr: Ind c^t-.urn of labourers - Speciaxly project ar^as
(bofi- in Chios co nine resistant and sensitive strains).
Ch 1 or pgui ne
Drug policy 1
in
i n P ,£a lcipar wr. are ar,
si.;.2£2^J^^2H1®^2£2.
Contd.•<2
I
cl.OL Ku
oi •
six •/iS-ri.iLcr’i/.'
•
.- j . i
1.?^
/-
ShOO. :
•-/it
U
(
(s3. ■
/
i
c^zr tcu ■'GV -.•.
tri
:.t-h okj
' c-ci dnd at pr-
z-
n:
•
• i
V ■.
1
•^r.
Or-LI (.
'f- be .fesi aic of cbi.aht *
• f -driissrhit t o
■ of 2_ rm az: io
. ..gv io | la_
f th
Tgl j.■.■■.•
sot•»?.•»■
■
-bt ?
c.j
ncc (-i •
.-. • . GtV'iiGf
; r ■io j d:io~
iii se veral others, tner ' are doubtf u 1
.... not; aovisat-lo ro ch~ ».gc the e?’. Jot ir-g
C: ■>
District.
As
r-
ks
J
-do13
3
►
f
•f
-i s _•
A k
T - • olc •? .■■''. rj t Ulc obar
1. i L' L J. v. : j j. c cf :■ j r
I'.
on Jy .
t
C oVC:- r ? rjg tte area
o. Xadnya Pradesh b
Or isbe •
x- _4. c a
fk 'y.
: .- :■
.....
A- 1
Ci
Aaca J .<• r .
■: dcar.-i!’<*1 s
t.: .
. .-.r .'■£ >!J"
>’ OT eP .0 -
Saktl uager
oo iy.
y.r c hloa GCT.;r/
(b)
Or
■ ...-x .- •
J -
AEo JSTAITI* P .FZaLC1P?J>L^
L .• .
” ’ '5 •
O • J.
DL-C
c:cr>)
o'd. 6 O
•l Lal. let a CiL «e
.Ci •
» 1000 mg. dose* of
Soipf. _.ir<! 5 9
: rlGGO c-i‘
py r i r»e t ha if - j ne) .
7va od 1 ■; qi.’ x ne 600 mg - baa a.
dose .? r ;
O dull
I Vi d\i lo )
(ado21)
• •• • dvc.-H ot - time .-.-•ft-.-r ; ne a J.;..«
Ch 1 j dr c .
’* 14 w J 1.1 r e o a j 5 \ J ,; / J
l//2 '■nd 3/4 of the
oose ro.:.
(h) R d'J io a u Tia dtrrK nt
ChloroouJ r-c i -g .' : J. rt a* )v
c-irt a.r )
Co. -L-d. - .
I
• . .3 ..<
iasistant Palcj-parun
In the- above districts with chlc^oquine
Sulphalenc and 50 mg. 'u
the radical treatment will c^7’t"'P°pJ^lo^alonowith primaquine
Tfe ciliarej exooi.t infants will
v/ill
receive the drug-in pror,ortinnately small dps-.
II;
and uiegnant, womon ned'd not be..
ir,>. ai^ricta the drug schedule for radical treatment for.
ln
I infection M -ill
P.vivax,
chloroquine 600 mg case on the fxrut o<.y ant I rima
unaltered i
quire 15 mg base daily for 5 days.
Areas vzhei'c P ♦falciparum is sensitive t o ch lor o^iuin£i*
B.
i.
Presumptive treatment by ACD PCD & FTp/DDC.
ii.
Zi3ult
Use of
Chloroquine will be continued as per the dose uUeady in
use ,(i.e. 600 rag. base for
£or adult)
R /f .
- •600 mg. chloroquine + 45 mg. Primaquine
(smali dose)
Radical Treatment of P.vivax/P.malariae or hixcdl
A.
1st day
600 mg. chloroquine + 15 mg primaquine
2nd-5th day
only 15 mg. primaquine daily
Drug scheduled or Labour ^opulatipn.Jn^^^area;^
Labourers before, lea^ijiq PfCP area .(con^-J^r,
high incidence of Pf■
Mass drug administration with 600 mg. chloroquine and 45 mg.
Primaquine (adult) single dose.
Labourers coming from Zone-I & on detection in Zone-II L- III
follows:
S: other zones the regiem will be as
.
9«O
r Presmotive .
. Chlor equine 600 mg.
Pr imaqu ino 45 mg•
(adult singe dose)
Chloroquine 1500 mg in three
divided dosage and Primaqiiine
45 mg. adult single dose on
1st daf . If there is no response
to this regiem within three day*
(72 hours) 1000 mg. Sulphalene
-r 50 mg* Pyrimethamine with
45 mg. primaquine (adult single;
us already stated Primaquine
will not be given to infants
and pregnant women.
Contd.•.A
/
...4
- GENg<AL:
i.
'Pse of paraecVxmqt ■* 6Q0 mg\ (adult) of this drvg will
J be Given bv ?^D/FCTyr-121«oi•nly
\ -ln .current fever Cc’.ses.
at a ? 1-
1.1,
iii •
□uiiJ.ne
drochlcr-irfe ~ m-acarati
salts arc l^ic savino. if cases where ctr.cu c.- iq ■
For acute cfcwb”! of other• <?er±ous .types of malaria,
iutr a venous preperut-ion should be- uS’ d.
' -} should be taken
■ ‘
~’SpeciaX precaution
Chloroquine Injectable
as
shock
rtay be produced.
for the vs? ofthis in children^
p
faIciparurn
cases should
In chlorcduine resistant areas,
with chloroquine<
not be
L- treated
..
$
I
I
PRWCI'PLLS OF ICFEaKIA
OS Ji J t S gzJSP L
Sir Ror - c Rosf dircovex' x2 cL jI •Kluli.-i waS^ti-insnuiRd
through the bite c>i' mosquitoes. f: icr to this discovery
there
r»o raciorw] basis of contrulxing ns J ar 1* vo& i.t
existence no the first attempt to contra.-. ”®*aria by mos-.._u*to
tehuerios wao out io’-'.-erd by Ross bimseif iu 1699.
Co 'or prevention of malapia in individuals
The measures
and for larger scale contEGl of the disease can be divided
accord Ing to the classification proposed by Russen
Measures designed to prevent mosquitoes from
y. e cd i n g o n n a n •
Measures designed~ tc prevent or reduce the breeding
2.
otf moscuitoes by eliminating the collections of
water.
Mo a s ur e s design ed to destroy tlie lar^zae of rnosquitoes •
3«.
c• ;.rco des5.gned to destroy adult mosquito
. 4.' *
r
feasures' des-igned to eiiriiiria Le -the malaria parasite in
the humar' h'ost^
TOES PROM•B
Tn-.prow ip g -tVie. ecorrcraic status of the ^people whi»_.h -7j.il
result-jn better* liying dond iticnr and less facilities fcr
breeding of ^osquitoesu. .
•*-
<C- ed.._ t. - -’T-' :./:bl ic ahcut^.the neces^ity^of ^controlling
the descase a-nd the simple and 1practical me-thoci of avoiding it.
ilECi^irrtrt
•,
....
-• ■
. -Herrenxng.. c f build ing
. x. TJfJ* of" n-?sQ
i
.5^ '
’
.^i•; -Ses troy i ng mosquito shelters»
■’
*
”
■
--------------
..
_‘T”
*
mosquxro. rupeliants ..on. eiofhing and skin-,
-
.Dimethyl pthalata,
...... ’ ‘ *7
r
Con tn v. $« 2
■'• \
>itg
'Il .
•iJt - J ci . -
J
rrcJv
''’ent the cr'.ritior. or in^n
. n'jer
..r-xco:J rc
ire i o \ t ron
Coor -1 i oh o' pch i xc
i t i _ cl X t h
(B)
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c; ictrictit.riC chfc.suica2. contents •
V.V:
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<.>xls and chemicals for destroying the
TFootie stxjges of mo sot*5 toes e
(XT) /• qaXf^"A:M LJIl£S2ui
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i Auamerr.n-<j n^V-C.r'cl enenles^
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Protozoa, heir^rodes*. Fish,
Insect pvfxiarc^ s v- Plants «
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i
RESIDUE, INSECTICIDES, FORMUUi’fIONS, MODE
Of ;A;TIOi-V AND DQUIPMCNT >__ _
/
Z-Tx Ln: ectAJcK
produ c that kill im ?cts. The value of
an insectlcii- C Y”-' •■'-•• on. t/ie. interaction of a number of factor
. related to tl?: insecticidal compound, its for^uJ-tions, the mode of
application, the surface on which it is aopl.-.ed and the insects
against which, it is used.
The residu?.! insecticide used under most malaria eradication
proorararaes are chlorinat.ed hydrocarbons (DDT, Dic-ldrin, DEC and
No lathi, on .)
DOT is .still
s t i 11 th. most
»•. ost ccnrnouly
eccfirnonly used insecticide
ins oct ic 1 de -< It is a
o2.ry’rc-3 crystalline pewder
powder possessing a fruit like
whit'-,- -cue-my coloured
odour. It is a stab
stabl .c: conpound with a melting point of 190 C and
its solubility in water is Jess than 0.2 ppm.
It is moderately
soluble in petroleum and vegetable oils and readily soluble- in many
organic solvents such as Xylene
Benzene etc.
j
Mode cf Action:
DDT is primarily a contact poison acting on the
nervous system of insects and causing paralysis of legs and wings
un-coordinated movement, convulsion and finally death. It is also
a stomach pocion. It lias a slow knock down effect# often takes
s e ver a 1 h our r. r c kill.
Formulations3
DDT may be applied in a variety of ways# the
manner of app..ication depending upon conditions under which jI is
to be v-rod and against what insects it is intended* DDT is supplied
coKtf’^rcially in a ut^nbor of. standard forms, although from pure 100
per cent technical grade of DDT# some of the formulations detailed
be low .can Do easily prepared in the laboratory •
1.
Dry durtinq powder mixed wxth an inert diluent such as talc,
chlr.a clay or chalk.
2.
As a suspension of fintJ. DOT crystals in water (water disperssible p swder).
.3 .
Solution in Kerosene, diesel oil, used engine oil or malariol.
4.
Emulsion concentrate in a special solvent with higher degree
of. solubil ity such as t oluenet Xy 1 ol a* id turpent ine .
5 e
I'>s an Ae. oso 1 spr uy .
.VJotcr disperse a ble powder of DDT ii’ us^d. under NMEP*
j-?ogr.gible ;>owner s
Water dispersible powders are preferred
to otner types o£ DDT prepar at ions because of. the storing and
transport facilities and comparatively lower cost. DDT suspension
in water is prepared from commercially available water dispersible
powder v’hich may contain 50% or 75% DOT - For making suspension of
75% w.d.p. for 2 If . or the insecticideuse 3 gallons of water
for a 5% suspension. Normally this is adequate for 4 hcu’ses each
....2
hav Lite; r.b
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Of f’OGG sq.ft*
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fzrr no'zrjlip-.
err-:
C- ‘ .-■ C hdI i *e
rbo'J.?1 be betweebetwee• ? to 3b office per
nrr<- ,
cm s
o.'* 4b cm(1C
inch' from th-; curtdcc to i.>e
b <
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' h wit? inpes?^ j.
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EFC being ve' \
’joic.-.r-f-: a ?hrct'^r
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7‘bfe parent ne ne \ drec.-iixenc” 2.s he Id by t •>'■ ’ •’ipcr 5 ■■< ?. <- bvrirra}
f./fT. ;_• ■•_
k'
incus trios, .London v.ho nave done- rne^t. of th-?
v.ith tnis prcouct .is.rf x,.;■? jiu J;eced vri„ Jcur -t .-.iu-- Lor.
1 3u5' CO*,
Wiite /.
(Jj L pCa
J 1?-
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r; T.' d -O'-i-.' I ?•
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urofc?. lor
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poses.
s Wv. ».r 3.1'! e ponder
! ALL Ci.
Dr nidk
isomer c.
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a ■ '.c?rsuspen:'ion i
<••?.£-
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mix 3 d
lbs
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xi 2 q”. loiis of
er
.5 Ib‘'• r> 3 a a L} tcr-.r of
water •
lhe hioloj: qg!
■fixccrr?
lest5
j.
E-rrur. & we ?ks
Mai achior:
It is a
rl; brown liquid and has strong pur.li? odtn^r,
}?h i s i n s <s r +- i c ?. de 1 r :.v?viable in the foria of water aisner5ible
p (.ri*r6e r a r?«•' ■ ;> \\s <. d .? •: he control of heir\ uold pestr* and ocher f T^
sects vhiicb .hove be.
r esistant to chi or_uneU d hydreerhon
•-■ e ois 6 0«- b0/.• r • eno- -: it»• t 0 ;
or of wc?ter <c spcuv-.iol^ powd rs containing 25% of the acii'?'- c ?•
pound r Th-.: cert v.s tt •'cr.rciu- .1
o; .\ialc.>. hi •..>n
: aj-r- abort
3‘-4 i-or-i hs w.yzrq f1 <■•
of ths cCt i v •:• s'itetauce is at i..?s:
standard ?. grr/iT •* o- ~pra\ able surface.
Whilci n:o?t ei ^ h-- .or g o nep I *c-sphat e s ar ■ < - vc? 1 •-, toxic to rl-Aiv the
t ox ic j. ty of 'T,a 1 r <■ k j o. -4 1 • -eLitiveiy lew.
