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NATIONAL

CONTROL
STRATEGY

MALARIA RESEARCH CENTRE
1

National Malaria
Control Strategy

(Revised on 1st Nov. 1995)

Malaria Research Centre
22, Sham Nath Marg
Delhi-110 054

1995

CONTRIBUTORS
Malaria Research Centre

Dr. V.P. Sharma, Director
Shri N.L. Kalra, National Consultant
National Malaria Eradication Programme

Dr. S. Pattanayak, Retd. Director
Dr. R.S. Sharma, Director

World Health Organization (SEARO)
Dr. V.S. Orlov, Sr. Malaria Adviser

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NATIONAL MALARIA CONTROL
STRATEGY
EXECUTIVE SUMMARY
The National Malaria Control Strategy
(NMCS) is directed to provide freedom from
malaria to the people of India as their basic
right. NMCS takes cognizance of prevailing
malaria situation and new epidemiological
paradigms in the country. These para­
digms are Tribal malaria, Rural malaria,
Urban malaria, Industrial malaria, and Bor­
der malaria. Malaria control under the
primary health care system requires: politi­
cal commitment, intersectoral coordination,
legislative support, interventions based on
epidemiological assessment, and flexibility
in control approaches. In the background
of new epidemiological paradigms, NMCS
brings out the need to review: (i) drug policy,
(ii) insecticide policy, (iii) re-organization of
NMEP in tune with the NMCS, (iv) decen­
tralization of malaria control , (V) epidemio­
logical reasoning in control approaches, (vi)
Community participation supported by
strong IEC programme, (vii) training and
Management Information System (MIS).

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PREAMBLE

India is a signatory to the Global Malaria Control
Strategy signed in Amsterdam in October 1992.
In keeping with this international commitment.
National Malaria Control Strategy (NMCS) has
been drafted to supersede the modified plan of
operation (MPO). The main tenet of the strategy
(NMCS) is based on the commitment of freedom
from malaria as the basic right of the people of
India.

National Malaria Control Strategy requires:
• Political commitment;
• Intersectoral coordination;
• Legislative support;
• Epidemiological approaches in
malaria control
• Community participation;
• IEC Programme;
• Management Information System (MIS); and
• Training
• Research inputs

INTRODUCTION
Historically malaria is a disease of great socioeco­
nomic importance. The history of malaria in India
is dreadful. In 1947, malaria was causing an
estimated 75 million cases and 0.8 million deaths

4

annually. These figures often increased 2- to 3fold or even more during epidemic years. In addi­
tion to large scale morbidity and mortality, agri­
cultural production suffered badly in some areas
like Uttar Pradesh (UP) Terai, Wynad in Kerala
and Malnad in Karnataka. There were many in­
stances where colonization was impossible due to
ravages of malaria, and UP terai (distt. Nainital) is
a classical example of that. Industrial develop­
ment also suffered badly during those years. Start­
ing with a moderate attempt to control malaria in
Lahore (now in Pakistan) in the first half of 20th
century, remarkable success was achieved through
malaria eradication programme when about
1,00,000 cases were reported in 1964, and no
malaria deaths. The success of the programme
was so pronounced that malaria was no longer
considered a problem requiring persistent efforts
in its control.

PRESENT MALARIA SITUATION
There has been a considerable reduction of total
malaria cases during the 1980s as reported by
the NMEP. In 1976 there were 6.47 million cases
which have declined to 2.1 million cases in 1992.
However, P. falciparum, cases increased from 0.75
million recorded in 1976 to 0.88 million by 1992.
From 1983 till 1992, there has been stabilization
of total malaria cases, although P. falciparum per
cent is increasing steadily, i.e. 21.8% in 1981 has
almost doubled to that of 43.9% in 1991. Deaths
5

