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National Health Mission (NHM) - Park's Textbook of Preventive and Social Medicine

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1. OVERVIEW

• NHM replaced and subsumed earlier vertical programmes
• Has two sub-missions: NRHM and NUHM
• Achieved reduction in out-of-pocket expenses from 72% to 60%

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2. STRUCTURE OF NHM - FLOW CHART

                    ┌─────────────────────────────────────────┐
                    │       NATIONAL HEALTH MISSION (NHM)      │
                    │         (Approved May 2013)              │
                    └──────────────┬──────────────────────────┘
                                   │
               ┌───────────────────┴────────────────────┐
               │                                        │
   ┌───────────▼──────────────┐          ┌─────────────▼──────────────┐
   │  NATIONAL RURAL HEALTH   │          │  NATIONAL URBAN HEALTH     │
   │     MISSION (NRHM)       │          │     MISSION (NUHM)         │
   │   (Launched: Apr 2005)   │          │   (Launched: 2013)         │
   └───────────┬──────────────┘          └─────────────┬──────────────┘
               │                                       │
      ┌────────┴─────────┐                    ┌────────┴─────────┐
      │ Focus: 18 States │                    │ Focus: 779 cities│
      │ (8 EAG + 8 NE +  │                    │ with pop >50,000 │
      │  HP + J&K)       │                    └──────────────────┘
      └──────────────────┘

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3. PROGRAMMATIC COMPONENTS OF NHM

┌─────────────────────────────────────────────────────────────────┐
│                 PROGRAMMATIC COMPONENTS OF NHM                  │
├────────────────────┬───────────────────────┬────────────────────┤
│  Health System     │   RMNCH+A             │  Disease Control   │
│  Strengthening     │  (Reproductive-       │  Programmes        │
│  (Rural + Urban)   │   Maternal-Newborn-   │                    │
│                    │   Child-Adolescent    │  • Communicable    │
│  • Infrastructure  │   Health)             │  • Non-            │
│  • HR development  │                       │    communicable    │
│  • Untied funds    │                       │                    │
└────────────────────┴───────────────────────┴────────────────────┘

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4. HISTORICAL MILESTONES (Timeline)

1992 ──► CSSM (Child Survival & Safe Motherhood Programme)
   │
1997 ──► RCH I (Reproductive & Child Health Programme)
   │
2005 ──► RCH II
   │
2005 ──► NRHM (National Rural Health Mission) - April 5
   │
2013 ──► RMNCH+A Strategy launched
   │
2013 ──► NHM (National Health Mission) - May 2013
   │
2014 ──► INAP (India Newborn Action Plan)
   │
2018 ──► Ayushman Bharat Programme

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5. NATIONAL RURAL HEALTH MISSION (NRHM)

5a. Launch & Coverage

• Launched: 5th April 2005 for 7 years (2005-2012), extended to 2017
• Special focus on 18 states: 8 EAG states + 8 NE states + HP + J&K

5b. Main Aim

Provide accessible, affordable, accountable, effective and reliable primary health care; bridge gap through ASHA cadre

5c. Plan of Action - Infrastructure Strengthening

┌─────────────────────────────────────────────────────────────────┐
│             INFRASTRUCTURE STRENGTHENING UNDER NRHM             │
└───────┬─────────────────────────────────────────────────────────┘
        │
        ├── 1. Create ASHA cadre (1 per 1000 population)
        │
        ├── 2. Strengthen Sub-Centres
        │       ├── Essential drugs (allopathic + AYUSH)
        │       ├── MPW (male) / additional ANMs
        │       └── Untied funds: Rs. 10,000/annum (18 states)
        │
        ├── 3. Strengthen PHCs
        │       ├── Essential drugs + equipment
        │       ├── 24×7 service in ≥50% PHCs (with AYUSH)
        │       ├── Standard treatment guidelines
        │       └── Upgradation for 24-hour services
        │
        ├── 4. Strengthen CHCs (District Hospitals)
        │       └── Specialist services
        │
        └── 5. Public-Private Partnership (PPP) for RCH II