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I
I
PLAJvT!;iKG AND OKGAl^ISATlOl. Or SPRAY OPERATION
The purpose of spray operation in an antimalaria cotupaign, is to interrupt
ransmiEsion, by reducing the longevity of the vectors to less than a period
lecessary for the development of the
vnrarites to mature fornus
n mosquitoes. This is accomplished when the vectors come in contact with re^reual
.nsecticide applied on all the probable resting places of the mosquitoes, in the
louses e.g. walls,
under surfaces of furniture etc.
In order to ensure such interruption, the spray operation must be through
liming at total coverage both in quantity and quality. So before actual corsnence^
tent of operatioiij the basi requireia-ants are proper planning and organisation of
ipray operation.
Following few points may be mentioned for planning and organisation of
;pray operation,
I.
Geog r aph ica I re conn a i s s anc e (G, R..):
It is an intergral part of the spray operation. It serves as a base for
planning, organisation* implementation and evaluation of the compaign.
i
G.R. is a fie'a operation (preceded a 1 supplemented by tudies and calcu
lation) which through census* mapping, .numbering and sampling piecechires
:he quantity, qualit-y*. location and means of accessibility; J.nformtion and dr-.lechich-may be required for the success of the spray operation. Though the G.R< oi
all the sections are already available, continuous updating is needed to .incorporate
changes.
-C.R. includes (i) Happing of the district/PHC/Sector/Sections/area planned
to be sprayed, besides demarciir5.cn cf different geographical boundaries,
lave to indicate locations of villages, mode of approach to each sections, streasss
to be crossed, project areas rad ether special features (ii) recording of
louses, rooms, cattle shed, and source of water in each sections, (iii) route for
tocmnmication .and. accessibil'ity and dir-itanca from village to village and secti?^n
to section, (iv) quality of the sprayable surface (v) spraying surface area (by
house measurement on sampling basis) £vi) areas subject to flooding and alterna*’
tive routes (vii) population and hourcs enumeration to know exact number of house
and population to be covered In. the spray operation^ Since this is done regwiarly
every year, the same could' be compared with enumeration under decennial census.
Sect ion-wise/village-wise increase of decrease of population and houses in each
year would help in the planning- (viii) recording of the names of the village
headmen and health guides.
2<
Calculation of requireinent c-f. ingecticide dosage and inforwation:
2.1
Scale per million (lQtOO;000) population is as belowr
DDT
DD? .
BHC
Malathion
50%
75%
50%
2 %
150rl.Ton*
100 n
336 v
900 ”
for 2 rounds
for 2 rounds
for 3 rounds
for 3 rou is.
A
■■■'
i-oatb;. fc. '•PI *.:'iUC-X m liutai
» rh*;sc ? f-5 j.c*.! period is considered a’lc Lht spray tiring
v ■' • ■ •. ij \- j riAy i-Eium £ t f e c c.
„.: ■ t.
it£ ad j ’•< v ■•. C
a-.-j th-vv rr-;r<A-
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; Ir n' :i: i-
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of TiR: < re c^r-:--d out (bio-
.
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ear* v? '.
i.-.<.; r’^-f.'
’’
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ic ■■ yi’
pW'-.p,
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in Z-TKrn’
p-Th: b
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b.: iv>f kox?.:
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ybxn 6,VU’xop >v^U|- ••:- ■->.<■■ ejji.t.i iVv
finin' (two
pvftiO tr-'V
uf-^Kun ^A by fivv prirsaJif;
los pi.opai Ar.!-;
s.uppiywg
■- *• ir>n;i'.:d by i i ■(.
.;u •.
t?> usi.^ five
vo:; I.;, IGC.
>>
u-’
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A) ? '•; i y;■ vb
• -:.' _
t. iUJA- .
^tild
tihre* junp*
p!>pv«AZi.?. i. .';;
^£<51
1
?•■■ ,• ^ppr ov<-'A F’itti-;:?? i.s
■: 11 y
rc^chrV• Iv
-
;
$s.;.'«Y
t-r.
r-fu .-Jiutuv
4?- i^.5^. of S.'p-.?: ,? fc'f CSlaJ
A5; U WU
L>5;=t
4.
.Gvi. p’-';‘ K«r;
F- ;■
vas.y fr<«^ p7a<-£ t».> plu<<-
of
rc.i of h>-ut-'-- •-.
I
6
A stirru^ p^p car: over 45 to 5C noiwes per day wh i the der -ity of
population is high.
Experience showed that a H.C. sprayer could cover 30 housea ger day bfct
the out-put varies according to the. terrain. population density and coiociunication» The range of coverage therefore is 10 to 30 houses per day per pumpw
I
It is better to calculate squads on population and possible
out-put per pumps.
St rati fi cations of areas on the basis of API:
This is a very vital experience in planning of spray operation,> All the
this
sections are to be stratified on the /ii'l basis year-viset Frac
L
-- -sciatification section with population are grouped into different API grouping like below
2 API, AOI 2-9, 10-19. 20 and above, This will show the sections and population
to be projected ior spray operation. This will also help in taking up spray
The requirement of spray
operation in sections with high API on priority basis
squad and insecticide can also be worked out.
Advance spray schedule:
On the basic of all the above mentioned relevant informations, and
advance spicy prograr^e shows the- daily spray tc be carried C/Ut by the squadt>.
It should indicate date, sactior* No., came of the villages and population,
houaea, cattle-shed, and
to be sprayed day to day. The names of the super*
visory staff an I coining place of rhe squads also have to be indicated.
While preparing an advance spray programme the following few points have to
b£ kept in mind..
(a)
All the SG<:tioi< with API 2 and above are to be covered (Total coverage).
(b)
Sectioc» with b;gh API in the recent years are to be covered first in a
descending orde..
<c>
.Sections where tie falciparum rate is high or recently appeared are
to get t op most priority to interrupt furth&r t ranf♦
«)
Programme has to be prepared in $uch & way that contiguity of ths geetions arc maintained. This would base the t%;wscnt and working of the
spray party and the coverage could also increase..
fe)
While preparing spray prcgramxe in area^ bordering snother Hist,/
PRC/State the concerned officers may he consulted so that spray operatic-ns
synchronise.
7-
cruise nt of s t s f f:
/Spray men are recruited for five months in a year Recruitssent should norsi*
ally be made PHC wise. The number of spray wen to be recruited will be
as per quota and population under spray.
(8)
Vehicle:
Vehicle are tc be k^pt in order before the coisiiencement of spray
operation. Vehicle are necessary for dumping of insecticide end
wovexaents of sprayswhereever required.
Contd».»f'.
Spray punps y>d ac^ycyo.-.-; <•<;
I
^pt<sy puftips Ftu.i-ulu bts edv •,s<:d orderly and tep-oii/••.•.?••1
v
be
?u^de before the conKr^nce.wcnt
rpray opeidi.oii.
opcicViOn. spare
t
,;)1kv
---------- - o£
-~ the
--•- rpray
parts
Norrie tip?., coshers etc, vihich arc vfiti? * eq.. •; i.
ut-ring tr.w spray operfc-"
ticn should be procured
kep in stock* A p£o' tion of one spare*. pun»p
for evevy tvo squads :;:<-y be made for ^r:*t<h runnxr.g of th<?. prograii^K of
spray opurs L i :•?..
|
R.B.; Sozzlc : Apr. t o br prcvid» d 10 per pvripr- - c b, changed every 15 days
or when discharge rate goes up which <-..t i;<
ri It ;■«
i?. vjxiier.
0.
Traani m; r e la ted to c; * r •_ •.'
.•n •
.nciudirsg Sifl/lfl. arc to he recrier.i
- u) AM rise cupcrviscr;’
following:
i) Cr-^oncni
• • .-
cl cr..
the
spray punsps opening and r-c.iseD&Hnp.
z if 'rea
zGc why ij is
JLnecessary t-, check tbo discharge raize/i
, is to prevent over co.sage thus
increasing tin- cost of the operation or to ensure-, that tbcr\ is no utder
<iOfc-&ge which dcf.<utG thtz purpose ci sp'. cyiii.° opera* iont
iii) vorreet procedure i>£ application of insecticide and the •at Khicb
surface area to b-< covered.
iv) Actual spray operation '.raen the inspectors are to act as spray cieri and
superior field worker:..
) ^rai“iE.g and
*
Ihe sp^-yrer arv recruited or-ty £o? < tenths. Of course &0’ to 70% of the
xew cOFtif. back to kcrh year after year, They ensst he given r; shore trainirig cn
■px'ey before f.eiidir^ thua to .the field, The training should be aimed st the.
clicking.
i) Correct mc-a2UFic-'i<ent <of. insecticide for preparation of suspension - use
of staau^rcsupplied,
11) Correct qvantivy cf. wat^r tc prepare- suspension each tir.<7 ^i?h standard
contain*?r supp lied.
iii) Actual preparation of suspension.
iv) Technique of spray -distance of the nozzle tip froK the sprayable sur
face bolaing of the lance. movement of the F»pr<>y i%n bolding the Ic^ee,.
wideth Gt the stripe ec,f Vn^ out freui the nortlc tip. ovcrlaping of th.;-- vv
xitr:;-..-, tor-vr^uv. of pvo^iv-g
cooidin.-:?.cr. berw. r. two spray
oper^txtjg <. t-cii.r up ousui-f-niurbor of strokers s:»u sjpeeC etc
V7.Total coverage vrth through applicetiau in every
with cpecial
iEporrance of t*pr';ying the bed rcoEis, varandah^ inside panels of doors
and k-in<-ows under Si^riacez of bed and forniture. aud nor to forget the
chilling irrespective of the height (u.?-e extended isnee) and
caves,
vi) ine spraynien are to be trained to recctify ainor defects in the pU>Bp.
vii) Washing 5?id c.
. f the piraps after every day?s wrk*
-:iii) Super ioi fie Ac voj koi who is jsupposec to i^iov reauin' snd vriting
shout- be trained ic- measure the nenzie tip disch -rg.? rate *i>d to iLaintain
rtcords of spr^y a: d u-arjf.ur.:’. tlou of in^ecr ' c I ch:.
5
<
I-
5 “
11.
D ur; pj ng of 2215.
ti. -iu*.
i
u. difl^reiit strategic pla.es ttay be done before
Durapiiib of IhSucc
vificd
to
the S.F.W./M.r.W./SI/SuI/MI/ so that there should
the spray and to ba a.
;oi.
:o
find
out the place. ?DT holders shojld be reliable
be no difficulty for i
and insecticides to
kept ;n safe places.
12.
Advanc2 Not if ic 31 ioa•
Prior infornv^:rL6arding date of spray in v.ry important to get full
coordination _>f the public. It is found out by experience that bust way to inform
the villagers regarding t:;O date of spray operation is through the MFW/SU during
tbeir regular domiciliary visits. The house wives may be contacted as success of
spray operation rests on their cooperation. The village headman should always be
informed ahead.
13.
Movement of Squad:
The squads are moving frea one village to another ai'.d one section to
another on foot. But ’when they are to move to distance places transport may be
provided to avoid delay7 in spraying.
14.
Involvement of village liealth guide;
Since the village health guide is known to the public and his/her position
is well .established due to the nature, of his/her job, he/she should be involved
for giving advance iniormation and during the actual spray operation which lAay
prove to be /try useful for the success of the spray operation. Health guide may
be involved in imparting Hccilth Education to the villagers in regards;to spray
operation.
15.
Supervision:
a) Both concurrent and consecutive supervision are important. Concurrent
supervision helps in understanding th? training status and capability of the
squad to follow the- routine instructions of the technique of spraying, to check
upon the condition of the pumps and accessories, acceptability of the programme
by the pepopie and to ensure the timely operation as scheduled. ON the other hand
consecutive supervision refers to checking up the quality and coverage already
sprayed i.e. either on the same day. previous day, week or month.
b) Malaria Ins’pector/Senior kalaria Inspector should
directly put
incharge of spray squeds. if onv lil/SMl lov>ks after thyre than one PMC, he may &
take up .spray PHC wist, and the advance programme ujay be so chalked out as to
cover all PHCs under his jurisdiction within the specific schedule of Epray round.
The MI/SMI should move with the squads under his charge during the spray
operation and remain in the field to personally guide and supervise the spray
operations. He should inspect and get the houses sprayed in his presence and
correct the defficiencies in the spray operation by personal guidance. He should
get at least 30 houses .‘.prayed in his presence per day. He should maintain a
record indicating cate, name and the number of houses personally supervised by
him. He should also sign the spray record maintained by the SFW whenever
supervised.
c) It is not possible for a supervisory staff to visit every room in every
house in every village. But they could take a stratified sample. Normally the
sample is highest in respect of the inspectors and proportionally lower in the
higher rank of officers.
- ....6
- 6 -
d) Points to be chucked during supervision?
Concurrent supervision? 25Z of the supervisio' should be of concurrent
nature. The following shovld be checked during such inspection.
i) Dace of advance notification and the correct maintenance of time table
for spray operation.
ii) Turn out of spray crew.
iii) Condition of the spray pimps.
iv) Nozzle tip discharge rate.
v) Preparation of suspension.
vi) Actual spraying operation including the technique spaed and coverage
etc.
vii) Extent of actual refusal to accept spray and locked houses.
viii) Maintenance of record.by SFH.
ix) Consumption of insecticide as determined by the quantity issued and
Stock in hand.
x) Date and time cf checking of the squad by inspectors and other super
visory personnel and resiiarks - if any.
xi) Arrangements for ’’Mopping" up.
xii) Future prograjame and time schedule.
