Dr. Keerthi RatnayakeRegional Malaria Officer

Badulla

MALARIA

Caused by a parasite Plasmodium

Two parasite species are reported in Sri Lanka• Plasmodium vivax (94.8%)• Plasmodium falciparum(5.2%)

Other parasites (not in SL)• Plasmodium malariae• Plasmodium ovale• Plasmodium knowelsii

(more recently )

Vector – Anopheline In Sri Lanka –

1. Anopheles culicifacies ( Main Vector )2. Anopheles subpictus3. Anopheles annularis

Vector of Malaria

Present Malaria Situation and Epidemiology of Malaria

Malaria is a curable and preventable disease. One of the commonest diseases of mankind. Spread over 101 counties. Every year - 110 million cases

- 90 million in Africa

- Over 01 million deaths. 80% death in Africa and 66% at risk. 15% deaths in Asia and 49% under threat. Tiny fraction of death in America and 14% at risk.

Worid Malaria Situation

Malaria in Sri Lanka

• In 1911 first organized state intervention towards prevention and control was established in Kurunegala.

• Subsequently Anti Malaria Centres were established at Mahara Prison, Anuradhapura and Trincomalee during 1923.

• At the time several measures were taken to prevent vector breeding such as

– Filling, draining and oiling of breeding sites – Introducing of larvivorous fish into breeding sites of the vector eg: Guppi , Hadaya

• In 1934/35 a devastating malaria epidemic was reported. The effected areas due to epidemic was

North Western ProvinceMajor parts of Kandy, and Matale

• 3.1 Million population was hit by the epidemic. It was reported that 1.5 million contracted the disease and approximately 80,000 died during 07 months period in October 1934 to April 1935.

• Introduction of residual spraying with DDT took place in 1945/46. First country in Asia to start DDT spraying for malaria control.

• Vector density was reduced due to the long period of residual chemical activity of the DDT.

• 1955, DDT spraying had been withdrawn. During this period the early detection of malaria patients was established.

• 1958 - 1,037 patients were reported.• 1963 - 17 patients were reported.

• 1967 - 3466 patients were reported. • 1968-1970 only 125 deaths have been

reported and case load of 1.4 million was reported during the same period.

• 1969 indicated the vector resistance to DDT. • 1957 -10,442 malaria patients were reported.• 1971-1972 upward trend of malaria incidence

was observed due to DDT resistance in the vector.

• 1975 cerebral malaria patient was detected.• At the same period malathion spraying was

introduced.

• After 1971 , following methods were used as the main strategy to control vector.

– Indoor Residual Spraying (IRS)– Chemical larviciding using abate– Thermal fogging– Surveillance systems was strengthened

• In 1984, first falciparum malaria patient showed resistance to “chloroquine” was detected

• 1992 there was evidence that susceptibility level of the vector to “malathion” was rapidly decreased.

19111913191519171919192119231925192719291931193319351937193919411943194519471949195119531955195719591961196319651967196919711973197519771979198119831985198719891991199319951997199920012003200520072009

0

1000000

2000000

3000000

4000000

5000000

6000000

Malaria cases recorded annually in Sri Lanka, 1911-2010

Year

Num

ber

of c

ases

in 1

000

DDT resistance in A culicifacies first detected

Introduction of malathion

Chloroquine-resistant

Pf first detected

1911

1989

Activities of the AMC

decentralized

Widespread malathion resistance in A.culicifacies

first detected

Lambda-cyhalothrin introduced

WB project commenced

RBI launched

GFATM Project

1997

1999

2003

2007

ACT introduced

First Anti Malaria Centre set up at

Kurunegala

Incriminationof Anophelesculicifacies as

the vector

Appointmentof first

malariologist

1913

1921

1934 / 35

Introduction of DDT

A devastating malaria epidemic

1946

1994

1992 / 93

1984

1975

1969

1967 / 68

1963

1958

Resurgence of malariaLeading to a

countrywide epidemic

Neareradication

achieved

Malariaeradicationprogramme

launched

2009

Malaria elimination

project

Microscopically confirmed malaria patients

in Sri Lanka 1988 - 2011

Years

Source: Anti Malaria Campaign Data Base 2010- 6842011- 119

Total cases = 119

2011

Year No. of Blood films No. of +ve cases P.v. P.f. API

1993 1503902 363197 285227 77970 20.61994 1370831 273502 225864 47638 15.31995 1098105 142294 119056 23238 7.91996 1288990 184319 139362 44957 10.11997 1330659 218550 163856 54694 11.9