due to malaria started in 1974, have varied be­
tween 200 and 500 a year.
The in-depth evaluation of the modified plan of
operation (MPO) of the NMEP in 1985 commented
on the malaria situation that “the problem of ma­
laria in India is grossly under-estimated”. This
observation was based on several reports of
underreporting by the research organizations in
the country. However, malaria morbidity esti­
mates can be made by the consumption of antimalarials as well. Yearly production of chloroquine
phosphate base in the country is 270 metric tonne
(mt). Assuming the use of 70 mt for other thera­
peutic purposes and export to the neighbouring
countries, at least 200 mt is used in the country in
the treatment of fevers. One metric tonne yields
4.0 million tablets of 250 mg, and therefore 800
million tablets of chloroquine are available. If we
take out 300 million tablets required by the NMEP,
the balance of 500 million tablets are available for
the treatment of fever cases outside the NMEP.
Since in the private sector 10 tablets are used to
treat a case of fever/malaria, and taking into
account the children and low dosage required due
to combination of drugs used by the doctors, and
also the poor compliance, on an average 7 tablets
may be used in the treatment of one episode of
malaria. Therefore, 500 million tablets would treat
71 million fever cases. Since about 50% case may
be due to malaria, a rough estimate of morbidity

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due to malaria comes to 35.5 million episodes in
addition to malaria cases treated by the NMEP.
So far as mortality due to malaria is concerned
the exact statistics of malaria deaths are not avail­
able. However, in 1989 crude death rate in the
country was 10.8. Of this fever deaths were 7.3%
and deaths due to malaria in fever cases were
estimated to be 18%. Based on this information
estimated deaths due to malaria have been calcu­
lated as 1,20,625. Vital statistics of India also
reports similar deaths figures e.g., 1,37,846 deaths
due to malaria in 1985 and 75,285 in 1987.
To measure the burden of disease, World Develop­
ment Report 1993 uses a new measure expressed
as disability adjusted life years (DALY). DALY is a
measure that combines healthy life years lost
because of premature mortality with those lost as
a result of disability. DALY for malaria in India in
1990 was 0.47 million for women and 0.48, million
for men (total DALY 0.95 million).

STRATEGY OF MALARIA CONTROL
NMEP is responsible for malaria control in the
entire country except defence sector, and par­
tially railways and municipal corporations of met­
ropolitan cities. However, under the NMCS, re­
sponsibility for financial, technical and adminis­
trative aspects of malaria control should be shared
by major establishments/institutions both in the
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private and in public sectors. These institutions
are the following:

•

•
•
•
©

All mega projects and industrial establish­
ments under various sectors of economy, viz.
steel, petrochemicals, coal, cement, mining,
fertilizers etc.
Tea gardens/coffee plantation areas
Irrigation projects during construction phases
Railways/airports/seaports
Autonomous institutions, and a few more to
be identified

The main strategy of malaria control so far has
been the control of malaria vectors at their resting
sites by spraying residual insecticides. While this
strategy would continue to be applied on selective
basis, the situation of malaria has deteriorated
rapidly due to creation of mosquitogenic potential
under the impact of developmental activities. In
such situations where malaria is generated by
human activity, the primary preventive responsi­
bility of vector control should lie with the sector(s)
responsible for generating malariogenic conditions,
at their own cost.

Taking into consideration the diversity and hetero­
geneity of malaria problem in India, existing tech­
nical, operational and administrative constraints,
it is felt that at present there is no radical solution
to the problem of malaria. Therefore, the major
feature of the proposed National Malana Control
8

Strategy is the “Improved Management of Ma­
laria” with the following general objective:
• Management of serious and complicated ma­
laria cases;
• Prevention of mortality with particular refer­
ence to high risk groups;
• Control of outbreaks/epidemics;
• Reduction of P. falciparum incidence, and con­
tainment of drug-resistant malaria;
• Reduction of morbidity; and
• Maintenance of low incidence status.