Conscctirive supersion:
75 per cent of the supervision must be of consecutive nature. The
following required to. be checked on 10Z sample basis (I to 10 houses).
1. Evidence of insecticide deposit in every sprayable surface particularly
on the ceilings "History of spray operation is written on the exiling of houses".
2. Dispersal of the deposit.
3. Evidence of recent spray (as determined after removal of the deposit by
rubbing off with finger and flashing a beam of light from a torch where deposit
of recent spray shines brilliantly white).
4. Number of rooms on each house (taken as sample) sprayed safisficatorily
partially and not at all.
5. Percentage of refusal and locked bouses.
6. Factors responsible for not spraying any area as elicited through
enquires from the residents.
7. Factors rerpnnsible for high refusal rate, if any, and action taken.
8. Attempts mede for "mopping up" operation in the even of high refusal.
9. Extent of mud-plastering on the wails, if any, and otner relevant
matters.
10. Correlation between actual coverage and dsta presented.
?
I.
i
i
7 -
16.
..
'•hipping up” operation:
The experience is used for spray squads following the main team in order
to ensure that the houses left unspiayed by the previous squads dur to one rea
son or other, are attended
This is one of the most vital parts of the compaiga.
When the refusal rate is high or when at times large number of houses are found
to be. locked, as may happen during rice tianspiant&tion season, an iiaat”
(weekly bazar) days or during harvest, the main team may leave behind many house
unsprayed. In such cases it if argentla) that the team should relay nack massage
for the "mopping up” team to visit the areas within a feu days (and not after a
month of two and certainly not after completion of round) to ensure coverage of
the houses not sprayed earlier. Occasionally the wain team may stop for the
night in the particular area or leave a squad or two behind to ensure such
’hcopping up” the following day.
Mopping up teams are formed.by making adjustment amongst seasonal staff
and also from those employed on 12 months basis.
17.
Health Education:
Though the programme is going on for more than two decades, a large
section of people are not aware why these activities are being carried out.
Objectives are not clear to them and many expect the elimination of all mosquitoes
and insects. The programme has a very large number of workers and these staff
members can act as health educators besides holders of PTDs, DDCs and Health
guides are also motivated well towards this prograzeme. Health education
materials are being propagated through television. Radio, Postal stationery, wail
posters, photographs, cinema slides and feature films.
Paper: Technical Directives and Administrative
by Dr. A.P.Ray.
guidance”
I
I
INSECTICIDE FORMULATION DOSAGE - ADULTICIDES
•SI. [ Insecticide
|
Used as and
Dilution
Effectiveness
Dosage
(a.i.)
Discharge at
Nozzle Tip
i
I"
10 weeks on mud !
(sorptive) sur- •
face iay be
longer on other
non-s rptive
surfaces
DDT
50% wdp
»
iI
I
=
I
II
i
75% wdp
Malathion
j 25/q wdp
I
(3 Lab)
2/3
(2 lbs)
10
(3 gals)
---------------- J
>
' (6.5%
; g annua isomer)
t
750-900 ml/Diin.
Sprayed Q. 5.1/
0 sq.nu in 6
minutes (26-30
Oz/pjin. sprayed
gal/1000 sq.
ft. in 3'minutes)
Lt“
5% suspen
sion in
water 2/3
-do-
I|3.
—!;-HCH
------6 weeks
5CZ wdp
4.
1
2
1 gm/r?.
(1Q0 mg/
i
k-2. I DDT
I
50.% susr.ension in
water 1 Kg/
10.1
Coverage
Remarks
Ready to |No.of |
use spray <houses j
litres
1--10
' 4
Eampinent
(3 fals) j a.PPI used
spraya-1 !I. hand
| ble
Compression
area9
sprayers
50 Oar
stirrup
pimp
(6000
Insecti
cide kg.
T
Kg/k^J^
i
1% suspen
sion in
water 1.5Kg/
10. 1.
0.2 gm/m
; (209ir.g.u;
j ft/)
5% suspen
sion in
water 2“Kg/
10 I
-do-
Ii
i
—"T
-do-
2
T7~~~
■ 2 gm/ .a
-do-
2
| (230 mgra/
ft.. 1,
-do-
1600 ml/min.
syr:
■ >.
1680 ml/250 sq.m.
in 6 mins.
z’ids.mt. sprayed®
1/2 gal/1000 ft
in 3 idin.)
1.5
(4.5
Ibx)
j
(6 Ib-j)
< 10
( gals)
10
(3 gals)
-do-
9
-do-
I -do-
~do~
1
2
-dasprayuble area
250 in
(3000 sq.
ft.)
I
(
I
I
I
OF MALARIA CONTROL ACTIVITY THROUGH
STRENGTHENING
PRITfARY
HEALTH CARE SYSTEM
Primary Health Care is defined as a system where by Essential health
care is made available to all people through a means Acceptable to them,
i
at a cost Affordable to them and at the place where they live and work.
Primary health care is envisaged as the essential component of the General
Health Services of which it forms the base at the Primary level.
Its
philosophy is catering to the Common health needs of the many: and calls
for-Equitable distribution of health man power, health organizationsand
health
activities among the population.
and self sustinance.
Its economy ds self reliance
For its effectiveness and efficiency it has to have
the support of Political will. Appropriate Technology, Peoples participation
and Inter and Intrasectoral collaboration Content wise it addresses itself
to the following eight felt-need areas, in the health realm which are:
1.
Relevant Information and Education on the prevalent health problems
and methods
to over come it.
2.
Proper Nutrition and supply of Food.
3.
Safe drinking Water and basic Sanitation.
4.
Maternal and Child Health services including Family ’Planning.
5.
Immunisation and Prophylaxis against communicable and non communicable
diseases.
6.
Control and Elimination of prevalent Endemic Diseases.
7.
Treatment and Relief of Comon Ailments.
8.
Provision
of Essential
drugs.
I
Malaria Containment through PHC strategy:
It can be noted that Malaria is very much an issue calling
attention of ev2ry conscientious PHC worker as focused through the 6th
element of PHC codified above.
Items 1,3,7 and 8 of the PHC elements
also indirectly have a bearing on Malaria elimination.
be highlighted
elemination.
But what is to
is the potential of PHC system as an approach to
malaria
}
- 2 -
/
Reviewing the history of NMEP, it can be seen that an untimely
and hastely attempt to build up a system based on PHC in the year around
1967, when the NMEP was not yet consolidated., had brought about a set back
resulting in Malaria resurgence.
It can be noted that even at the present
moment, indiscrete emphasis on certain PHC elements or part thereof, as
inexclusive importance being given to FP or Immunization under MPW scheme,
is impeding the progress of Malaria containment.
Rather than decrying
these essential elements, such as Family Planning or Immunization, what is
essentially required is an emphasis on Malaria Containment work which can
go hand in hand with
of the latter.
such works, but could even enhance the credibility
Field staff as well as Supervisory staff engaged as
Multipurpose Health Workers have to be conscentized that asking the Malaria
eliciting question or making a prick for Malaria detection, or administering
a Malaria curing
does of drugs, adds to their credibility
as helth
workers, rather than adds brunt to their routine FP , immunization or such
other good work.
PHC
as a channel for Health Education:
PHC harps on common health problems and their solution through
Community Participation.
In an area where Malaria is known to be conflag
rating what else could be cognised as the peoples health problem?
Primary Health Centres as the operational units of the concept of Primary
Health Care if not sensitized to the people’s health problems, what for
doestit exist gnawing on the purse and health of the
suffering tax-payer?
Malaria in a PHC area is a people’s health problem and the primary
responsibility for it rests with the local PHC«
home to all health providers.
Training should bring this
But more than Training, Health Education
as envisaged in element, of the PHC
contents, should bring this fact to the
awareness of the health beneficiery.
The community should be made aware
that the Malaria problem, at least to start with, was of their creation,
inadvertent though it be.
People have much to contribute to Malaria preventionf
control/elemination by way of avoidance of mosquitogenisity, mosquito-man
contact, neglect of intermittent fevers, refusal to blood screening -.or
treatment, refusal of antimalarial measures such as insecticidal spraying
- 3 -
and of being part of indiscrete mass movement
and congregation.
1Unless
the people act, out of conviction generated by enlightenment, well
meaning measures even by the best of official organizationswill be
futile.
near
Health Educating the public is the only sure method for community
participation.
Without Community Participation a collosal and spread out
proft^anL like Malaria in the community finds no easy way out.
No Public Health Programme can succeed without people’s partici
pation and no peoples participation can be obtained without Health Education.
Unlike family welfare programme, there is no special Health Education or
Extension Education tompenent d-n the’NMEP.
Yet the success of NMEP depends
entirely on people’s participation sought through Health Education activities.
Health Education aimed at Malaria Containment:
The NMEP is carried on through (a) Surveillance (b) Case finding
(c) Treatment and (d) Transmission control.
In each of these fields
of
activities, people’s participation is essential and we can examine how
Health Education plays most vital role thereon.
i
Surveillance:
The Surveillance worker pays visits to the house-hold once in a .
fortnight, and enquires about any incidence of fever in the family.
While doing so, (a) he has to first
of all ’identify himself* as the
Health staff for that section, in case he is not yet famiHer to them.
He has to tell the people that malaria ia a dangerous disease, and it is a
matter of life and death for the infants and children, and more than a eristmg ^diseases
, for-the "bread earning adult.
malaria is fever, and
past
The prominent symptom of
he has come to enquire if there is or was in the recent
any fever case in the house.
To make the surveillance
(b) it is necessary that the surveillance worker should
to the
people and be able to elicit
correct reply.
effective,
become acceptable
It is therefore
evident, that through Health Education., people’s cooperation should be
forth coming.
I
- 4 -
/
Case 3Finding;
a)
If the enquiry in the surveillance elicits the reply as ’Yes'
it is necessary for him to tell the people that the only method to know
whether the fever was due to
blood from the finger tip.
blood.
malaria
or not, is to examine a drop of
People may be afraid of the prick or loss of the
The ’Surveillance worker is required to explain that many people
often accidentially get cut injuries and lose lot of blood.
Here only a
small careful prick is given to get just a drop of blood and immediately
medicine is applied on the prick.
He may tell the people that •S.hout their
awareness mosquitoes may be taking more than a drop of blood every day;
and all that he wants is a drop of blood once for all.
b)
In order to prevent lot of suffering and even loss of life just
a drop of blood is needed to detect if the blood it poisoned by Malaria
germs.
Such type of Health Education can convince the people to allow
obtaining their blood smear.
If the blood smear is not obtained, the case
detectior. will not be possible and the efforts on NMEP will fail.
Treatment:
a)
The people should be told that anybody having history of fever
should also take a few tablets of medicine, so that in case it is Malaria,
the medicine, will help in treatment.
fruit is sweet.
fever
The tablets may taste bitter, but in
Further more if the blood examination reveals that the
is duo to malaria
health worker will come again to treat him for
five days.
b)
The NMEP staff should also educate the people that in between the
visits of Health staff
if any person get
community Health Guide
who also can given medicine and collect blood slide
(ii) or better
fever he should (i) report to the
they may contact the local dispensary or PHC to consult the
doctor.
It is therefore evident that through such Health Education, people’s
participation can be obtained and treatment of all malaria patients thereby
becomes possible.
- 5 Transmission Control:
The transmission of Malaria can be controlled in many ways, one of
the most important measures is spraying of residual insecticides.
a)
The people should be told in clear terms that the object
spray is to kill the malaria carrying
mosquitoes.
mosquitoes and
of DDT
not killing all
The big size mosquitoes which cause so much annoyance in the
evening are not carriers of malaria germs.
It is the lean and thin small
mosquitoes which are responsible for malaria (b) DDT does not have much
effect on insects and ugly looking fat mosquitoes, while the beautifully
thin
malaria carrying small mosquitoes are easily killed when they come
in contact with DDT.
An ugly fat woman does not care spray of dirt on her,
as seen during Holi/festival while a slim fair woman is very sensitive to it.
a)
It is necessary that every room in every house should be sprayed.
If some house or some rooms are left out, Mosquitoes will take ’ shelter in
those house or rooms and bite the people.
It will be as ineffective as
in putting up fence on three sides of a garden leaving the other side
upprotected against entry of goats and cattle.
b)
After spraying walls are not to be white washed or mud plastered. else DDT,
Sticking on the wall will be covered up and the malaria carrying mosquitoes
will not be destroyed.
c)
Effect of DDT lasts only for 2 to 3 months,
that the houses
d)
It is therefore necessary
should be sprayed twice during the transmission season.
Only spraying the houses is not enough,
People must keep their
compounds clean of bushes and jungles, as it is in such places mosquitoes
take shelter and happen to bite people.
e)
Mosquitoes breed in water.
Water should not be allowed to collect
in drains, pot holes, and water collections etc. giving chance for mosquitoes
to breed.
- 6 -
f)
People should sleep inside mosquito nets asf/it'as possible to
protect them from mosquitoes bites.
Finally, in adoption of all these measures for control of transmission,
peoples active participation is of utmost importance.
team cannot forecefully spray the house.
mud plastering the sprayed rooms.
They
Fors the spray
can not prevent people from
They cannot enforce use of mosquitoes
nets, nor can they keep the peoples houses clean of bushes and water
logging.
The people are to be educated and constantly perused to adopt these
health measures,
participation.
No health programme can succeed without people’s
They have to be made health conscious through persistant
efforts of health education.