5d. Major Initiatives under NRHM (Point-wise)

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6. NATIONAL URBAN HEALTH MISSION (NUHM)

6a. Objective

6b. Coverage

• All state capitals + district HQs + ~779 cities/towns with pop ≥50,000 (Census 2011)
• Cities below 50,000 population covered by NRHM

6c. Target Groups

┌──────────────────────────────────────────────────┐
│            NUHM TARGET GROUPS                    │
├──────────────────────────────────────────────────┤
│ 1. Urban poor in listed/unlisted slums           │
│ 2. Homeless, rag-pickers, street children        │
│    Rickshaw pullers, construction workers        │
│    Brick/lime-kiln workers, sex workers          │
│    Temporary migrants                            │
│ 3. Public health - sanitation, water, vector     │
│    control                                       │
│ 4. Strengthening urban local bodies (ULBs)       │
└──────────────────────────────────────────────────┘

6d. Service Delivery Structure under NUHM

          COMMUNITY (Outreach)
                ↓
        ASHA / Link Worker
     (1 per 1000-2500 urban poor)
                ↓
    ┌───────────────────────────┐
    │  Mahila Arogya Samiti     │  ←── Rs. 5,000/year grant
    │  (MAS) - 50-100 HH       │
    └───────────────────────────┘
                ↓
    ┌───────────────────────────┐
    │  URBAN PHC (U-PHC)        │  ← First point of service
    │  (served by ANM/FHW)      │
    └───────────────────────────┘
                ↓
    ┌───────────────────────────┐
    │  URBAN CHC (U-CHC)        │  ← Specialist referral centre
    └───────────────────────────┘
                ↓
    ┌───────────────────────────┐
    │  7 Metro Cities           │  ← Managed by Municipal Corp
    │  (Mumbai, Delhi, Chennai, │
    │  Kolkata, Hyderabad,      │
    │  Bengaluru, Ahmedabad)    │
    └───────────────────────────┘

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7. KEY INTERVENTIONS UNDER NHM (to reduce IMR & MMR)

NHM INTERVENTIONS
│
├── MATERNAL HEALTH
│   ├── Janani Suraksha Yojana (institutional delivery)
│   ├── JSSK (free delivery + free transport)
│   ├── 24×7 obstetric care at SC/PHC/CHC/DH
│   ├── Name-based web tracking of pregnant women (MCTS)
│   ├── Mother & Child Protection Card
│   └── ANC with IFA supplementation
│
├── NEWBORN/CHILD HEALTH
│   ├── SNCUs, NBSUs, NBCCs (facility-based newborn care)
│   ├── HBNC (Home-Based Newborn Care) through ASHA
│   ├── NSSK, IMNCI, FBNC, IYCF trainings
│   ├── INAP (India Newborn Action Plan - 2014)
│   ├── RBSK (Rashtriya Bal Swasthya Karyakram) - 0-18 yrs
│   ├── NRCs for severe acute malnutrition
│   └── IDCF & IAPPD for diarrhoea/pneumonia
│
├── IMMUNIZATION
│   ├── Universal Immunization Programme (UIP)
│   ├── Mission Indradhanush (528 high-focus districts)
│   └── National Iron Plus Initiative (NIPI)
│
└── DISEASE CONTROL (Integrated into NRHM)
    ├── NVBDCP (malaria, filaria, kala-azar, dengue, JE)
    ├── NLEP (leprosy)
    ├── RNTCP (tuberculosis)
    ├── NPCB (blindness)
    ├── IDD Control
    └── IDSP (surveillance)

---

8. NHM TARGETS vs ACHIEVEMENTS (12th Five Year Plan, 2012-17)

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9. ASHA - KEY ROLE IN NHM (Flow of Services)

COMMUNITY
    │
    ▼
ASHA (Accredited Social Health Activist)
    │  ↑ Selection: Resident woman, 25-45 yrs, ≥8th std
    │  ↑ Norm: 1 per 1000 pop (relaxed in tribal/hilly/desert areas)
    │
    ├── Promotes: Institutional delivery, ANC, immunization
    ├── Facilitates: RCH services, contraception counselling
    ├── Refers: High-risk pregnancies, sick newborns
    ├── Distributes: ORS, IFA tablets, OCP
    ├── Conducts: HBNC visits for newborns
    └── Links: Community ↔ Health System (PHC/CHC)