1998 1338146 211691 169295 42396 11.4

1999 1582111 264549 200671 63878 14.1

2000 1781372 210039 150389 59650 11.1

2001 1353386 66522 55922 10600 3.5

2002 1387953 41411 36535 4876 3.4

2003 1192259 10510 9237 1273 0.9

2004 1198181 3720 3171 549 0.8

2005 971121 1628 1494 134 0.4

2006 920655 590 566 24 0.1

2007 1044114 198 191 07 0.04

2008 1047104 670 623 47 0.15

2009 909132 558 529 22 (M-07) 0.10

2010 1001107 684 668 16 (M-10) 0.12

2011 119 115 03 (M-01)

Number of confirmed malaria patients in Sri Lanka 2009 / 2010 (district-wise)

558 cases

684 cases

Imported Malaria Cases – 2009 / 2010

India HaitiLiberia NigeriaPakistan RwandaSouth AfricaSudan Uganda

NigeriaGhanaIndia W AfricaLiberia ChinaHaitiSouth Sudan

Pv- 34Pf – 12Pm -1Mixed-5

Pv- 14Pf – 11Mixed -2

(95%)

(5%)

Microscopically confirmed total malaria patients in Sri Lanka – 2009 / 2010

Year No. of deaths1998 1151999 1022000 762001 532002 302003 42004 12005 02006 02007 1

2008 0

2009 1

(imported from Nigeria)

2010 0

Mortality due to malaria in Sri Lanka

3308 3457 3589

4996

24421773 2048

3538

2559

5339

8101

1342

330 69 25 5 6 6 1 1 20

1000

2000

3000

4000

5000

6000

7000

8000

9000

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Malaria Cases Reported to Badulla District(Only Local cases from 2003)

Introduced Impregnated

bed nets

2003 2004 2005 2006 2007 2008 2009 20100

2000

4000

6000

8000

10000

12000

10510

4050

1640

650 196670 558 684

140 54 5 6 6 1 1 2

Sri Lanka Badulla

Comparison with all IslandYear All Island Badulla %

1999 264549 5339 2.02 %2000 210039 8101 3.87 %2001 66522 1342 2.02 %2002 41411 330 0.80 %2003 10510 140 1.33 %2004 4050 54 1.33 %2005 1640 05 0.30 %2006 650 06 0.92 % 2007 196 06 3.06 %2008 670 01 0.15 %2009 558 01 0.18%2010 684 02(13) 0.27%2011 119 00(04) 0.00%

Elimination of MalariaWhere we are ?

VISION OF THE CAMPAIGN

• Sri Lanka with no indigenous malaria

  MISSION OF THE CAMPAIGN

• Plan and implement a comprehensive malaria control programme preventing the indigenous transmission of malaria in Sri Lanka.

Objectives

• Elimination of indigenous P. falciparum malaria by the year 2012 in the country.

• Eliminate of indigenous P. vivax malaria by end of 2014

• Maintain the zero mortality due to malaria in the country.

• To prevent the reintroduction of malaria into the country.

Eliminate malaria from SriLanka• With the support of the government,

NGO`s and political influence we have planned to eliminate malaria by year 2015. We have already launched malaria elimination programme starting from 03rd of June 2010.