- 5 -
/
Transmission Control:
The transmission of Malaria can be controlled in many ways, one of
the most important measures is spraying of residual insecticides.
The people should be told in clear terms that the object
a)
spray is to kill the malaria carrying
mosquitoes.
mosquitoes and
of DDT
not killing all
The big "size mosquitoes which cause so much annoyance in the
evening are not carriers of malaria germs.
It is the lean and thin small
mosquitoes which are responsible for malaria (b) DDT does not have much
effect on insects and ugly looking fat mosquitoes, while the beautifully
thin
malaria carrying small mosquitoes are easily killed when they come
in contact with DDT.
An ugly fat woman does not care spray of dirt on her,
as seen during Holi/festival while a slim fair woman is vgry sensitive to it.
a)
It is necessary that every room in every house should be sprayed.
If some house or some rooms are left out , Mosquitoes will take ’ shelter in
those house or rooms and bite the people,
It will be as ineffective as
in putting up fence on three sides of a garden leaving the other side
upprotected against entry of goats and cattle.
J
b)
!
After spraying walls are not to be white washed or mud plastered, else DDT,
Sticking on the wall will be covered up and the malaria carrying mosquitoes
will not be destroyed.
c)
Effect of DDT lasts only for 2 to 3 months,
that the houses
d)
It is therefore necessary
should be sprayed twice during the transmission season.
Only spraying the houses is not enough,
People must keep their
compounds clean of bushes and jungles, as it is in such places mosquitoes
take shelter and happen to bite people.
e)
1
Mosquitoes breed in water.
Water should not be allowed to collect
in drains, pot holes, and water collections etc. giving chance for mosquitoes
to breed.
/-
- 6 -
f)
People should sleep inside mosquito nets as f/it as possible to
protect them from mosquitoes bites.
Finally, in adoption of all these measures for control of transmission,
peoples active participation is of utmost importance,
team cannot forecefully spray the house,
mud plastering the sprayed rooms.
They
For$ the spray
can not prevent people from
They cannot enforce use of mosquitoes
nets, nor can they keep the peoples houses clean of bushes and water-
logging.
The people are to be educated and constantly perused to adopt these
health measures.
participation.
No health programme can succeed without people's
They have to be made health conscious through persistant
efforts of health education.
h - .
SbPPLEhl JTARY NOTES
/
HEALTH EDUCATIC^A^^
cioi^u contact, with the nassess as the N’MEP. firstly during
the spray season every house is approached toi ap^. a, »
insecticide, secondly every-house is visitea twice in a ^nth
by the surveillance inspector. Therefore, they are the bed
media for propagation of health education m tne counury. - ->
is more so because of the influence the surveillance staff nas
oo the people who consider them as part of their own community.
It is therefore# obvious that these personnel can assist in in
ducing the people to accept spray in every part or the house,
in dissuading them from mud postering the walls make them agree
to submit to blood examination and accept the necessary treatmenetc It is also obvious that these personnel can transmit all
types of health messages to the people. In course of time as
and when the NMEP unit areas complete the task of malaria
eradication these very woekers could serve the best purpose for
other health activities like those under the smallpox eradica
tion program <•€> compaigns, to control tuberculosus# leprosy et^.r
under which domiciliary visits should be one of the essential
activities. It: is however necessary that before they are
deployed for other public health activities these personnel
should receive re-orientation training.
1i
These workers should be provided ^ith series of talking
points in simple language which could be grasped by the psople
easily. Under the n^laria eradication programme such talking
points are toj^rovided to every worker in the field# if not done
already. The theme should be sprcidic and must pertain to
subjects relating to some of the essential activities for which
the acceptance and cooperation from the beneficiaries of the
program tie are the basic needs,
' It is useless to
to explain to the people about the
intricacies and the progress of malaria eradication campaign or
the manner in which malaria transmission is interrupted.
Therefore# the subject for communication should be very carefully
prepared. As examples some of the talking points are indicated
below for guidance.
TALKING POINTS«
1.
Thj prinary object of spray operation is to prevent
The
malaria and not just an attempt to kell mosquitoes#
2.
There is no intention to kill the big mosquitoes which
cause so much annoyance in the evening#F nor the bed bugs
cockroaches and other pets.
In any case they can not be
Con+
9 K » • 2 ft
- £: I
Killed or r emoved by spraying the H meb icine”
3.
The big mosquitoes, beu bugs etc. may disappear after the
first or the- second application but they get gradualjy
used to the 11 medicine11 and come back. It is almost like
ppium which puts one to sleep in very small dose in the
beginning, but v;ncn one gets used to it even large lamps
are inc-f r- ~+
4.
But the insectiol.'-cs de have effect on the small mosquitoes
which arc? car gz rous as the.y carry malcria.
5*
Forfadults rcil.iria ircy not be so dangerous, but it is a matter
of life and death for the children and infants
ii if ante•. In order
co protect them it is necessary to spiay the “medicine1' •
6.
When the spray crew still continues coning every year it
should be understood that there is stiJ1 risk of malaria
conti ng back even though not’many cases are noticed.
7t
It is very necessary that every room of every house in
every v iliagv isprayed .
g
9.
If some parts of a house are sprayed and the others are
left out protection from malaria cannot be guaranted. It
would be just lik^ putting up fence on three sides cf a
garden leaving the fourth side unprotected against the
intrusion of goats,- cattle etc.
Aftei spraying the walls are not to be plastered with mud
or else the “medicine” will not have any effect as it will
be covered
mud r
|
10.
Government spends a lbw of money every year forgetting the
houses sprayed. It costs about Rs.1.50 to Rs.2 to spray
house.
If the walls are plastered with mud after spray,
it is as good as throwing the rroney into mud. Further if
one house is not sprayed it does not mean that ffs.2 are
automatically saved because 11 medicine 11 has been bought
and. workers have been appointed and their salaries have to
be paid .and so on. It is like cooking food for ten people
and onJy six
c wm up-. It does not mean that money
has been .navec beet use four people did not eat. But rather
food is wasted.
11 .
Yes, we agree that bed bugs are 11 eating you up*’ every
night. But the Medicine used for control of malaria can
not eliminate bec: bugs. We have really no effective and
yet long lastiirg weapon against bed bugs. It does not mean that
these posts cannot be controlled or ultimately got rid of.
For generations hot water has been used on beds to kill
these insects, kerosene.oil had also been used in the past
on thebracks in the wall tonere bed bugs hide. Beds and.
clothes^ are to be exposed to the sun frequently. General
cleanlines$ of the house is of help. There are lot of
things wh?.ch people can do themselves as outf fore-fathars
Contd . . • . .3 •
i
/
I
I
I
did vdthcut asking the government tb help.
/•z to be self sup.xzruing <' > much as one c n.
Ori^ rr/ust. try
-• z • "But malaria is d n iicvlu to control through individual
efforts and hen :o government is extending all assi uince.
Tncy arc not satisfied with spraying alone. They want to
knee how rrr.ch benefit the people have derived, how much
rulcria it st?,!! left. Therefore checking is • e ’
done
for which worker:? are visiting every house croc in 2 weeks
to find out if any one xn suffering from fevc? .
1 *5
When there is 'ary favor case, these house visitors take
blood front the finger for examiaution ir-case there are any
malaria germs hilueri in the L-loea • I'hure is. r.c- other
means of detecting mc-se dangerous organisms. Therefore,
when the workers come to your house, get your blood exam
ined if you arc suffering from fever or have had fever
recently.
14.
Inform toe house visitor if any one else is suffering from
fever or had fever recently.
15.
Take the “medi-cine’’ given to you after blood is taken, If
germs are found the malaria worker will come and treat yoy
for
dc-t\- •* Po not refuse drug -•ft*--!' one or two days
simply, bee a? -o yc.,. have ro fev^r. The terms musfr be removed
completely arki hence- medicine has to be taken m full does.
16.
If you or any one else in the family gets fever in between
the visits cf the hcuoc visitors, report to the local
dispensary’or doctor.
’f none is aval a-'le request your
Panchavat, school teacher or sarpanch to send information
to malaria department.
- ‘V
/
I
The i ibr action‘^k» ; piece aicongst th*?
.if proper ly
peopJe arr5 they'borne- to definite rtcirl^s regarding remmunity
or.' now a<-fr ^r’< f r.n-bl.ir hcsl. a
acti on• Health Educator
The
need
lor
a
specialist
of thisjyind has < ris<-.r from
team*
the reccg-iiticn that healch is not raimarilv s urobJem of
legislation. Its arte inm-a nt ci epern - vr » be iateiest and vcHlingns s
■ ‘C-1 c.i c u? > 0*.• .. ?j. ■
* .•.*<s
lcr
the solution ui ' ac ir evu pzoblur^ on a u-11 ir.foirne-d basds.
People uie
p2 ■ h- to apply acceptable health practices an
their dailv life
±i they had part, in ueruerr-ining the cinn -g-.s
desire in par tnersim.p with the pr cress tonal he’lib workers.
This spir it cfd(?-v>p<i.aticn among r^slth -o.-cl< :sts anH tHr
people themse Ive'J/ at all stages of the development of o he si th
programme, is destined to have far leaching educationa.iuenc\
It will serve tc generate wide spread public gocdwill a*id support
for the total health programme.
1
~■?" tna of the lavjs of hvueu behaviour comers frcn; the
social sciences.
health educator provides an’essential link
between the social scientists, the doctor, public neal t.h engineer
ancibuher health personnel inrontact wicn tne jjeople of a particuiar area. The health educator can provide teaching aids wri3.cn
may be celled the ‘tools* of the tiads’ Sp-ciei liteiacure^
posters, health filns emd fil^ strips* Prirarii? h^w-.rv1.r be
is concerned v i sb individual and group motivation* He
^sts
in makina eflective contact between the health programme and
community
ticipation. Qualified expert of thi? type is
ential to the fullest success of any public health progrsKnrne.
Society has sought, to n et health need by 0;) providing
health services to de things for peoole and by (2; educating
people tc do things for thernselves. Trie .former is often e^syr
but it is expensive and often cf temporary benefits. On chc;
,
other hand stinulatino and guiding people to assume responsible a. ty
foi themselves nay tekc more time, but at is relatively rncxpensive
and its results an more lasting.
I
II
P_uties & Responsibilities of i
!•
Village Health Guides
1.
The village Health Guide (VHG) will make a thin and
thick smear on one glass slide from all fever cases reporting
to him for treatment.
Administer single dose of antimalaria drugs in reco—
2.
mmended dosage as presumptive treatment to the fever case from
whom Blood Smear has been collected^
Keep detailed records of individual - fever cases
3,
profoinma supplied to
treated by him in the register as per proforma
him by the FHC,
Maintain the accounts of anitmalaria drugs supplied
4*
to him from PHC or replenished by MPW/Supervisor*
Report to the PHC Medical Officer if the drugs and
5.
slides are not replenished by the MPWS or the Supervisor in time
and collect replenishment from PHC Medical Officer.
Report any death due to fever in the village to the
6#
PHC Medical Officer.
Administer radical treatment with the prescribed
7
dosage of antimalaria drugs according to the schedule furnished,
to him by the Medical Officer, PHC and ensure that complete
radical treatment is administered to the positive gase by person
ally contacting ‘him during the course of radical .treatment. This
activity will be undertaken only when full} trained in Radical
treatment of malaria case*
8.
Stop radical treatment administration of primaquine
8a
if toxic symptoms are observed and persuade the patient to visit
PHC for further advise.
9.
Assist spray teams during insecticidal.spray operations
in his village by motivating the community to accept insecticidal
spray.
10.
Inpact Health education to the community on malaria
and explain to them the necessity of minimising the mosquito
breeding places and for observing the personal protection.
Ha
Multi-Fucose Worker (Male),
Each worker shall visit all families in the section alloted
to him once every fortnight according to the time end space move
ment schedule given by FHC Medical Officer/^MO.
2*
Will enumerate the population of his section annually
and enter the details of all the family members in the family
register/ME-T as prescribed under the modified plan of operations.
Will
3n
^ill update these records at the time of his fortnighfortnigh
tly visits in respect of births and deaths or movement of a family
member outside tne area.
: 2 t
Will prepare Stencils and maiirtyain the same as recomm
ended under NMEP. He shall put his dated signatures during his
fortnightly visit to the family on the stencil.
5,
From each family/ he shall enquire about
i) Presence of any fever case:
ii) Whether there was any fever case xn the family in
between his fortnightly visits;
iii) Whether any guest had come to the family and had
fever.
iv) Whether any meirbcr of cho family who had fever in
bitter hir fortnightly visit hat left the village.
He shall collect thick ano thin bloxl smears cn one
6.
glass slide from cases having fever or giving history 01 fever and
enter details in MF-2 and put appropriate serial number on the slide
7.
He shall give presumptive treatment for malaria after
blood smear has been collected. He will follow the instructions
given to him regarding administration of presumptive treatment
under NMEP.
8«
He shall contact the Village Health Guide during his
fortnightly visit to the village and (i) collect blood smears
already taken by the Village Health Guide (ii) also collect details
of each case in MF-2 (iii) replenish both drugs and glass slides and
look into the account of consumption of antimalarial drugs.
9.
He shall despatch blood smears alongwith ^*-2 collected
9
from the Village Health Guide/Multipurpose worker (Female) of the
sub-centre and also those coll cted during hi visit in his section
to the PHC Laboratory twice a week/ or as instructed by the Medical
Officer PHCa
He shall verify the radical treatment administered by
10.
the Health Guide if any during his visit.
