DDT ALTERNATIVES FOR MALARIA CONTROL IN INDIA R.S.SHARMA rssharmanamp@gmail.com National Vector Borne Disease Control Programme Directorate General of Health Services Ministry of Health & Family Welfare Government of India 1
NATIONAL HEALTH POLICY GOALS FOR VBDs VECTOR BORNE DISEASES IN INDIA Reduction of mortality on account of malaria, dengue and Japanese Encephalitis by 50% by 2010 and efficient morbidity control Elimination of Visceral leishmaniasis (Kala-azar) by 2010 Elimination of Lymphatic Filariasis by 2015 MALARIA About 2 million cases annually LYMPHATIC FILARIASIS Endemic in 250 districts with about 525 million population KALA AZAR (VL) Endemic in 4 states in 52 districts. JAPANESE ENCEPHALITIS Widespread viral activity with occurrence of outbreaks DENGUE FEVER and CHIKUNGUNYA - Wide spread with frequent occurrence of outbreaks 2
MALARIA CONTROL IN INDIA SIGNIFICANT DEVELOPMENTS 1953 - Estimated Malaria Cases in India 75 Million Estimated Deaths Due to Malaria 0.8 Million Launching of National Malaria Control Programme (NMCP) 1958 - Launching of National Malaria Eradication Programme (NMEP) 1966 - Cases Reduced to 0.1 Million Early 70 s - Resurgence of Malaria 1976 -Malaria Cases 6.46 Million and 59 Deaths 1977 - Modified Plan of Operations Introduced 1977 - Pf Monitoring Team - Parasite Sensitivity of anti-malarials 1981- National Drug policy for Treatment of Malaria cases Introduced 1984 - Annual Malaria Incidence Reduced to 2.2. Million Cases 1984-1998 - Annual Reported Incidence Within 2-32 3 Million Cases 1994 - Resurgence / Emergence of Malaria outbreaks in Some States 1995 - Expert Committee on Malaria 1997 - World Bank Assisted Enhanced Malaria Control Project 2004 -Introduction of ACT for Pf cases in drug resistance areas 2005 ( July) GFATM- IMCP- (106 districts of 10 states ) 2007- Revised National Drug policy 2007-1.48 Million malaria CASES 2008-World Bank Assisted Malaria Control Project 3
MALARIA VECTORS IN INDIA DIRUS STEPHENSI MINIMUS CULICIFACIES PHILIPPINENSIS SUNDAICUS FLUVIATILIS FLUVIATILIS 4
MALARIA ENDEMIC AREAS PERCENT CONTRIBUTION OF POPULATION, MALARIA CASES, PF CASES AND DEATHS (Compared to the country total) States % Popula tion % Malaria cases % Pf cases % Death API 0-2 2-5 5-10 >10 N.E. States Other high endemi c states 4 7 9 19 43 69 81 56 Maximum malaria cases from six states Orissa, Jharkhand, Chhattisgarh, Madhya Pradesh, West Bengal and the States in the North-East. 5
MALARIA SITUATION IN INDIA (2001-2007) 2007) 2500000 1800 1600 Nos 2000000 1500000 1000000 500000 1400 1200 1000 800 600 400 200 0 2001 2002 2003 2004 2005 2006 2007 Year Total Cases Pf Cases Deaths 0 Year Total Cases Pf Cases Deaths 2001 2085484 1005236 1005 2002 1841229 897446 973 2003 1869403 857101 1006 2004 1915363 890152 949 2005 1816569 805077 963 2006 1785109 838555 1708 2007 1476562 725502 1173 6
MAGNITUDE OF URBAN MALARIA PROBLEM-2007 Country Level Population (in million) Total Cases Pf. Cases Deaths Country total 1084.0 1476562 725502 1173 All 131 UMS towns 112.0 (10.3%) 108573 (7.3%) 18262 (2.5%) 103 (8.7%) Problematic towns (27) 54.60 (48.7%) 95615 (88.0%) 17288 (94.6%) 100 (97.0%) UMS Urban Malaria Scheme (with >50 thousand population 7
% CONTRIBUTION OF MALARIA CASES BY CHENNAI CORP COMPARED TO TOTAL CASES IN THE STATE Chennai corp., 67.73 100 Rest of the state, 32.27 Water harvesting large scale 50 0 1 8
JUDICIOUS USE & SELECTION OF VECTOR CONTROL IN INDIA Chemical Control Environment Management Biological Control Legislative Control INTEGRATED VECTOR MANAGEMENT An Evidence-based decision making process, rationalizing the use of vector control methods and emphasizing the engagement of communities 9
STRATEGY FOR URBAN MALARIA Vector Control: Shift in control strategy from macro to micro level: The proposed strategy is evidence based and paradigm specific. The common paradigms are (i) city centre, (ii) peri-urban, (iii) construction sites, (iv) industrial estates and (v) market places (floating population). Application of the tools in integrated vector management (IVM) mode in synergy. Component includes: Source reduction Use of larvicides Use of larvivorous fish Space spray Minor engineering Legislative measure 10
INTEGRATED VECTOR MANAGEMENT (Insecticide Treated Bed Nets) N o s o f n e t s 4000 3500 3000 2500 2000 1500 1000 500 0 Coverge of IRS (in 000s) 3775 3490 2500 1200 60 175 90 230 40 1998-99 1999-00 2000-01 2001-02 2002-03 2003-04 2004-05 2005-06 2007-08* Years *Proposed Bed nets are supplied to high risk areas. Priority beneficiaries - Below Poverty Line population in rural tribal areas. Involvement of civil society organizations are encouraged. Modalities for social marketing through public-private partnership initiated. Surveys are carried out for assessing community owned bed nets for organization of insecticide treatment camps. 11