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10. SUMMARY FLOW CHART - NHM COMPLETE STRUCTURE

┌──────────────────────────────────────────────────────────────┐
│                   NATIONAL HEALTH MISSION                    │
│              Ministry of Health & Family Welfare             │
└──────────────────────┬───────────────────────────────────────┘
                       │
       ┌───────────────┴──────────────┐
       │                              │
┌──────▼──────┐               ┌──────▼──────┐
│    NRHM     │               │    NUHM     │
│  (Rural)    │               │  (Urban)    │
└──────┬──────┘               └──────┬──────┘
       │                             │
  ┌────┴────┐                   ┌────┴────┐
  │ ASHA    │                   │ ASHA /  │
  │ VHSNC  │                   │  MAS    │
  │ RKS     │                   │  RKS    │
  └────┬────┘                   └────┬────┘
       │                             │
  ┌────▼────┐                   ┌────▼────┐
  │  PHC    │                   │ U-PHC   │
  └────┬────┘                   └────┬────┘
       │                             │
  ┌────▼────┐                   ┌────▼────┐
  │  CHC    │                   │ U-CHC   │
  └────┬────┘                   └────┬────┘
       │                             │
  ┌────▼────┐                   ┌────▼──────────┐
  │District │                   │ Metro City    │
  │Hospital │                   │ (Mun. Corp.)  │
  └─────────┘                   └───────────────┘
       │
       └── Integrated Disease Control Programmes:
           NVBDCP | NLEP | RNTCP | NPCB | IDSP | IDD

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Key takeaway from Park: NHM is the "overarching umbrella" that merges NRHM and NUHM, integrating vertical disease programmes with a community-based approach through ASHA, and focusing on RMNCH+A as its core health delivery strategy.

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Filariasis & Kala-Azar Elimination Programmes

Park's Textbook of Preventive and Social Medicine

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PART A: LYMPHATIC FILARIASIS

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1. CAUSATIVE AGENTS

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2. GLOBAL BURDEN

• Affects 49 countries in tropics/subtropics of Africa, Asia, Western Pacific, Americas
• 893 million people at risk; 120 million infected
• 15 million with lymphoedema; 25 million men with urogenital swelling (hydrocele)
• At least 36 million with chronic manifestations

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3. PROBLEM IN INDIA

┌────────────────────────────────────────────────────────────────┐
│              FILARIASIS BURDEN IN INDIA                       │
├────────────────────────────────────────────────────────────────┤
│ At-risk population  : 650 million people                      │
│ Endemic districts   : 257 districts in 16 states + 5 UTs     │
│ Lymphoedema cases   : 9.21 lakh                               │
│ Hydrocele cases     : 3.96 lakh                               │
│ Heavily affected states:                                      │
│  UP, Bihar, Jharkhand, Andhra Pradesh, Odisha,                │
│  Telangana, Maharashtra, West Bengal                          │
└────────────────────────────────────────────────────────────────┘

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4. LIFE CYCLE (Flow Chart)

                    MOSQUITO BITES HUMAN
                           │
                    Takes up Microfilariae (Mf)
                           │
               ┌───────────▼───────────┐
               │     IN MOSQUITO       │
               │  Mf exsheaths in gut  │
               │  → L1 (sausage form)  │
               │  → L2 (alimentary     │
               │         canal forms)  │
               │  → L3 INFECTIVE LARVA │
               │  (migrates to proboscis)│
               │ Extrinsic incubation  │
               │  period = 10-14 days  │
               └───────────┬───────────┘
                           │ Mosquito bites
                           ▼
               ┌───────────────────────┐
               │      IN HUMAN         │
               │  L3 → Adult worms     │
               │  (in lymphatic vessels)│
               │  ♀ 50-100 mm long     │
               │  ♂ ~40 mm long        │
               │  Produce 50,000 Mf/day│
               │  Adult worms live     │
               │  15+ years            │
               └───────────┬───────────┘
                           │
                  Mf circulate in blood
                  (nocturnal periodicity)
                           │
                  Mosquito picks up Mf
                  → Cycle continues