He shall administer radical treatment to the positive
11.
cases as per drug schedule prescribed and as per instruction issued
by the Medical Officer PHC and take laid down action if toxic manifestations are observed in a patient receiving Radical treatment
with primaquine v
12.
1He shall visit Drug Distribution Centres and collect
details of persons given treatment for malaria by the DOC and
replenish antimalerialdrugs during fortnightly visit.
13©
He shall inform in writing his supervisor or PHC
Medical Officer the reason for not having contacted the Village
Guide/Fever Treatment Depot/Drug Distribution Centre during his
routine fortnightly yi f'.tt if any.
14.
He shall intimate each house-hold in advance regarding
date of spray on the basis of advance spray programme given to him
and explain simultaneouslv the benefit of insecticidal spray to the
villagers.
6 «•e •3
:
3
i
15.
lie shall contact the Village Health Guide and inform
him cf the spray dates and reiuest him to motivate the community
and prepare them for accepting the spray operations.
16.
He shall assist the Malaria Inspectorialtipurpo&e
Supervisor for spray supervision in his section. During this
period, his routine fortnightly cycle of visit to his section/
village may be disrupted but he would carry cut the active surv
eillance and contact’village Health Guide during supervision, of
spray activities, collect blood smears and administer pre.sur.rptive
treatment to the fever cases end sign on the Stencil' also.
He shall contart Gram-Panchayat menbers during his
17.
visit and seek their help in inpleraanta^iov; of the
^^txviuies.
Multi-pump
j!Lorj^ .(Female)
Multipurpose Worker (Female) entation of the NMEP in her area as
wil1
5 rr.rxl
—-
i)
If any fever cas^ redoxes to hex at the
she will collect thick and thin blood smear on one glass slide
and keep records as prescribed and administer siixjle dose of
presumptive treatment with antimalarials according to schedule
given to her,
!
ii)
I’uring her routine
fre the
ror --CH work/
if she finds 3 fever c**se* she will collect blood sv^ear botn thick
and thin and administer single dcse of presumptive treatiuont and
keep the relevant-records.
iii/
routine visit.
visit, she wixl impress upon the
During her routiue
house-wives about the utility cf spray operations for control of
malaria and to accept the same.
iv.'
Multipurpose Supervisor (Male,1
Multipurpose Supervisor will supervise the work of'Multi
purpose /Workers placed under him.
i)
He w;.ll ascertain regarding the fortnightly visit of
Multipurpose Worker (Male) to the village by looking at the Stencils,
verifying the date of visits with the schedule and enquiring from
the families.
ii)
He will supervise the work of Multipurpose Worker(Male)
WorkerlMale;
during concurrent visit and will check whether the worker is perf
orming his duties as laid down in the schedule.
iii)
It wil i. be desii^able that he should check rninimum of
10% of the houses Ln a village to verify the wqrk of a Multipurpose
Worker.
He will pvt dated signature on wall-stencil during his
iv)
inspection of the ■ork of the Multipurpose worker.
4
; 4 :
v)
He will visit the Village Health Guide/ FTOs 6>nd
as veil
Fub^rentrcs
Fnb"Oentras and verify their records of Blood smear
collecticm and stock of antir larial drugs a..d mi ci os) ides and
render any advice necessary*e
viz
He will carry with him a kit for collection zt blood
smears during his visit to field and collect thick and thin snK->ai
iron- any fever cose he cornea across and he will administer presuriit tivf ureatrient
prescribed dosage of antimalaxial drugse
*11.1 H resne risible lei p^c-npt radical tieutmout
to poriyiv-f* cases in bls area*: He wilZ plai t
and isapc-i vps.r
the edminietretion of xedieal treatment ?n ceaseIt .tion with bHC
I j€-dicu 1 01 flee? „
viii^
I"
' ‘
‘ is being gxven _____
, _________________
________ ____
If radical
treatment
by the
Mul tipurpose
worker (Male) anc* Village Health Guide he will verify the radical
treatment and send his observation to the I-’HC Medical Officer/ and
discuss the deficiency a£ anyz and he wi .l ensure that full radical
treatment ? s gi ven tc all positive cases in rn s area.
ix7
He vzovld
Inspectors during sprav
woi'jcl assist the Malaria 'inspectors
spray
operations aid ensure thee coverage under spray operation is
satisf
actoiy both qua]
itati\-e) y and quantitatively
satisfactory
itjo] itatively
guan tit ati red.*- # He will errry
carry
cut the work related to the malaria as per instruct io ns of Medical
Officer of PH l/T:<r^r- e
x)
r
" ‘
Mk.ltPiiur.es.
Supervisor
(Male? wculd g^tne-r infonviatiun
from the Villcg^. rhaul‘ tn Guide/Mu
/ 11 ipvryns-e
rker (Maie) i ^garding
migraiJ.on of p;-prl a Li or, in his area,
,
If a aenip or migratory populatioii is locate o in ?zis area, Lv..
<.11^ visit vhe will
to ascertain rhe number
place or o* igm and enquire at ut
at the fever incidence,
incidence. he will then
report immediately tr the Medical Officer PHC for instituting suit
able remedial riessores.
xi )
_ the
_ Iiedical
______ Officer
___ _ FHC he will
As pe~ instructions from
be responsible fcr taking prompt remedial measures like Radical
Tie^tm:?n’;i Mass aid ccnuact survey, focal spray etc* round about
positive cares defected in areas with API of last* than two*
xii)
He- should also investigate initially the positive cases
and any deat b due co Feverc
^5
r..«.5 •. #.
I
V.
Malaria inspectors have txje.n.-pi ovj cWl to the
j
rrpppula^tn ^siZ One malax ia i^ec^ is allotted tx
/--ore
*han ore
3nd hr will v, undec bhc Medicsr Otucer in o:^ of the
PHCs. He'ir. a unipurpose worker mean;: for r l-n.-J.nq orparr cut .x. a,
execution and supervision'of irsecticidul spray in tne ////• •> •
should prepare Advance spray p^n.^ consultation wxtn M.C. PIJC .nd
ncr ii’dr• .1 v’-a cc t,o ri> t q-iu2’tck s vze 11 in r■ \ 3ncc; •
2.
He is primarily resi:or.>ito supeivx^e the spra} cper-et i ons
'.■jc 'K donrcarr ier’ ou- trv spray t?;ms« He shouJz: col~eet
o..
The
malaria officer under intimation to Mh.'<
3.
He is responsible to organise the spray t^a* —- ■
3 e
wise and vilJege •dae visits by the spray teams.
p- ‘-v ..... e
4.
Ho
of the
the kwkipumcsfi
workers and
Ho snonli
should reqesitien
requs.ition services
services of
*
nult^purpose : ^xrvicoi r for their arnistance
?upa"of ep.ay
Ui>crv.-.wOi i> x--.. —
should •'e/rer-possible to
operations Jn their respective areas#
receive the insec tic trios
the spr-y
1
he should mainta-'-n the spray equxpmexitr-# _ Ho should check the
5.
r3te ch~
t ips perxoaica ly ona. u»dXntci.L
rCk..cu. ciw at
discharge
game
for
c>rinc;irg
when
necessary
.
the
He should ■•een account of insecticides revived and consumed
6- indicate the s«me in the pi scribed profor .a to be furnished to
and
M*0 PHC/District Malaria Officer.
Be should a..oo check survexll-rgc activities jmd pur forme nee
7.
of FITS, DDCs sue health guides and Sispensaiufes during the v-sxt to
-the viliegfe*
8.
Undertake or..up -ratings in the vinages/sCbools_and Panchayats
and explain .the ol jective^ <of IMEP operations to the public#
9<
He should keep Tiason. with other agencies lake block development
■•j f f 1 cf'-- x s f 'u i 11 a g e 1 e vc. 1 ; ? ork c n etc.
10. Hc/will be r€5spo£sible for undertaking
m^asurs^ like
in
the
sect
ions
with
API belcn.< 2
focal spray and mass blood survey
H'ehouId 3 nves tigate pr 1 niar i ly a 11 pos it .x ve
around positive cases#
r
rases detected in acea^ less then APX-2<
VI- 1ABCRATCRY
TECHvICIAr (Micro?CCpi.£.t L
1.
The Microbcooi.st will be responsible for the stairriny and
oxarainatior. of all surveillance blood srnears a?- expeditov^ 1' a~
possible and for the despatch of the results to th® reaper.xve
surveillance inspector hPS (Wymalaria J ispectcv s -
•J
■
i
He wall maintain ©31 rea> ds of s3.ides c amaneo by hxn. and
2 .
get
the positive tlidxs confirmed by the Medxcei OtziCvr ct Pri-.
mns*
3,
He-- v; ill re 3? ons il > 3 <• [o- t^ie cleaning of alt nev and vseo
blood smears one. xor proper distrihut f O’? i o the r.nr vei I’anca sri-i —
p&ctors (MPS/w) dnd s:--.! vT'j ] lance workers bW (M) «
/. r
c >< »>; 5 r rc- s cop 1 n *•
i ? e■:r-x c t r- t: ? er■'r ■• 5 n*:. e t t ©St e.[ ■ )/.; nod Sir.f cx'J-: •
'aind.teattl uuy. He vill m^inta.ir : c ion-w.i 5e _M.•: / f criu.*? •'/ bj ooc
srA..?
v.hlch
is
1
■.
und
o<
j
bill\
c
*
'.;')e Mp:
the
inc case nuxibei acaii <3.
:
.
'
.
ro
lbu
’
J
o
i
of
t
ne
cr
iC'ZCquine
tablets
•rorn which indicates only
: s /T" • < ■ obe
cli < • r f ’ v t - r trc a.trtci i oepot s w> 2 2 r.-.
rectived ' ro;r trie ranchc
i-.f-C-C: n
s
r<:i. e
neecssa
kept separately aft.ei
5.
He will raaintoiri section wise ,.1-2 forms of blot>d smears
etgainst the s?ci6es which us round pOoiti^e.
indicating case number
i
The MF-2 form which indicates oxxy rhe tijscrioutioh ex cnxoi equine
tablets received from the Panchayats/'feoche-' or Tev< i t re^tm^r.t
depots will y>e kept separately after ne ce 5 • ’ s xy e rf-1 i e fe a I e < n. i .>• -»
6*
**?
He will maintain the following registerss
a) Flood smears receipt and examination
b) Section-wise details of positive cases and
c-i rewitUdiX
measure? recister (MF-7)
c) Epidemic J ogical evcJuation rr^scer registe’\ :eci3 on
wice village v.’xse and month v/xse (W-9)
d) Daily progress and cnxtput register of blood slide
exa rrd nati on •
He will maintain the following charts:
a) Master chart of active collections, exanination and
total positives, section-wise and monthwice.
b) Master chart passim agencies indicating fever cases
treated whether any bicod slides collected and the
positives detected fran the passive slides (rponthwise.c) Tnc bcicv log chart of pending examinations of blood
slides vis-a-vi5 collected slides.
d) The •'’bach log chart of pending radical treatment, vis-a-vis
posit «,’>e cases detected.,
e; Lin^d c.t aph chart showing possti'-es ax J bbooc flideo
c1J tict ed v• o^*1;- '■ ■' 1 se.
f) C'h<-rt- foi technique of staining v;ith
gj Map of PEC indicating section rond-rry and rar-os of,
adjoining PHCS.
He should send prescribed perceritage cr necrcxve and positive
8.1
i x-c/KOE I.- FW for con
slides to State Malaria crcanisat.i oiv’^onal
firmation -
8*2
He- w.i.jl prep;of-' tbs following raport* to re sx^toitted^by^rh^
Malaria Officer
Medical Officer^ P>-?iarv- -ealth Centre tro rr-. r?..'>tricc
1‘with a copy L-\- the ry l-svi
Inspector.
ti) vcot'kly ^p?uemioi'xjical report (on every Saturday)
....,?
i
i
i
.. i..
/
b) Monthly Technical I .epcrt, Sect.! on-wr e si vel)lance data and
remedial measures (MF*4
5)
c) 'lire repent wj ii be sent tv the District Malaria Officer^
d) He ”? i j ‘■nemteir. the eccourr:/•. i?£ the enti^malarials
used in the Irimary Health Centre.
e) He wil2 run the Malaria clinic at PHCh
viI. Mrnic
3-TICER 02 PHO
6.1 H*2 wil)
operations in his PH areu
wll) bo
be responsible fox all
and will be responsible lor all administrative and technical matters*
0.2
He should r-e conpjetely acquainted wit/* c»i. 1 problems and difflcuities regarding surveillance and spray operation in his PHC area
and he responsible for immediate action w’nenover obe necessary arises«
6«3 He will be responsible for th^xocution of the surveillance
procedures as approved by the higher authorities and should be ccnrpletely familiar with all aspects of the Programme.
6.4 He will
vill bo
I responsible for the proper deployment of the £?;'rs
taking into consideration density of population/ terrain cc^tunication and other factors as related to sur veil la nee. He should
activities fur
ensure that tpe MPWs adhere to the fixed cauender
f or t n i g hr. ly visits.
j
I
6*5 The medical officer vi 11 guide the mui*'••pvrpsupervisor (M)
on all treatmeiit schedules, especially radical treatment with prime
quine * As far us possible he should investigate all malaria cases
in the area
regarding their naturo and origin and
institute necessary measures in thic connection, M*0, PHC should
ensure that prompt remedial measuret. are carried out by MPS Ul)/
Malaria Inspector round about positive eas-es detected in areas with
API less than two. He should give specific ihstraction to 12?3 (M)/
Malaria Inspector in this respect, while sending the result cf blood
slides found positive.