Malaria Elemination Logo of the Campaign

Malaria control measures & activities towards Elimination

1. Early Detection :- BF & RDT

2. Prompt treatment :- New drugs, New schedule, Assure complete treatment

3. Prevention :- LLIN, IBN.

4. Selective vector control methods :-

Adult_ IRS, Larvae_ LC, LF, GHR

5. Assesment of Vector behavior by Ento survey

6 . Enhance Community Awareness:-

7 Coordination & Monitoring of all activities by GPS technology.

8. Regular Reviews :- To assess the progress of activities.

- Monthly – AMC

- Biannually – Provincial

Early Detection

3438633180

28756

3760036044

28670

35961

38661 38676

44915

53084

35616

41047

3385731342

23809 22934

31401

19773

16040

19863

3308 3457 35894996

2442 1773 20483538 2559

5339

8101

1342 330 69 25 5 6 6 1 1 20

10000

20000

30000

40000

50000

60000

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Comparison of Malaria Cases & No. of Blood Films Taken - Badulla District(Only Local Cases From 2003 to 2010 )

No. of BF Taken Possitives

No. of Blood films Taken YEAR Badulla

1998 386701999 449152000 530842001 356162002 410472003 338572004 313422005 238092006 229342007 314012008 19773

YEAR Badulla2009 160402010 198632011 14193

APCD - PGH/BH/DH

PCD - Blood Banks

ACD - Mobile Clinics

ACD - Maternity Clinics

ACD - VSU0

2000

4000

6000

8000

10000

12000

2619

10930

5520

983185

1854

8566

3773

0 0

2010 2011

Comparison of Blood Films Taken - Badulla District - 2010 & 2011

PGH - Badulla

DH - Gira

ndurukotte

BH - Diyath

alawa

DH - Kandaketiya

BH - Mahiyangana

DH - Meegahakiula

DH - Uraniya

RH - Ekiriy

ankumbura

CD - Dambana

DH - Haldummulla

BH - Welim

ada0

200

400

600

800

1000

1200

1400

944

44 34 5

1388

17 19 0 0

168

02 0 1 0 4 0 0 0 0 0 01 1 1 1 1 1 1 0 1 1 11 0 0 1 0 0 0 0 0 0 0

No. Blood Films No. +ves No. PHLT Available No. PHFO Available

Blood Films Taken by APCD Centres - 2010

PGH - Badulla

DH - Gira

ndurukotte

BH - Diyathalawa

DH - Kan

daketiya

BH - Mahiya

ngana

DH - Meegah

akiula

DH - Uraniya

RH - Ekir

iyankumbura

CD - Dam

bana

DH - Haldummulla

BH - Welim

ada0

200

400

600

800

1000

1200

1400

570

38129

1

711

21

384

0 0 0 01 0 1 0 2 0 0 0 0 0 01 1 1 1 1 1 1 0 1 1 11 0 0 1 0 0 0 0 0 0 0

No. Blood Films No. +ves No. PHLT Available No. PHFO Available

Blood Films Taken by APCD Centres - 2011

0

2000

4000

6000

8000

10000

1200011376

20791143 1129 330

2491548 50 853 2382 0 0 1 0 4 0 0 0 0

No. of Blood Films No. of Positives

2010

Badulla

Giranduruko

tte

Haldummulla

Haputale

Kandake

tiya

Mahiyangana

Meegahakiu

la

Rideemaliyadda

Welimad

a0

2000

4000

6000

8000

10000

12000

7531

674 483 1090180

2137395

14792241 0 0 1 0 2 0 0 0

No. of Blood Films No. of Positives

2011

No. of Blood Films Taken & No. of Positives by MOH Area - 2010

PGH - Badulla Blood Bank -Badulla GFATM - Mobile Clinics0

2000

4000

6000

8000

10000

12000

944

10104

328570

6961

0

2010 2011