GENERAL APPROACHES TO MALARIA
CONTROL

General approaches to the management of ma­
laria are as follows:

(i) Organizational
• Decentralization of malaria control
• Enhanced support for the development of epi­
demiological approaches
• Appointment of a “link worker”^ in tribal and
difficult areas
'a'For accelerated malaria control and early case detection
and prompt treatment (EDPT) it is proposed to appoint a
link worker in each village (preferably a women). Link
worker would be responsible for surveillance, keep rou­
tine antimalarials. will have access to life saving drugs,
help early hospitalization ofserious cases, motivate people
through information, education and communication (IEC)
and participate in malaria control operations.

9

(ii) Disease management
• Early case detection and prompt treatment
(EDPT) even at the most peripheral level of
health services
• Disease management through improved hos­
pital infrastructure
(iii) Transmission control
• Selective and sustainable vector control
• Rural and urban sanitation
• Intersectoral coordination
• Legislative support

(iv) Strengthening malaria control
• Prediction and early detection of epidemics
• Capability and capacity building at the pe­
riphery
• Health System Research (HSR)
• Information, education and communication
(IEC) approach
• Knowledge, attitude, prejudices and believes
(KAPB) approach
• Community participation
• Periodical programme reviews, e.g. drug policy;
insecticide policy; drug resistance status; op­
erational problems; inputs from research; so­
cial, political and economic determinants; and
training needs etc.

10

PREVALENT MAJOR EPIDEMIOLOGICAL
TYPES OF MALARIA
Based on existing malaria situation, the follow­
ing malaria epidemiological type have been iden­
tified in the country.

Type 1. Tribal Malaria
Sub type 1.1: Tribal malaria of the deep for­
ests and forest-fringes: Features of this ma­
laria are stable and high malaria transmission
with (i) predominance of P. falciparum moderately
resistant to chloroquine and, focally, to sulphapyrimethamine drugs, (ii) An. dirus. An. minimus
and An. fluviatilis as major vectors refractory to
transmission control, (iii) predominant mobile
tribal population and constant measurable mor­
tality among pregnant women, children and mo­
bile non-trib-al population groups, (iv) inadequate
health infrastructure, and (v) lack of treatment
facilities at the village level. Control objectives
should be prevention of mortality in high risk
groups and reduction in morbidity.

Sub type 1.2: Tribal malaria in proximity of
forest-fringe areas and with disturbed ecol­
ogy: The features of these areas are moderate to
high endemicity with (i) periodic epidemics/outbreaks, (ii) predominance of P. falciparum, (iii)
widespread low to moderate degree of resistance

11

060 42

to chloroquine, (iv) An. philippinensis (= nivipes)
as main vector amenable to transmission con­
trol, (v) aboriginal tribal migrated to these areas
also recently established non-tribal populations,
(vi) high mortality among non-tribal and moder­
ate among tribal population during periodic epi­
demics, (vii) limited health infrastructure, and
(viii) lack of drugs at the village-level. Control
objectives should be: (a) prevention of mortality,
(b) reduction of morbidity, (c) prevention and con­
trol of epidemics, and (d) reduction of P.
falciparum in mono- and multi-drug-resistant ar­
eas.

Type 2. Rural Malaria
Sub type 2.1: Irrigated areas of arid and semiarid plains: The features of this malaria include
(i) moderate to low endemicity, (ii) P. vivax pre­
dominance during lean years, and P. falciparum
during periodic exacerbation of malaria trans­
mission, (iii) localized P. falciparum resistance to
chloroquine, (iv) An. culicifacies as the main vec­
tor, (v) multiple vector resistance, (vi) moderately
developed health infrastructure, and (vii) mod­
erate impact on health and substantial mortal­
ity during epidemics. Control objectives should
be: (a) reduction of morbidity, (b) prevention and
control of epidemics, (c) reduction of P. falciparum
and (d) elimination of mono- and multi-drug re­
sistant P. falciparum foci.

12

Sub type 2.2: Rural areas without irrigation:
Important features of this malaria are: (i) low
endemicity, with P. vivax predominance and peri­
odic localized outbreaks, (ii) in desert areas with
An. stephensi as major vector during interepidemic
periods and An. cnlicifacies during epidemics, (iii)
in other rural areas An. cnlicifacies as the major
vector amenable to transmission control, and (iv)
fairly well-developed health infrastructure and
marginal impact of malaria on health. Control
objectives should be maintenance of low inci­
dence status and prevention and control of epi­
demic outbreaks.