5.6 I'
_
•
He is responsible
for proper maintenance
in this .connection and their preper despatchi
headqvarteio •..
LJ ously as possible
all record and catr*
from the PH?
6*7 He will make surprise visit fc^. randon checking of tlx ^ork or
the surveillance inspect or/MP3 (M) and su-rwxllance woxkexs/HPW(M) .
He should also check spray operations ar far as possible during ii.c>
village visits<
6.8 Ho will similarly check the microscopic work of the laboratory
technician and despatch prescribed percentage cf such slides to the
zonal organ! sat tor/Regional Office for Health b FW (Government of
India) end State r..0. for cross checking as laid down fran tir’«e to
time. *
6.9
He .should chair the monthly meeting and ensure prefer accounts
JSB STAINS-SLO^*) SMEAR FRhPARAI if>k
STAI^11
EWnrh i’ION OF bbOOP SHE
j ^‘! H0DS
;ifY^£;.kAIiO?; AND S7AIVTNG TECHNIQUE/
mr/jiaTiGN or
i.
<-L STAIN. (Jasuant Singh a BhaCtfithar’i ” 1926)
The original luelbod. anu. the subsequent iodi.fie-i t ?rho ■- of the Etam can be
bad from the Publicatio;- csotroned '’Review
JSt sitin' . Tie latest modificat
ion by which the stain can be prepared in an hours boiling, vould only be descri
bed here.
■ •
J.S.E. Stn^r
Soluti^u/
recites of 3 solutions: J.S.t ,-1, 3.S B. ~Il» Lurffci:
CCtiSTITUTEhTS:
2.
a) The JSW
lidthyleue DJ.ue (Medicinal)
Sulphuric Acid Soln. 1%
Potassiuui DichroD>ate
Di sodium•Bydrogea PhotpHate
Water
0.5 r-
b) JST-II Eosin Tel lev (Water Soluble)
Water
1 g.n.
500 cc
3 cc
0.5 gTu
3.5
500 cc
c) Buffer or Warn Water is prepared by
dissolving 0.617 gms. of uisodiiiin hydro^c-- pb<>sp;>:tz’
pliate arid €>732 gms. ci pc-1&ssium acid photphatu
2000 c. of distilled watci.
3/
' TECHNIQUE OF PREPARATION OF .JSB- I
The technique of preparation of JSB-I is simple. Take 1 litre flask and
500 cc. of water. Di solve Methylene Blue. Then Sulphuric Arid should be added
gradually in three stages^ one cc. at each time and the solution should be
sti-red for proper niixin^. Potassiur.-. Dichwattc should ^e added at thid stage.
With the addition of Potassium dicbro»i>ate; the blue colour or the mixture will
change and preeipitate will be formeu. Now disodium hydrogen phosphate should
be added. It will be evident at this stage that the precipitate will appear to
get dissolved if rhorouah fixing is ensured. The r isultant mixture is then put
on the .flame uwing a i metre glass tube of condenser. As soon es it starts boilin,
the time should be noted and l?n to bull for one hour. Ou cooling, the stain is re
4«
'
fOi
TECBNIQirc _Oh-PREPARATION OF bLOOD FXLMS;
Ubw.
a) Introductions The present practice is that both rhe thick and thin
smears should be taken on the same slide for ex&’ninat'Jon for inalsna parasites.
Thick film examination saves a great deal of time in the search for parasites
when a large number of smears are required to be examined. The concentration of
parasites in thick smt.rrs works cut on an average or 10 to 15 times more than
that in thin smears. P.equired skill to identify speciet' of malaria parasites in
thick films is only acquired by practice and experience.
The thin smear, howeverj is still considered valuable for the ideniifica-*
tion of species of paiasites as a 1 s c s t ud y i ng t n e i r mo r p ho lo g y,
It is, therefore, advisable that both r.bick aud tbxo smears should be
tsken on the sarie elides.
contd»*.2
8
/
of slides and anti-malarials drugs to the surveillance inspectors
MpS(M) and surveillance workers MPW (M) through the area Malaria,
Inspectpr who will also attend the meeting• The MPS (H) vzill also
plan distiibution radical treatment of positive cases under the
guidance of medical officer* The Malaria Inspector should also pre*
pare spray programme in the PHC in consultation with M>0.
6.10 He will organise passive surveillance in his area in o
operation with all medical institutions and personnel as well es
other voluntary organisations and voluntary workers, For this pur
pose he will give necessary training to the persons concerned and
djjrect MlrS(M) to issue necessary slides and antimalarial drugs that
may be required from time to time. He must contact all hospitals
and dispensaries m his area for examination and administration of
anfcimalarial drugs for the cases that may be reporting to such
institutions. He should ensure that all fever cases are blood filmed.
I
I
■
6.11 He should check the returns from the surveillance inspectors
MPW(S) and laboratory technicians will be responsible for forwarding
the PHS reports to the higher authorities.
6.12 He will maintain close watch on the quality and quantity of
work as carried out by the surveillance staff by periodically
referring to the data maintained ?t the PHC level by the laboratory
technician*
6.13 r
*
“ - check
•
He should
the consumption or anti maJarial drugs based
on the return from: surveillance inspectors MPS(M) and workers» as
prepared by the Malaria Inspector in the Month’’y meetings.
6.14 He should organise the. fever treatment depots <and‘ drug
‘
distribut ion centres. He should also keep watch over the availabaility of
chloroquine to t'ne above centre.
6.15 The publicity
‘
material and mass media equipment received from
time to
time
will
< tfr.s ..ill e properly distributed or affixed as per the in
structions from the district organisation.
6.16 He should consult the Booklet on "Management and Treatment of
Cerebral Malaria^ and treat cerebral malaria cases as and when required.
6.17 He should ensure-that all categories of staff in the periphery
administering medical treatment to the posititive cases should observe
the instructions laid down in under MsEp on the subject and in case
toxic effects are observed in Q patient who is receivix^g primaquine
drug is stepped by the peripheral worker and such cases are brought
to hxs notice for follow up actioryadvise if any.
**
* **
I
• T
/
PRECAUTIONSr
a) Scum if foi a.ed oa the top oi the staining solution should be removed
v?ith filtei paper before use.
b) The.
6.
of uabh water should be ranging from 6.2 to 6.8.
EXAMINATION
IHL THICK BLOOD FILM:
a) The thick film is not es thick drop. It. is a smear vhich transmits
nation ’.fhen haecoglobin is partly or wholly
enough light for ndcio:. . x
is thus rhe first
remove d. HaemoIyais nr dissolving of the red blood corpuscle
essential and staining is second, The thick film field shows leucocytes, platelets, and blood protozoa on a back ground of lightly stained remnants of the red
cells.
The normal thick film field contains leucceut.es and platelets with
occasional bluish cloud, the remains of dissolved reticulocytes. The cytoplasm
is always somewhat scattered cytoplasmic granules are often lost except the
granules of eosinophils which have a special resistance and usually shine out
with great clcarity. The film may contain a few degenerated white cells which
are structureless and rccogaisab•c only by their size, shapes and otainingT The
blood platelets, single, in small groups or occasionally in clusturs of several
hundreds arc1, stained pale purple and have a wcoly texture and outline which is
unmistakable.
Other rtruerurers seen in “he microscopic fields are probably extraneous
such as dust, moulds, yeasts,
apores, bacteria or deposit of stain.
b) ..rtefacts:
I
Structures uhich confuse diagnosis from their resemblance to malaria
parasites are sometimes seen* no meter how carefully the films are taken and
stained:
1
The commonest sources of error are”'
*So*°^^^11 grouot of platelets may be 'toigtaken for Chrom&tin
and quartan trophozoitts at the early compact state, and the l.-.tcr for advanced
vivax trophozoites at a stage when cytoplasm has broken into a cluster of frag
ments while the chromatin is yet intact, ii) The resemblance between vivax at
this stage and small platelet groups is extraordinarily close particularly when
the staining is not good and the light is inadequate.
1
The above facts.cannot oe avoided and they must be learnt from experience,
; Other artefacts which are extraneous and can be avoided by scrupulous
cleanliness in taking the smear, and protection of slide from dust etc.
cParasite Merphology in thick smear:
4
I
The technique of staining thick-film destreys the host rail and exposes
the parasite to changes in shape and size. The parasites appear smaller and are
less regular in outline. Parasites are seen in unfamiliar setting, no longer as
in the fixed then films neatly framed by their host red cells, but stripped and
distorted on a mettled grey grounds of red cells residue. With the disappearance of the host cells, nsurer dots in falciparum infection arc not seen in thick
V film. Scheffner*s c-ois may be seen in thick smears. In thick film the red stain
chromatin with associated blue cytoplasm must be seen before it is pronounced as
a parasite <,
...,4
A
In^SS^T
ChildrCn and ‘dults> blood
collected from the find
tip. in infants, however, the toe it preferred for the purpose. The site Iron,
where the blood is to be ccllected should be cleaned thoroughly with a piece of
cotton soacked in
needle taken out
al-owed to dr>’ completely.. . The hagedorr
prik is then Xn™ £ “X-"
case mPin ,•,
•
‘hv
fmger of the left l^nd or the toes, as
X>7iir:. "Tt ?r^klng.7 P—“ S!-'JW tc
rted or. tne finger or rhe
of blood on gentle ;rc3‘2. pr 11
36 lQ 3^ just, a good ..ited drop
blood to picl it un 4T;-‘ '■
thcn
‘i* rfro., of
bigger drop should be
3/
The first drop of bioo- ^7’,
the thick snear
t<- t
7
attended to by the app^ic^i n ot
over the injury.
aPP^C“^n Oi * P—
Ha
1
,get bl^ei droP
b^d- This
.S1-lc‘e aoout 1L'.. from the edge.
‘!n“fir Wh’ le tbe
taken
f^r should be
cotton ao^ud i.t -^t
.spirit
.
edge of a second
—----- Thc ’ spreader'' should bp l.Ad •Hd ar an angle of 36 to
45 degrees on: the slidecontaming the blcud drops and time
- should be allowed for
the blood dropO rf>
to jspread
cnrz> ^.1 . .. * c ~,... i .
•»
-i-foiMily along
thei edge, Then the "spreader11 is drawn
forward so that the bli< td
e:*
behir.d it making
ar. . ^cr- film on the surface of
the slide.
An ideal thin, tmec: is
which occupies the middle third of
on which it is drawn. It should
the slide
ve even and unbroken with continuous edges.
Ihe tail end of the sn,2£r bb.ouic’ ere
i firmer
finger like proce sgs,
or ti
should then !
a thick circular
the'he Ip of ^^7'^
■
.
:
’
lL
should
be
1/2
rr
inLii^t?7
and neither too thick nor tc^Th^rJ
Its thickne-s should be such
as to enable
one to see the second hand of wrist
watch through it.
The time for the preparation of a thick aud thin
than a few seconds. If more tiue is taken the blood may clears
clot should not be more
taking of another smear.
■ necessitating the
e) As soon as siucars
the air for
drvinp
the 31idc should be moved
and fro in
for drying. The thick
than the thin one for drying Th^h °f course» would take a little
]
longer time
nne for drying.
the i' 1'30 ‘
will be the Preservation
of the The
^d shorter
cenrxn^'
the ^tter"
--J cells m
in .the
the smears.
• •
s.
STAINING TECHHIQUE:
• a) Behaeipogiobinise the
thxGk smeer as descjibed.
b) Dip the thin t
smearJn methl alcohol for a second or f.
c) Dry thoroughly in
two for fixation.
uhe air -ma slanting position keeping
J thin smears
downwards.
d) Immerse the■ thick and thin smears in JSK-U soiution for a
second or twn.
Wash twice i
thrice m a jar containing h«ffer water.
f) Immerse in JSB«I
- • i.Qr cjj seconds.
g? Wash several Itimes ip buffer water to remove the <excess stains.
h) Dry in air keeping
stained smears side downwards
i
— in
<?;'(( mg p i«‘
tion to avoid deposit of dust.
>... 3
*
*
- 5 -
I
k) Precautions;
1. Ko preliminary fixation of thin sneer is necessary
2. Distilled water should be used in all steps
3. The undiluted ci the diluted stain should on no account be allowed to
dry,
the £ilm should not be lowered off but should be flushed
4. The stain
off with distjlled water.
2.
Gieosa
Stain:
a) Technique■
i)
ii)
iii)
iv)
v)
vi)
vii)
viii)
Dilute the concentrated stain in the proportion of 1 c. c. of the Stain
to 9 cc of distilled water.
Fix the thin film in methyl alcohol^ Better leave the 1/4 of the
head and of the film unfixed to avoid fixing of the thick smear by
the vapour cf alcohol. Immerse the film in a jar containing alcohol
and rapidly remove it.
Allow the alcohol to diy completely
Put the al ide on a staining rack with film surface upward
Pour rhe diluted stain on the slide to cover both the thick and the
thin smear
A11ovt the stain to work for 20 minutes.
Flush off the stain with distilled water.
rty rapidly in the air.
b) Precautions.
i)
ii)
iii)
5:
Dilution of the stain ir' r^'ivc^ to be do e only before use.
Diluted stain in the film should not be allowed to dry.
Stain on the film should not be poured off before flushing.
J.S.B.Stain:
a) 'technique;
i)
ii)
iii)
iv)
v)
vi)
vii)
Dip the thin smear in methyl alcohol for a second or two for fixation
Dry thoroughly in the air.