COMPARISON OF BLOOD FILMS TAKEN - MOH AREA BADULLA - 2010 & 2011

DH - Girandurukotte GFATM - Mobile Clinics Maternity Clinics 0

200

400

600

800

1000

1200

44

1052983

38

636

0

2010 2011

COMPARISON OF BLOOD FILMS TAKEN - MOH AREA GIRANDURUKOTTE - 2010 & 2011

DH - Haldummulla GFATM - Mobile Clinics VSU - Kirawanagama0

100

200

300

400

500

600

700

800

168

790

185

0

483

0

2010 2011

COMPARISON OF BLOOD FILMS TAKEN - MOH AREA HALDUMMULLA - 2010 & 2011

BH - Diyathalawa Blood Bank -Diyathalawa GFATM - Mobile Clinics0

100

200

300

400

500

600

700

800

900

1000

34

826

269

129

907

54

2010 2011

COMPARISON OF BLOOD FILMS TAKEN - MOH AREA HAPUTALE - 2010 & 2011

DH - Kandaketiya GFATM - Mobile Clinics0

50

100

150

200

250

300

350

5

325

1

179

2010 2011

COMPARISON OF BLOOD FILMS TAKEN - MOH AREA KANDAKETIYA - 2010 & 2011

BH - Mahiyangana Blood Bank - Mahiyangana GFATM - Mobile Clinics0

200

400

600

800

1000

1200

1400

1388

0

1103

711 698 728

2010 2011

COMPARISON OF BLOOD FILMS TAKEN - MOH AREA MAHIYANGANA - 2010 & 2011

DH - Meegahakiula GFATM - Mobile Clinics0

100

200

300

400

500

600

17

531

21

374

2010 2011

COMPARISON OF BLOOD FILMS TAKEN - MOH AREA MEEGAHAKIULA - 2010 & 2011

GFATM - Mobile Clinics0

5

10

15

20

25

30

35

40

45

50

50

0

2010 2011

COMPARISON OF BLOOD FILMS TAKEN - MOH AREA PASSARA - 2010 & 2011

DH - Uraniya GFATM - Mobile Clinics0

200

400

600

800

1000

1200

19

834

384

1095

2010 2011

COMPARISON OF BLOOD FILMS TAKEN - MOH AREA RIDEEMALIYADDA - 2010 & 2011

GFATM - Mobile Clinics0

50

100

150

200

250

238

0

2010 2011

COMPARISON OF BLOOD FILMS TAKEN - MOH AREA SORANATOTA - 2010 & 2011

GFATM - Mobile Clinics0

50

100

150

200

250

0

224

2010 2011

COMPARISON OF BLOOD FILMS TAKEN - MOH AREA WELIMADA - 2010 & 2011

PGH - Badulla

BH - Diyathalawa

BH - Mahiya

ngana

0

2000

4000

6000

8000

10000

12000 10104

826 00 0 0

No. Blood Films No. +ves

2010

Blood Films Taken by PCD Centres (Blood Banks)

PGH - Bad

ulla

BH - Diyathalawa

BH - Mahiya

ngana

0

2000

4000

6000

8000

10000

12000

6961

907 6980 0 0

No. Blood Films No. +ves

2011

Badulla

Giranduruko

tte

Haldummulla

Haputale

Kandak

etiya

Mahiyanga

na

Meegahakiu

la

Passara

Rideemaliya

dda

Soran

atota0

500

1000

1500

2000

2500

328

2035

975

269 325

1103

531

50

834

2380 0 0 0 0 0 0 0 0 0

No. Blood Films No. +ves

2010

Giranduruko

tte

Haldummulla

Haputale

Kandak

etiya

Mahiya

ngana

Meegahakiu

la

Rideemaliya

dda

Welim

ada

0

500

1000

1500

2000

2500

636483

54 179

728

374

1095

2240 0 0 0 0 0 0 0

No. Blood Films No. +ves

2011

ACD by MOH Area

Diagnostic tools – 1.Microscopy

2.Rapid diagnostic tests – Malaria RDTs, also known as Dipsticks or Malaria Rapid Diagnostic Devices (MRDDs), have potential to greatly improve the quality of management of malaria infections in these areas when the main alternative form of diagnosis, high quality microscopy, is not readily available.