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5. DISEASE MANIFESTATIONS

LYMPHATIC FILARIASIS MANIFESTATIONS
│
├── A. ASYMPTOMATIC (most common)
│
├── B. ACUTE MANIFESTATIONS
│   ├── Lymphangitis (retrograde)
│   ├── Lymphadenitis
│   ├── Epididymo-orchitis
│   └── Filarial fever
│
├── C. CHRONIC MANIFESTATIONS
│   ├── Lymphoedema / Elephantiasis
│   │   (legs > scrotum > arms > penis > vulva > breasts)
│   ├── Hydrocele (commonest in Bancroftian)
│   └── Chyluria
│
└── D. OCCULT FILARIASIS
    └── Tropical Pulmonary Eosinophilia (TPE)
        (hypersensitivity to Mf antigens)

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6. DIAGNOSIS

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7. NATIONAL FILARIA CONTROL PROGRAMME - CONTROL STRATEGY

┌──────────────────────────────────────────────────────────┐
│         NATIONAL FILARIA CONTROL PROGRAMME               │
│              (UNDER NVBDCP/NHM)                          │
└────────────────────────┬─────────────────────────────────┘
                         │
          ┌──────────────┴───────────────┐
          │                              │
┌─────────▼──────────┐         ┌────────▼──────────────┐
│  MASS DRUG         │         │  VECTOR CONTROL        │
│  ADMINISTRATION    │         │                        │
│  (MDA)             │         │  Urban areas:          │
│                    │         │  Antilarval measures   │
│ DEC + Albendazole  │         │  (3km peripheral belt) │
│ (single dose,      │         │                        │
│  annually)         │         │  Rural areas:          │
│ For 4-6 years      │         │  Indoor residual spray │
│ ≥65% coverage of   │         │                        │
│ total population   │         │                        │
│ Target: Mf rate    │         │                        │
│ reduced to <1%     │         │                        │
└────────────────────┘         └───────────────────────┘

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8. MDA REGIMEN (Point-wise)

1. Drug combination: DEC (diethylcarbamazine) + Albendazole OR Ivermectin + Albendazole
2. Dose: Single annual dose
3. Duration: 4-6 rounds minimum (≥5 rounds per WHO)
4. Coverage target: ≥65% of total population
5. Goal: Reduce Mf prevalence to <1% to stop transmission
6. Global achievement: 6.7 billion treatments to ≥1 billion people since 2000 (~73% of at-risk population)

---

9. VECTOR CONTROL MEASURES (Filariasis)

ANTI-LARVAL MEASURES (Urban + 3km belt)
│
├── CHEMICAL CONTROL
│   ├── Mosquito larvicidal oil (MLO)
│   ├── Pyrosene oil-E (pyrethrum-based)
│   └── Organophosphorus larvicides (temephos, fenthion)
│       → Applied weekly to all breeding places
│
├── BIOLOGICAL CONTROL
│   └── Larvivorous fish (Gambusia, Lebistes)
│
├── REMOVAL OF PISTIA PLANT
│   └── (for Mansonia mosquitoes - breaks aquatic breeding)
│
└── MINOR ENGINEERING MEASURES
    └── Filling drains, converting pits, sanitation improvement

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10. MORBIDITY MANAGEMENT (Lymphoedema)

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11. ASSESSMENT PARAMETERS

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PART B: KALA-AZAR (VISCERAL LEISHMANIASIS) ELIMINATION PROGRAMME

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1. AGENT, VECTOR, RESERVOIR

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2. ENDEMIC STATES IN INDIA

KALA-AZAR ENDEMIC DISTRICTS IN INDIA
│
├── BIHAR → 33 districts (Maximum burden)
├── JHARKHAND → 4 districts
├── WEST BENGAL → 11 districts
└── UTTAR PRADESH → 6 districts
    (+ sporadic cases in few other UP districts)