Iwersc the thick and thin smears in Solction-II for a second or two,
. Wash twice or thrice in a jar containing wash water.
Immerse in Solution-I for 45 seconds.
Wash thrice or 4 times in wash water.
Dry in ail;
'Precautions:
i)
ii)
Scum if formed on the top of the staining solution should be removed
with filter paper before use.
The wash water should be little acidulated with PH ranging from
6.2 to 6.8.
LABORATORY SERVICES;
1.
AIM:
Under » i.*e Malaria Ei ad If.at ion and even in Central Pregramme the importance
of laboratory services is top most. Examination of all the blood smears collected
6
-
d) Pigment in thick film:
is Scan
clearly in thick than in thin films./
Been mere
j
A trained
. server Bay
may often identify
identifv th..
the species and .u,
the stage of thc parusites by
noting the shape5 size, and distribution of the pigment granules.
e) Adyantcge of examining thick film;
a) Less time is required for identifying the parasites.
.01 Less chance of missing^parasitc
missing parasite - even when parasite density is low.
f) Risadv• entn.ge:
-nt ■'» ?e:
At times 9 it L-coiiec-: diiiicult to identify th\? stege correctIv.
event, thin smear is examined for confirmation.
XI!
whl ch
g) Microscopic examination of blood smeerg;
i) Thick film is 1to be examined first
II) At least 100 fields are
to be-examined and this normaly takes about
5 minutes.
iii) If one ]parasite has been detected, there mus.t be other
stages or other
;
. . species of malaria
----- parasite
may be present.
XV) If there iP/ny doubt in identifying the stage o- the species, the
thin smear.is tv be examined for confirmation.
SUPPLEMENTARY NOTES
The following-three Kinds of - *ain are normally
f i Iras;
sed for staining blood
i) Lieshman stain,
Geimsa stain and
$n) J.S.B. Stain
The methods involved iin staining blood
smears with Chase different kinds
of stains have been detailed below;
1‘
ki^sl^an Stain;
a)
i) Drawn a line with
grease pencil across the slide between the thick
and thia smears.
ii) Place the slide on the
1
staining rack with the smeared surface
upward and the two edges of the
slide* on the same plain,
-- ---iii) Pour 5 drops of'stain
to cover the whole surface of
iv) Allow the stain to act for 1/2 minute only.
thin <smear.
V) Dilute the stain with ^5 drops of distilled
water (PH 7.2).
vi) Draw the diluted stain across the
grease pencil mark to the thick
smear with a glass rod and mix throughly.
vii) Allow the diluted stain to work in both thick and thin smears for
5 minutes only.
viii) Flush off with distilled water.
ix) Allow the water to remain on
i
x) Place the slide up-rig^t vertically for drying.
5
I
7 A thick film usually contains "bout 5 cubic w. of blood vben IGO fields
are examined only about G-l-0.2 mm 3 of blood is usually covered. Ihereffore, when the parasite density is scantly, the detection uepeuds ou
chance and also ou excellence of stalling, ar.dcareful observe ions. In
such a.situation if a parasite is seen and missed, it is solely due to.
the negligence of the mocroscopist concerned.
Coated advcBtagos cf thicVfilr - The thick.film method
in 1903 b< Ross for raoid detection of malaria parasites., out its me
be recognised only relatively recently. Ine thick film method depenas on tae
fact that it is possible, by dissolving out the haemoglobin from
.
to render the thicx layer cf blood on slides sufficiently transparent for uxanu
nation by trarimitted lightr
The vAlue of the thick film is due to its concentration and to the subse
quent great saving of time in searching for parasites.
It must be emphasised that thick film calls for great care in preparation
for good raicroeoopy and for adequate practice. The ^aig^n for t>_cru.i^. - e
is small. The clear outline cf the leucocytes and parasites soen.iu .am fi.m
become distorted. Parasites lia naked on a blue-grey, back grcun_.
..
g
of infected Red cells is seldom seen and species ciagnesis is sometimes -iffic .
Nevertheless the adventages cf the thick f’lm are so great that it is. always
worth' the time and trouble to acquire proficcncy in this method..
-The superiority of the thick film; over thin' film for the rapid ■aetectior.
cf malaria parasite can be illustrated as below:
. Thin film
Thick film
1
16
Time- required to find fix st parasite
23
minutes
1
minites
Average difference in. ccanentration
1
20
ThTciranT~tbin‘ film prepared from the blood
Parasites iu ’tOU fields
STAINING OF SlOCp-SKEARS;
Virtually alt stains used in Malaria work were derived from Methylene blue
processed in one of the severe? ways to form by oxidation the polychrome assuyes .
and are called Romonowsky Stains, after the discovery cf this principle of stain- .
ins’. Before Romonovgky also mixtures of Methylene blue and Eosins were used, but
these mixtures always stained the nuclear chromatin blue. The oxidation product
of methylene blue now used,.stains the chromatin rec.
The most importance principle cf this stain it tnat its selectivity for
different cellular elements is maintained wiehiu a narrow range of the reaction
of the diluent. The Runonowsky effect gives s range of-colours ranging from
red through purple to.blue which are constant at a given PH, but with the change
of PH the whole range 'is shifted.
for instance:
* RBC stain bluish
• if.coo alkpline
- Basophilic cytoplasm of malaria parasites
if too a;idie
hartflv stains at aH<
3.
i
f
I
<
i
-
-
through the ’.ctivu. pacsivi. and ether vrluntary agencie^ nd their treatment in
time to cut dow;. trancc.issjon is very important. Under tU Modified Plan also
the spraying strategies ate to be fine lised on the basis of Annual parasite
incidence. Fro... our expv.rinncc it has been seen that from most of the areas the
collection of rhe blood clears Is less than !0 p^r cent of the population per
wbich desired. Tn vieu of thatj proper diagnosis cf all the blood smears with
malaria parasites to j-.now the actual epidemiological picture of the areas is
necessary.
There a~e certain baric corditicns connected with good micro;copic work at
any level, auen couoxt one refer to the microscopist and the cite of his wofk
to the mxciojcopj.c and to the rscterial to be examined.
y
iIc should be properly selected and trained. His position should be stable. F
’ “ ‘ ’have reasonable security of
He should
tenure of
his position and an adequate salary.
b) Site of jv££k: The
iue site
sice or
ot the
the microscopist
microscopist should
should be such that
of work of
the routine vzork could be done with minimuni of fatigue through the provision of adequate building r.ud furniture.
c) Ki£ruscGP3:_ J. good
good microscope
Microscope with
with adequate
adequate illuminating
illuminating facilities
facilities
snoulu be provided to the microscopist.
Blood
ana exarematu n as properly as possible. For good staining and exaoinacion it is r.ucesssry thnt blood smears arc received from the field without
exposure to du:;t or heat, dropcr labelling of the bloo< smears is also
very importcut.
of efficiency c
the fol lowing points7 ~
each microscopisv should be based on
i) Quality of the blood film
ii) Quality of sta'ning
iii) Correctness of diagonals
iv) Daily cut-put
2.
F
F
r
1!
I’
PREPARATION OF BLOOD SMhAE
For detection of Malaria Parasites both
thin the thick smear is collected on the sama slide. but only the thick film the
is
— examined
------ [ as a routine.
-T-O.V*
i& a single .layer of blood. The -RBCs should be contiguous
than overl-aping. ir is better to have such ff.l^ too thin than too thick.
A good thin film should;
a) evenly spread
b) must be free from streaks and lubs
c) i--- ' •
must not touch
be tapered off so that the tail is
d) the end . should be
--tapered off so that the tail is not lost bevond
ithe
nJi end
Onn nof
r
1 ■« J
the slide.
b) The thick fihh is a drop of blood spread <
over an area of 1.2 cm. in
diameter which imay contain 15-20 layers of blood cells, sue lilms are
--- ---- j. But films
with several layer of RBC in the
centre and has a thin edge c f one cell
thickness *
7
i
II
,k
l
1.- ~\F» 0 ■'• Al lUI - -u-hy- -
*i
A Il l
5n Con-r >3 Programme the
Undo-': the ?•*■ ’:. r? ? D. a <J 2.c a t.i on a nd c- ve n L.. Examination c.f all
services is
importance of
or Jen'T • v <•
t
ad
through the activ o z pas s ? vo and rl h*- r
'
the bio x: me a 's
tiaament : i. ti rm re <u~ do\.v trerrvoluntary •; rjc- 3C '■-- ••' ■
?■: sprev:: r*g
mission rs vx:y -;-1 • ’ r . - . ? . _4 lax.
c<
s. -.tc incii.-.cCi
■
C-L-.rc 1’5 o
t. of the
bu. u.4:rifR f— ;-TC
- <-•__ fi .1- • ■■■'*■•
.
. , ..... " . x,.
t
donee . u-frcH cc:: ex.
u; 1“• .-.-r cent oi
'
'
■:■■
—creas ch r r r-. - .•■ -. •. ->
..
of that. propei
the
^sit^ c know tte
jj
^rSiSdolcXic^y.ctvl ex th. arsus is necessary.
i
: j a s i c r c n i.r i- on s connected with good mict o-~
There arc ce
to iihe htiCx'Oi'ccpxsx
Sv ah ac. -di-cicnss refer
.
scepic wore at •-.y J ve Lp
t o' the m i c ro‘- c cpa and to the material to
and the site ci: hi3
be examined.
p
. •->;
be prcr=r.iy selected and trained. His
•
LX-xxx‘2s/A..*.- ii’»•- -1- -.t ‘ — ^rv-- r r-asonaoj.e seou.-/.,-Y 0-position should be s-abh-- -•-/“—/—
tenure o= his positicn a;id an adaqua^=
.
i
^t.
...r-n- ■■ site of work of uhe microsccnist ^honld Lx
i-=.
x-V ^x.1..
xknitTR-i of favujuc
such that the rcuurne
-xu .•.....
- _ •rbr-ough she provision or aoeauave cuxiax^
------
liic-Tcscoze
s A good mircosccpc
inWlinatin^
llic
cvidtk' to the microscopist.
£acilitics"sy.nuld be
e.
/ ' BloS“sSearsCShould reach of the
and examination as properly as pos^roxfc.
™tlo= « - ^eessary
are ^ceived drop the iteId without exposure to aus. o. auau. Uvp-r
labelling/of tYie bleed smears cs also
axso very
very important:
imporvanu -.
|
Th*?'
e«
—. .-—r
■•■.
baaed c-j the
1<
of each microsrcpist should be
3_
j.
’- .
Quality of the blood film
Q-c -laty -f eta:ring
3 ,
Ccrrect.ncisn of: diagnosis
4-,
Daily aac-puL
2.
PRE p
: Ru.' 10 *1_AA Az
-f.-. t: .-■ r i Malaria Parasites b~th the thin £nd thick
smear iz coltAA.m. m. the same slide, tuv cniy the thick film is
examined ~s 3 r ■;. . i:R-«
c • *2
■J
8 There are ajanv variations of the original Roiaoriowsky stain, but the ones
of interest: for srainint
parasites are Gieiusa, Leish^ns, Wright, Field
and ’dSB.
‘
.....’
a) Thick fiLnr*1) Dehaemoglobinisation of thi^k filr in old new net required •like wanr. water 10-30 minutes.
• 2) Iwiucrse the slide in soln. II for 1-2 seconds.
3) Dip the slide in Buffered wash water.
4) Immerse the slide in suln. I for IP-15 seconds.
5) Dip in Buffered water for 3-4 seconds
‘J’ Steed on one and to diy.
b) Thin fir.*?- »/ rlxa-ion of thin film by dipping ouu or twice in Absolute ccthyle
a1co he1 (Met hano1)
2) IiHmerse Soln, Il for 1-2 seconds.
3) Dip in Buffereed water
4) Imseise in soln.I for 30-40 seconds.
gin in buffered water
_In absence of the Buffered wash vater. tap water ar.d well or river water .
can be used. Whatever the sovrce of water it must be filtered before use. The
vash water dees not have to be distilled.
JSB sti-iu does not require very precise adjustment of PH in the riusing
water. The optimum is between 5.5 and 6.5, If the tap water is alkaline adjuct.
by adding soiue patasiun ciliydrogen phosphate or a feu drops of
Acetic Acid,
4.
EXAbHNATIQN BLOOD SMEAR FOR K/^iFIA PAJ-^ASITE
Set the microscope for best resolutions Plain mirror adjusted xr>.«
diaphagm, completely open condensas at highest pcsition.
2. Only thick film is examined as routine.
3. Lower Oil insersion ?en? to the file,. Unless parasitised RBC is seen
immediately- the slide will be gently moved until a leucocyte is found. Sowetimv
beginners bring it into focus because of slide placed in inverted positirr i.e.
with blood film downwards.
4, CoLLrcn errors in focussing under the oil iweiswu.
Lense: a) incomplete rotation of the revolving eye pieces
b) defectively centred objectives
c) blood'sr^ear placed upside down
d) no blood film on the part cf the slide directly under the objective
e) th a filin 5..? dxrty
f) the objective ia dirty
the eyepiece is dirty
5.
Parasite will show in its true perspective - if Chromatin is too red
unlikely to find any blue cytoplasm of parasite. %£ RBC stains much blue, unlikely
to find chiomatin with much red colour. Under these conditions it is better to
search for an area whar-?. leucocytes are more suitable stained.
6.
Tlia best resolution is in the centre of the field.
ing careful examination to be brought to the centre.
So any object requir
7.