Type 3. Urban Malaria
Sub type 3.1: Malaria in towns: Important
features of malaria in towns include: (i) mod­
erate to low endemicity, with P. vivax predomi­
nance and focal P. falciparum transmission, (ii)
sporadic epidemics around construction pro­
jects, (iii) An. stephensi and An. culi-cifacies as
the main vectors refractory to transmission con­
trol, (iv) limited impact on health, and (v) well
developed health infrastructure.

Sub type 3.2: Malaria in peri-urban areas: This
malaria is mostly influenced by An. cnlicifacies,
poor sanitary conditions with low socio-economic
groups living in unplanned settlements, prone to
periodical epidemics. Control objectives should

13

be: (a) prevention of mortality and duration of
illness, (b) reduction of morbidity, and (c) reduc­
tion of P. falciparum incidence.

Type 4. Industrial Malaria

Malaria in development projects in various epi­
demiological strata with: (i) disturbed ecosys­
tems and epidemic-prone areas, (ii) one or more
major vectors involved, may be amenable or re­
fractory to transmission control, (iii) substan­
tial impact on health of labour force, (iv) lim­
ited health facilities for prompt treatment, in­
variably associated with chloroquine resistance,
and (v) in the north-eastern states, with monoand multi-drug resistant P. falciparum. Control
objectives should be: (a) prevention of mortal­
ity, (b) reduction of morbidity, and (c) suppres­
sion of transmission.
Type 5. Border Malaria
Malaria prevalent along high transmission belts,
international borders and state boundaries.
These areas have their own problems in regard
to malaria control, e.g. frequent exchange and
mixing of population, illegal activities and poor
administrative control thus making malaria con­
trol problematical, and at times impractical.
Control objectives should be the same as for
the rest of the contiguous region, but selection

14

of control tools would largely be based on lo­
cal situation and quality of health delivery in­
frastructure present.

Malaria among migrant population moving from
endemic to non-endemic areas and vice-versa of­
ten presents a serious malaria problem. Migration
often brings localized epidemics and new parasite
strains are disseminated. Migration malaria cuts
across all the boundaries of epidemiological types
of malaria, but it is more pronounced in projects
and intensive agriculture areas. Control objectives
should be: (a) prevention of mortality, (b) preven­
tion of epidemics, and (c) suppression of mono- and
multi-drug resistant P. falciparum
In the major epidemiological types of malaria
discussed above, one may find overlapping ar­
eas of mixed epidemiology and therefore the
above classification should be seen in a broad
perspective of malaria paradigms at the national
level.

MALARIA CONTROL OBJECTIVES,
APPROACHES & INTERVENTIONS

There are some common features and approaches
in the management of malaria which are appli­
cable in the 8 epidemiological types of malaria
described above. These are the (i) occurrence of
drug resistance in P. falciparum, (ii) treatment

15

failures and use of alternate drugs, (iii) availabil­
ity of life saving antimalarial drugs and related
therapy at the periphery, (iv) early case detection
and prompt treatment (EDPT), (v) emergency pre­
paredness to control epidemics at the PHC level,
(vi) protection to high risk groups, viz. children,
pregnant women, tribals and migrants, (vii)
knowledge, attitude, prejudices and beliefs (KAPB)
studies in endemic areas, (viii) application of ecofriendly technologies in vector control, (ix)
intersectoral coordination, community participa­
tion and IEC approaches, and (x) the use of in­
secticide-impregnated bednets and repellents etc.

Table 1 gives specific control objectives, ap­
proaches for disease management and transmis­
sion control for each epidemiological type.

In addition NMCS requires that:

• NMEP should be reorganized at the national,
regional, zonal and state level in tune with the
objectives of the National Malaria Control Strat­
egy• Malaria control approaches should be based on
epidemiological reasoning through a well devel­
oped management information system (MIS).
MIS should be interfaced with other sectors to
provide holistic account of malaria ecology in
the area for planning of integrated malaria
control through intersectoral coordination.