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3. CLINICAL FEATURES (Point-wise)

• Prolonged fever
• Splenomegaly + hepatomegaly
• Anaemia + weight loss
• Darkening of skin - face, hands, feet, abdomen (kala = black)
• Family history common
• High mortality if untreated

• Appears 1 to several years after apparent cure of VL
• Multiple nodular skin infiltrations (usually non-ulcerating)
• Parasites numerous in lesions (important reservoir!)
• Caused by L. donovani

---

4. DIAGNOSIS

DIAGNOSIS OF KALA-AZAR
│
├── 1. RDT (rK39 Rapid Diagnostic Test) ← MAINSTAY
│   ├── Recombinant k39 protein-based
│   ├── Immunochromatographic assay
│   ├── Result in 5 minutes
│   └── NOT for: relapse, reinfection, KA+HIV co-infection
│
├── 2. Parasitological (GOLD STANDARD)
│   ├── Splenic aspirate (most sensitive - 98%)
│   ├── Bone marrow aspirate (safer)
│   ├── Liver / lymph node biopsy
│   └── LD bodies (Leishman-Donovan bodies)
│
└── 3. Slit-Skin Smear (for PKDL)

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5. CASE DEFINITIONS

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6. ELIMINATION PROGRAMME - KEY STRATEGIES

┌────────────────────────────────────────────────────────────────┐
│        KALA-AZAR ELIMINATION STRATEGY (India)                  │
│  Target: <1 case per 10,000 population per block/sub-district  │
└───────────────────────┬────────────────────────────────────────┘
                        │
    ┌───────────────────┼────────────────────┐
    │                   │                    │
    ▼                   ▼                    ▼
┌───────────┐    ┌─────────────┐    ┌────────────────┐
│ ENHANCED  │    │  VECTOR     │    │ BEHAVIOUR      │
│ CASE      │    │  CONTROL    │    │ CHANGE +       │
│ DETECTION │    │             │    │ INTERSECTORAL  │
│ + TREATMENT│   │ IRS with    │    │ CONVERGENCE    │
│           │    │ Synthetic   │    │                │
│ rK39 RDT  │    │ Pyrethroids │    └────────────────┘
│ Miltefosine│   │ (replaced   │
│ LAMB      │    │  DDT)       │    ┌────────────────┐
└───────────┘    └─────────────┘    │ CAPACITY       │
                                    │ BUILDING +     │
                                    │ MONITORING +   │
                                    │ RESEARCH       │
                                    └────────────────┘

---

7. ACTIVE CASE SEARCH

• Frequency: Quarterly (upgraded from single annual search)
• Method: "Kala-Azar Fortnight" - door-to-door search by peripheral health workers + volunteers
• Case definition used for referral to treatment centres
• PKDL cases also searched and referred

---

8. TREATMENT GUIDELINES 2017 (First-Line Drugs)

TREATMENT OF KALA-AZAR (India Programme, 2017)
│
├── 1. Single Dose Liposomal Amphotericin B (LAMB)
│       ├── Route: IV infusion
│       ├── Dose: 10 mg/kg body weight
│       ├── ALL age groups: paediatric, pregnant, elderly
│       ├── WHO supplies free of cost
│       └── PREFERRED (single-dose, high efficacy)
│
├── 2. Miltefosine (Oral)
│       ├── Only ORAL drug available
│       ├── Duration: 28 days
│       ├── Given as DOT (Directly Observed Treatment)
│       ├── Contraindications: Pregnant & lactating women
│       │   + women refusing contraception during treatment
│       └── Dosing:
│           • >12 yrs, >25 kg: 100 mg/day in 2 divided doses
│           • >12 yrs, <25 kg: 50 mg once daily
│           • 2-11 yrs: 2.5 mg/kg once daily
│
└── 3. Amphotericin B deoxycholate (multiple doses)
        └── Used in selected/pilot districts