Fines adjustment sr.culc be constantly tuinad feo bring the diff.?\ar? f-laiier
into focus.
8.
Move the slide fruu one end to another, than vertically one field, c.p anc
then hcrizoi*t-?Hy Iron eno to end again.
- ----- 3 —
Fn\7'.'? ? 1) TMC Ov
3<
A
■' fl'll;_ol ilj
.■"*
5
J"' *
rv. ru. derived from
use a _ ; y.lxiie
V i v t na 1 lc‘
sram •
of th1 spveroj. w-jys to form oy oxi*
F’c chy 1 £ ne b 1 no pr c«c e r c c. i n one are called °c.-cnov/cky Stain?. after
rcuiycs a ’ ofstaini^.
Ration the poJycnrz?
RanG-.r-sky aBo
.
h-.
•.
t,' inr 5pic
rhe d.-’•‘c'--^ r■.•
we: e ’-fr
o .<
\
yie;^- b. > i £)H Xu OS?
mixcures of H:
-cjr.
oluei
T"
:v'i
>•
i-vr.
?
'
oauct
ci
v,-. j- jc 1-e r a .‘■irc.'r'
i, 1 wo v s s ca 1 6
chvormin zcd<
•■.ow
uu’-.df sr^im z.j
nrc c ? iy 1 e. ne 11 v -•
x s v hcit - i- se 1 ec t.cut Y.-rirolp-e > 1 th?s .x-aun
Tnf- ’■nost
.-a writ sir o narrow
is
i
aa
into
iced
c: Is
tJvity foi diifeici I ccd.Au-u
i n .;■ -. on*t»no*.-?sky e x .uect g i ves
of. the
ir-ngc c... re act.ion of the x-¥. re 1 c hr oua 11 purt>
cede
to
blue w
which
are
le t
o bivc
r lie h ai
e
a range oi c o 1 ou? ‘ n ran' n fj f r ch • <
of
PH
the
whole
range
is
but with the chonge
consr?jnr a: a riven Plk I.-- .shifted<
For instance ?
If too alkaiine
Tf too acidic
-z
R BC St 'i ’• n L-1 ’ IS 3 h*
tx
Basor»hilic cytoj^lasi.
naJaria parasites herdJy stanifc re
all*
.: urjrpna5- RO'ViOrcwsky stain, buc
i ahi on s of the
a ? c menv
.’’ria p ar a ?• 11 e s a re
a en >t a,
ttis one cl liitcrest for staining rd
J.e i z hma r ■ f V<r 1 ght, Ijeld am uSB.
- - - - - —» Giemsa and
under
btalaida
Eradication
_L
1'LCl ^-0.1. .»
i“-"
•»--- — — Programs
.u
For mess.
In M12P st ein is mainly used IrS-Be
Fuiiahk-'*
—
JSB arc most i
film in old,
1 . IkihaemOt ■■ o.o ■’ rd °n.tion ci ch
z
U) Thick F? irn
iuke
warm
water
'L0-3C
nov? not re^Jiree *
r-iinutes •
II for 1-2
2 e Immer se ths 11 --fr- : oJ *
seconds <
3. !?•!“ tli- sitae in Buffered vne wetcr .
■n
SL/ln. I for
10*15
Ta , Ter terse the slide
i
seccndF?
Dip in •Buffered veter for 3-4 seconds
t f Stand or or-j end to dry *
(b)
Thin film
■j , Fiction cf thinx f}-V?. by dinplng one or
twice in Zibsoluf Mcctyla Icbhol* (Methanol)
Immerse Fol ;/
3
1 •• ■ 1'‘-
Dip in Buffered
.. immerse ia soln.
secorris
.
for
304 0 innts.
t.. Dip in Buffered water
.. . e4
I
----- L 2----1o
Thii.
is c s
- jyer of blood. The RBCs sno’.ud be coritl .r- v *an uv\:i 3 eying • j c rb t'-i.-s* to haye s^eu
c yo trrln L t.;an
coo thick* /• g-'^ci tha?/.. film should?
CV-
IDver-;. Ty spread
livst be free from streaks iud Jobs
tho long edge oi the slides
A
...c st
be tapered off
t.r so
.x,;onc thr'
os th:
' -f
the ta.il
Tiy- j. h ? c: k jr i im ■ ’t'
dreo of h? nod spr^a4 o*r?r an ares cf 1 ;
L
1 •. c 1 a :■ - o t c x v .!• ? ’ i aey c ot a i n '5-2 0 lasers of birch cellse But
films are
several layer of R"C •» n the centre erd hoc a thin edgeof: orifv c e 1 f?: i- ck; ? ? s s . A thick
centsins about 5 cubic m*
m. cf blood, •.<hen 1G0 fields are exa^-vnej c?’y coout Ch2 mm 3 of
blood is u_u ly covr-ie-.c Therefore, when :K-: parasite density is
sevury. tin o-.'vect •r c-penC? cn cnanoe e.'-r ^.Iso on excellence of
st a? ni ng. Lof 021: z j ti-crvati on, 1. ■:v...i' c_ ; ituotJ.on if a parasite
j.s s-r-cn nr-d r-;.’
is solely dua no t.?s
t :?s mqlogercc- cf .the micro
S C OO :■. ST
Ci GJ 1C:OL U ? Q u
f ilni « Ths tn lek film method
.>1. , r; 1133olvlnu ouv the haemc>*
. e rA:...j...
y-vcr
blood an
.■./.. ir- 2. :g
-..n by transmitted light,
-iln’ is du . ■; c its concentration and to the
c-f time- io searching for parasites.
Q
r5
subsooueu:;. g- :-.
;
t
Ic maot b? emphasised that thick film calls for great cere in
ni epar at.-I cm. for
5 ’idc.rosoopy : nr? f or’mdc quote pi act iceThe
?• -.er g 1 ji f ci t c cI’ 1 c. a 1 er r or ig sra;• 11 r it. c 1 ear out 1 ine of the leuc ucytes c.-nd parasites r-e-en in u?«n f ;• In become- distorted<• Pai elites
2 r’ce naked on a bl”e-g»
^cor.-gro'cn.d r The stippling of infected Red
LiiHs is sejoo-n seen and species diagnosis is sometimes difficult ♦
Nevectl^olcr r the ad'7"?nc^ges of tbe thick eiirn #re sc great that it is
alvrc-G v or tip the tiive -und tro^uble to aogu^re proficiency in this
Hi
de-: - c” •’ors n/
11 j - f o hs t h i c i' f i Im
r.:.a Tivran. ]
i
Thr/jk md tt.irJ; film prepared fran the
Pcr-cites in 100 fields
Time required to find first parasite
Hvei~o 0” • •. J f f e.r e nee in c one entrat i on
ov-?r thin film for the i soil
u:./ v.r =» r e d as ' x:* 1 Oe; .-
Thin
film
1
23 i-iInuits
1
Thick
film
16
1 minute
20
yF.grap.MA for eetat sd study CFJga
1.
harue of the visiting ctficer
a. Unit/PHC - visited•
b. period of visit
Ce Peculation of the uarc/PHC,
c
r:
.;..1 j .i. g
:
•.
j . bier os cop-? st
i i Other' sta ft a t Luc lie d t o t he
he Training status
i. Place. & period of. training
ii. Untes.ined
posts 2, Vacert
3 .
C lea n i n«j c f
a r
; i"
So/vticn in
ii.-e
1. Kev;
ii- via
bv Test.no c-.f ^Ic.iuLi.u slides
Is the a-1sent, cleaning practice founa to ?oe satisfactory •
A .
Drawing of
smears
•chic K DC-* b L - T ’ 03 it 1 on
Size
a. Thick
b. T •ii nk
Recurd
5 ♦
Numbering
6.
De he moq 1 ob.. ni s a 11 on
No, of per 10 slides selected
random*
4
a u Arc a noer- «e nt s of slides
&
be V’.eter used
<
c- T?jne given
d. Flushing
V •
r
’
-----------
/
ft PCl
nd
oi*
In c.bo .-net- <<f the Buffered wash •’riter, tar- w .i*7-1 6
r j ver WcVn ran K; u.^-q,
V’iiatevcr the source ci v?ater :H Ji j':-.. i>z: ‘M-.b-r^d
in., w'ash v\nter doos not lofe to "oe di^v-illrd fc
JSB J
riCX'S n. -c ■ - au. i < very precine adj vr?tn: rr- r>r pH in 11 . j .■
sin1?,
71zc cvt.i.ru-l. is hat»-;UGn •> Ji ^nd t-.i.
If the tap ;vcit
is alkaline- adjust by odd. inc fiernv pctash-v
dih/drcjeio pkorph t'.- •<
f'&w drcr>s ci .V/c /-.< v x \? xc*.;..
FCP
Cn »»st z e s c > 1 t z on .
\ L:>e •: c < 'rd/.; ns er at;
-1
V'. th- }<j.-7r;,s. .
du o pba if •;, «. cc - • j t.
2
Ur}1 y t hr ck 1 j. 1 n» is c. nac\i.J •-«s r o'.it a r' •
1
LOv/cr Gil. i.c"ic rsia.i J rv:»». s, t <.7 t r u.-- ;.? j i ? 4
3 .
‘ ”! j ■- ■: 5 p j.t a o it ist; d RGC
is seen izn»eriiclt -jy. the s i 1 d.- wi j ? he
r.r i.y 'r •...’ -’ u nt i 1.1 =i le uc o*
5 criPi tne« •?*-■ *c;. nnt?r b,-• i.;
it .. ;• o 'Icnc bor a use of
cytc Is fr ino
slide planed in .?.r;vcrto6 r o^iticjn
.
•t f ' ]m drwnv.^xdSe
4,
Ck'n^?cn £•■’ ‘ (‘v<: i
f -.<.•■■ >:?. n-, vn-ic .
rt
■.
£ s i cn > r
r-7i
t-;Ct .LVeS
<
K?.C-.JO
c.
Ho hlr>'-d
ob;;e : t u.Vv
%
1 ■■ e cj v ufjdex
uhe
Tho filr tr i'i
I
f•
ri-.^ dojc-c tJ v .. i l
s? •
xi-i?. eyepioca is dirty
1.1 v
wild ;- huvj’ m
1
l-.rur; p<j cspeori^
If .-*irLMTr-'t..’n is
too rca ur 1 1<e?.y to flnf/ airy blue cyccplosm .of ??
If W3C
r? is
1 •' S J tcVi: «<
stains
- ■•?« i f.ely i.o find diroT.^tln wrih Much red coloiv *
Unr t.h< n c bud it- '• c nr
is Letter to search for an r*rer< where
]r:-ucc-:\d
4- 0 '-ore
. y stained.
r .
ali; ijCu.-u j.
In.t -.o.ri. ->0 Jn the ccn'.ac ci: th-i fiala.
So ariy
oV Ject i oqui r:’ no car r- £u j exe«ni netion c o be b:' ou jn
co the centre,
7»
Fine sdiusureri: sno\<?Ld ba constantly tur ned \
dif fer ent j> j a iic
»nt o .f ex us .
brj.nq t.ijp
8,
Move the slide i'rom one end ro another . thc-n vert, rally one
field. up 9 a i ad t he n h or i z ent a 1 ly for m e n d t oa 14 d a j a ri»
»
J
/
Staining
a. Trial iv Eircr method
b. Vfnether only thick or both thick ani t/'-j n sncar stained.
c* Whether ni-<ss or individual
!
d. Destainine, or restaining
e. Defects nocod in staining
f. F j At e r 1 ng ot r he st aini ng
I
8<
Fixing :
a • ?.qent used
b< Method, in practice
c . Whether done after or before staining the thick smear.
9=
Buffered SoPution?
a. Agent used
b. Water
c , PH indicating paper
10.
Dust proof coeer
11,
Ivmclling of rnicrosccpe
a. . Mirror
b. Position of condenser
c <. Whether one eye or both eyes used
■!
d. Oil used
e. Cleaning
I
12»
Examination:
a. No. of fields seen
b;'No e‘xc<rnj nod by the technician (s) and the total output •
c . Discrepancies - RHO & State Central laboratory or any other.
13 e
Ma i nt e na nc e Rec or d i
a. In ward Register
b. Log Book or technician
c • Others .
14 •
Maintenance of Maps, Graphs and chaut
a. Maps of the Unit/PHC
b. Gr a £ > n s sb r>vr i n g - S <■ W. w i s e co 1 le o t.? on of blood smear
. e^3
I
Graphs snowing Wo of 5nicer r ecc ived
Graph sho-/7.ing positive per n.ortt
e. Graph shewing pcs-.ti^c cas^. p r mo/
r\’>. cxantinen p-
c
a.
1
f * Hack I*' p f- r;jrv •»
i
A
V
1’5 ,
Mier• sSc j;-.-
r
b. Cord it :o
16 .
Spot la^p
XI <
Inflow 03
a • Acn i"-b. Persia
c . Mass survey
i
I
(o' the day of visit)
18.
Back j oo
19.
Pigeon Holes
20
Check slides sent to RHO/STATE
Sent
•a. r.
P .C
c
Eoheduis - slide Ho. and result
etaiIs of disagreerr nt - if air/
d. Packing
22 ..
Positive -ecorded, species wise
22.
r uncnsti t3 on of positive slides
23 .
General coriGibicns of laborarc.cy
no»~’fie nt s
b. .Erpiipma nt
24 e
Testi ng of tecnnieion
AxamJ net? on c f o <.■'- e it i ve a nd Me g a t i w s 11 de s .
*********** * * ^
I
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