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Table 1: Malaria Control objectives and approaches based on new malaria paradigms.

Epidemiological
types

1 Tribal malaria
(Sub type 1.1:
population 50
million)

(Sub type 1.2:
population 20
million)

Control
objectives

Disease
management

Prevention of mortality • Infrastructure develop
in high risk groups
ment
Reduction in morbidity • EDPT. DDC and FTDs
in all villages
• Establishment of link
worker
• Mobile van with
diagnostic facility in
problem areas
• Referral facilities
• Prevention of mortality • Same as under
• Reduction of morbidity
Sub type 1.1
• Prevention and control
of epidemics
• Reduction of P. falciparum
in mono and multi-drug
resistant areas

Transmission
control
• Selective vector
control
• Impregnated
bednets and
repellents
• Ecological barrier
around settlements
• KAPB studies to
involve commun­
ities for improved
health delivery

Same as under
Sub type 1.1

2. Rural malaria • Reduction of morbidity • Strengthening of exist- • Engineering meth(Sub type 2.1: • Prevention and control
ing health care services ods of vector contpopulation 200
of epidemics
including referral
rol through intermillion
• Supression of mono
• Detection and treatment sectoral efforts
and multi-drug resistant of malaria cases by sta- • Rational use of
P. falciparum
tic health institutions
irrigation water
and private sector
• Improved aronomic
• DDC and FTDs in
practices
under-served areas
• Selective vector
control
00

(Sub type 2.2: • Maintenance of low
population 100
incidence status
million)
• Prevention and control
of epidemic outbreaks

3. Urban malaria
(Sub type 3.1:
population 75
million)

Strengthening of labo­ • Focal spray in areas
ratory services at the
with Indigenous
PHC/sub-centre level
P. falciparum
Private sector should be
activated for correct
diagnosis and treatment
Case detection for early
treatment

• Prevention of mortality • Malaria clinics
• Reduction of morbidity • Involvement of Indian
• Reduction of P. falci­
Medical Association
parum incidence
• Enhancing capability
of referral services

• Primary emphasis
on species sanitation
• Source reduction
• Anti-larval measures
• Implementation of

for malaria

(Sub type 3.2:
population 75
million)

CD

4. Industrial
malaria
(population
10 million)

• Control objectives as
for type 3.1

legislative measures
• Intersectoral coordi­
nation for vector
control

• Activated passive case • Same as for Sub type
detection in slums and 3.1
labour settelements.
Rest as for Sub type 3.1.

• Prevention of mortality • Screening of itinerant • Healthy settlements
• Reduction of morbidity
labour for radical
sites
• Suppression of trans­
treatment
• Efficient water manmission wherever
• Malaria clinics on site
agement practices to
feasible
• Strengthening of nearest prevent mosquito­
• Prevention of malariohospitals
genic conditions
genic potential
• Mass drug administra­ • Anti-larval operat­
tion whenever required ions

5. Border malaria • Control objectives as
for the rest of the
contiguous region

• Infrastructure develop­ • Information ex­
ment
change on outbreaks
• Synchronization of
• EDPT, DDCs, FTDs
• Referral hospitals
malaria control
• Alternate drugs in
activities
border areas for
• Selective vector
resistant P. falciparum
control

• Malaria control in urban areas should practise
species sanitation. There should be a common
legislation to cover all urban, peri-urban and
project areas in the country.
• Research on malaria should be strengthened
by an element of applied, field and health sys­
tems research to be taken up by NMEP in
collaboration with various research organiza­
tions in the country.

• Training programme should be decentralized,
diversified to include non-health sectors and
strengthened by setting up institutions at the
national and state level.

Published by Dr. V.P Sharma. Director, Malaria Research
Centre 22-Sham Nath Marg. Delhi-110 054 and printed at
Akashdeep Printers, New Delhi-110 002.

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