---

9. VECTOR CONTROL (Sandfly)

• Vector: Phlebotomus argentipes
• Main strategy: Indoor Residual Spray (IRS)
• Insecticide: DDT 1-2 g/sq.m (two rounds/year) originally; now replaced with synthetic pyrethroids (DDT resistance developing)
• Coverage: Human dwellings + animal shelters + resting places up to 6 feet from floor
• Fogging also used to eliminate sandflies

---

10. KEY ELIMINATION INDICATORS

DETECTION INDICATORS
├── Detection Rate (%) = New KA cases/year ÷ Total pop × 100
├── Treatment Completion Rate (%) = Patients completing full course ÷ All new cases starting treatment × 100
└── Vector Control Coverage (%) = Households protected ÷ Households at risk × 100

MONITORING CLINICAL OUTCOMES
├── Final Cure Rate (%) = Final cures ÷ Total started treatment × 100
├── Treatment Failure Rate (%) = (Non-response + Relapse + Deaths) ÷ Total started × 100
├── Loss to Follow-up Rate (%) = (Defaulters + Lost) ÷ Total started × 100
└── Mortality (%) = Deaths ÷ Total started treatment × 100

---

11. NATIONAL ROAD MAP - KALA-AZAR ELIMINATION

2014 (Sept 2) → Revised Total Eradication Strategy Launched
        │
        ▼
National Road Map (August 2014)
- Specific timeline
- Roles & responsibilities for states
- District-level vector-borne disease consultants
- Technical supervisors assigned
        │
        ▼
Key innovations introduced:
1. ICMR-developed Rapid Diagnostic Kit (rK39)
2. Single-dose LAMB treatment
3. Synthetic pyrethroids replacing DDT
4. Quarterly active case searches (Kala-azar Fortnights)
5. ASHA-linked incentive system

---

COMPARISON TABLE: Filariasis vs. Kala-Azar Elimination

---

---

National Vector Borne Disease Control Programme (NVBDCP)

Park's Textbook of Preventive and Social Medicine

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1. OVERVIEW

┌─────────────────────────────────────────────────────────────────┐
│         NATIONAL VECTOR BORNE DISEASE CONTROL PROGRAMME         │
│                        (NVBDCP)                                 │
├─────────────────────────────────────────────────────────────────┤
│  Nodal Agency  : Directorate of NVBDCP                         │
│  Under         : Ministry of Health & Family Welfare (NHM/NRHM)│
│  Responsible   : States - planning, implementation, supervision │
│  Diseases covered (6):                                          │
│   1. Malaria        4. Dengue Fever/DHF                        │
│   2. Filariasis     5. Chikungunya                             │
│   3. Kala-azar      6. Japanese Encephalitis (JE)              │
└─────────────────────────────────────────────────────────────────┘

---

2. THREE-PRONGED STRATEGY OF NVBDCP (Master Flow Chart)

┌──────────────────────────────────────────────────────────────────┐
│                  NVBDCP STRATEGY (3 Prongs)                      │
└─────────────────────────┬────────────────────────────────────────┘
                          │
      ┌───────────────────┼────────────────────┐
      ▼                   ▼                    ▼
┌──────────────┐   ┌─────────────────┐   ┌─────────────────────┐
│  PRONG 1     │   │  PRONG 2        │   │  PRONG 3            │
│  DISEASE     │   │  INTEGRATED     │   │  SUPPORTIVE         │
│  MANAGEMENT  │   │  VECTOR         │   │  INTERVENTIONS      │
│              │   │  MANAGEMENT     │   │                     │
│• Early case  │   │  (IVM)          │   │• BCC (Behaviour     │
│  detection   │   │                 │   │  Change Comm.)      │
│• Complete    │   │• IRS (Indoor    │   │• PPP (Public-       │
│  treatment   │   │  Residual Spray)│   │  Private Partner.)  │
│• Strengthen  │   │• ITNs/LLINs    │   │• Intersectoral      │
│  referral    │   │• Larvivorous    │   │  convergence        │
│  services    │   │  fish           │   │• Capacity building  │
│• Epidemic    │   │• Antilarval     │   │• Operational        │
│  preparedness│   │  measures       │   │  research           │
│• Rapid       │   │• Source         │   │• M&E + web-based    │
│  response    │   │  reduction      │   │  MIS                │
│              │   │• Minor env.     │   │• JE vaccination     │
│              │   │  engineering    │   │• MDA (filariasis)   │
└──────────────┘   └─────────────────┘   └─────────────────────┘