LONG LASTING INSECTICIDE NETS 1. Olyset (Sumitomo): Temporary registration by Central Insecticide Board for import of 6 million LLIN,s for data generation with commercial use. 2. Interceptor (BASF): Temporary registration by Central Insecticide Board for import of 6 million LLIN,s with commercial use 3. Permanent (Vestergarrd). Temporary registration by Central Insecticide Board for import of 6 million LLIN,s with commercial use 1.2 million LLIN,s under GFATM Project 12
IVM (LARVIVOROUS FISH) Promotion of use of larvivorous fish as costeffective, environment-friendly vector control option. Emphasis on perennial natural water bodies as hatcheries due to climatic conditions. Involvement of civil society organizations. 2203 district level and 19023 Block/PHC level hatcheries established. Gambusia affinis Poecilia reticulata (GUPPY) 13
INTEGRATED VECTOR MANAGEMENT (IVM) INDOOR RESIDUAL SPRAYING Insecticide wise population targeted for spray during the past 7 years 80000000 70000000 60000000 50000000 40000000 30000000 20000000 10000000 0 2001 2002 2003 2004 2005 2006 2007 DDT Malathion Syn. Pyrethroids DDT, Malathion, Synthetic Pyrethroids used for Indoor Residual Spraying selectively only in high risk pockets Overall shift from indoor residual spraying to a broader mix of vector control measures 14
Kiloliters 80 60 40 20 0 Quantities of insecticides procured for use as larvicides (2003-2007) 3.5 0.5 61.97 42 59.5 50 44.6 2003 2004 2005 2006 2007 51 Fenthion EC 82.5 Temephos EC 50 70 0 KL/MT Quantities of insecticides procured by NVBDCP for use in space sprayig (2003-2007) 150 100 50 0 110 67 30 73 20 50 0 25 44 26 2003 2004 2005 2006 2007 Malathion (Tech) Pyrethrum Ext. 2% Quantities of insecticides procured by NVBDCP for use in Indoor Residual Spray (2003-2007) MT 2500 2000 1500 1000 500 0 2136 673 477 600 257 637 50 350 406 45 2003 2004 2005 2006 2007 Malathion 25% WDP Synthetic Pyre. 15
HEALTHY PUBLIC POLICIES FRAMING AND INTRODUCING MODEL CIVIC BYE-LAWS AND BUILDING BYE-LAWS FOR PREVENTION AND CONTROL OF VECTOR BREEDING LEGISLATION Model Civic Bye-laws: Promulgation and implementation with provision to prevent /eliminate mosquito breeding in urban towns i.e. Mumbai,Chennai,Delhi, Kolkata, Chandigarh, Bhopal, Agartala, Nagpur etc. Building Bye-laws: Provision to prevent mosquitogenic conditions on the exterior of the buildings and clauses in the contract to keep curing tanks free of mosquito breeding during construction phase and dismantling of the same before issuance of occupancy certificate like Navi Mumbai Completion certificate to be issued subjected to above 16
ENVIRONMENTAL MANAGEMENT India developed high expertise in Environmental Engineering of Malaria control in Pre-DDT era 1917- Cantonments Mian Mir Lahore (Now in Pakistan)-Screening of houses 1928- Bombay Malaria Control by Legislative Measures 1930- Tea garden in Assam Canalization, Shading etc. of An. minimus 1936- Delhi Cantonment Filling of riverine land of Jamuna river adjacent Red fort then at a cost of Rs,2.5 million Currently Health Impact Assessment (HIA) has made mandatory for river development projects Implemented in Upper Krishna irrigation project in Karnataka and Sarda Sarovar Irrigation- Gujarat funded by WB. 17
SOURCE REDUCTION THROUGH ENVIRONMENTAL MANAGEMENT SABARMATI RIVER S S CHANGING SCENARIO Intervention:Channelization Narmada Fed Sabarmati 18
INFORMATION, EDUCATION AND COMMUNICATION (AWARENESS & KNOWLEDGE) 19
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COMMUNITY PARTICIPATION 21
MONITORING OF RESISTANCE IN INDIA CRITERIA FOR CHANGE OF INSECTICIDE- Resistance supported by Epidemiological evidence- Epidemiological failure Resistant to DDT DDT and Malathion Alternative insecticide Malathion Synthetic Pyrethroids 22
MONITORING OF INSECTICIDES RESISTANT MAP - 2007 Not Not Tested DDT DDT Resistant susceptible (<40%) Mal. DDT Resistant Syn. Malathion Pyr. Resistant 72 72 ENTOMOLGICAL TEAMS, ICMR institutions (RMRC/NIMR) carry out Entomological Studies periodically. 23
NEW INITIATIVES Introduction of Rapid Diagnostic Kits (RDK) Introduction of Artesunate Combination Therapy (ACT) Introduction of Long Lasting Insecticide Nets (LLINs) & Up scaling up of bed nets Focused intervention in 63 districts GIS mapping for focused IRS Intensified supervision and monitoring of programme implementation especially spraying Micro action plan for highly endemic NE states Technical Human Resource VBDC, MTS, LT, MPWs (M) ASHAs will be involved THANK YOU 24