General test procedure of RDTs capable of detecting all 4 species

Negative

C

P.f. positive (pure or mixed)

Pv

22

1 1

2

1

CC

Pf

RDT Kit

New Malaria Treatment Guidelines

PV-MONO INFECTION OBJECTIVE -Early radical cure

CQ - 10 mg /kg - D1

10mg / kg - D2

5mg / kg - D3

PQ - 0.25mg /kg Daily.; 14 days

Pf-UNCOMPLICATED MONO INFECTION OBJECTIVE - Early radical cure

Artemisinin based combination Therapy (ACT) ACT - according to body weight

-In SL – Coartem ( Artemether

20 mg + Lumefantrine 120 mg )

PQ - 0.75mg /kg Single Dose – D3

Treatment - P.f malaria

Number of Coartem Tablets to be administered5- 15kg (Yellow Pack)

15 – 25kg (Blue Pack)

25 – 35kg (Orange pack)

Over 35kg(Green pack)

0 Hours 1 2 3 4

8 Hours 1 2 3 4

24 Hours 1 2 3 4

36 Hours 1 2 3 4

48 Hours 1 2 3 4

60 Hours 1 2 3 4

Total 6 12 18 24

UNCOMPLICATED MIX INFECTION OBJECTIVE - Early radical cure

ACT - according to body weight

- SL – Coartem ( Artemether

20 mg + Lumefantrine 120 mg )

PQ - 0.25mg /kg 14 days

SEVERE - COMPLICATED Pf INFECTION IV – Quinine 10 mg / kg 8 hourly

- ACT

- PQ - 0.75mg /kg single dose

SEVERE - COMPLICATED MIX INFECTION IV – Quinine 10 mg / kg 8 hourly

- ACT

- PQ - 0.25mg /kg 14 days

IN PREGNANCY PV-MONO INFECTION

OBJECTIVE -Clinical cure CQ - 10 mg /kg - D1

10mg / kg - D2 5mg / kg -

D3 PQ - After 6 weeks of delivery

(0.25mg /kg Daily.; 14 days )

Pf MONO INFECTION in Pregnancy T1 - Quinine 10 mg /kg 8 hourly 7 days T2 & T3 - Coartem

PQ - After 6 weeks of delivery Single dose (0.75mg /kg )

COMPLICATED SEVERE Pf INFECTION T1 - Iv Quinine 10 mg /kg 8 hourly - Oral Quinine 7 days T2 & T3 - Iv Quinine 10 mg /kg 8 hourly - Coartem

PQ - After 6 weeks of delivery Single dose (0.75mg /kg )

INFANTS CQ - Can be given

PQ - After 01 year Quinine & IV Quinine can be given Coartem – body weight more than 5 kg

Prevention

• Chloroquine :-– 300 mg (02 tabs) weekly ( 02 weeks Prior to visit,

through out the stay , 04 weeks after )• Meflaquine :-

– 250 mg (01 tab) weekly ( 01 week prior to visit, through out the stay , 04 weeks after )

# maximum for 06 months

Prophylaxis

Selective vector control methods

Larval control

Source reductionThrough permanent environmental

modification, e.g. permanent drainage system;

Through repetitive environmental measures e.g. intermittent irrigation during drought season

Larval controlLarviciding (killing the larvae)

Synthetic larvicides, e.g. temephos (abate)Eg :Water pooling during drought

Biological, e.g. by using larvivorous fish. Eg abandoned agricultural wells, Rock pools

Provincial fish tanks supply larvivorous fish

Laval control

• Application of hormone – Insect growth regulatory hormone -Pyriproxyfen for gem pits.

Use of Larvivorous fish in malaria control

Species used as larvivorous fish 1 Guppy Poecilia reticulata .mams

2 Top minnow Aplocheilus sp k, y|hd

3 Tilapia O. mossambicus cmka fldr,s

O. niloticus f;mams,s

4 Danio Danio sp okafld, id,hd

5 Common Rasbora R. daniconius oKaä

6 Mosquito fish Gambusia affinis

Entomological surveillance

Year No. of Survey days

2006 1292007 1382008 1022009 1852010 1132011 176

Entomological Data

129138

102

185

152

176

0

20

40

60

80

100

120

140

160

180

200

2006 2007 2008 2009 2010 2011

No. of Survey days of Entomological Team

Control of malaria in migrant population

Prophylaxis treatment according to the WHO guidelines.

Community participation

One of the outstanding feature of malaria control in Sri Lanka is community participation.

Community participation

Example: - the impregnation of bed nets, follow up

visits; - Cleaning programmes - Correct irrigation practices to minimize vector breeding.

Health Education

Village level seminars Advocacy programmes Clinician awareness programmes

Thank you