---

3. DISEASE-WISE PROGRAMME DETAILS

---

(A) MALARIA

Milestones (Historical Timeline)

Pre-1953 ─► 75 million cases; 0.8 million deaths
   │
1953 ──────► National Malaria CONTROL Programme (NMCP) launched
   │
1958 ──────► Changed to National Malaria ERADICATION Programme
   │         (spectacular early success)
   │
1965 ──────► Cases reduced to 0.1 million (historic low)
   │
1970s ─────► RESURGENCE begins
   │
1976 ──────► 6.46 million cases (worst resurgence)
   │
Later ─────► Modified Plan of Operation; Enhanced Malaria Control
   │         Project; integration into NVBDCP
   │
2016 ──────► National Framework for Malaria Elimination 2016-2030

Elimination Goal & Objectives (National Framework 2016-2030)

MALARIA ELIMINATION ROADMAP
│
├── GOAL: Eliminate malaria (ZERO indigenous cases) by 2030
│
├── BY 2022: Interrupt transmission in 26 states/UTs
│           (Category 1+2 states of 2014)
│
├── BY 2024: API <1 case per 1000 population in ALL States/UTs
│
├── BY 2027: Zero indigenous transmission in ALL States/UTs
│
└── BY 2030: Entire country → sustain zero indigenous cases
             for 3 consecutive years → apply for WHO certification

Classification of States/UTs for Malaria Elimination

High Burden States (Tribal Focus)

Special Strategy for P. vivax Elimination

India accounts for >50% of estimated P. vivax cases globally - unique challenge:

P. VIVAX CHALLENGES:
│
├── Hypnozoites (liver stage) → prolonged parasite lifespan, undetectable
├── RDTs less sensitive for P. vivax than P. falciparum
├── Radical treatment: 14-day primaquine needed (vs. 3 days for P. falciparum)
└── Longer incubation period

STRATEGY:
├── Expand bivalent RDTs + quality microscopy
├── Ensure compliance of 14-day primaquine (radical cure)
└── Target urban malaria: An. stephensi → antilarval measures

Surveillance

MALARIA SURVEILLANCE SYSTEM
│
├── ACD (Active Case Detection)
│   └── MPW/ANM → fortnightly house-to-house visits
│       → thick + thin blood smear on fever/history of fever
│       → dispatch to PHC lab twice/week
│
├── PCD (Passive Case Detection)
│   └── Fever cases at: ASHA/volunteer → Sub-centre → PHC → CHC → Hospital
│
├── RDTs (Rapid Diagnostic Kits)
│   ├── Introduced 2003 (NVBDCP)
│   ├── Bivalent RDTs (P. vivax + P. falciparum) from 2012
│   └── Used by ASHAs/FTDs at village level
│
└── National Reference Laboratory
    ├── Cross-checking +ve slides
    └── Training master trainers + accreditation of microscopists

• ABER - Annual Blood Examination Rate
• SPR - Slide Positivity Rate
• API - Annual Parasite Incidence
• AMR - Annual Malaria Rate

Integrated Vector Management (IVM) - Malaria

IVM FOR MALARIA
│
├── RURAL: IRS (Indoor Residual Spray)
│   ├── DDT (1st choice; ~60% high-risk areas)
│   ├── Malathion (DDT-resistant areas; 3 rounds)
│   ├── Synthetic Pyrethroids (alternative)
│   └── 2 rounds/season (DDT/pyrethroids)
│
├── URBAN: Anti-larval measures
│   ├── Chemical larvicides (temephos, MLO, fenthion)
│   ├── Biological: larvivorous fish (Gambusia)
│   └── Environmental engineering
│
└── PERSONAL PROTECTION
    ├── LLINs (Long-Lasting Insecticidal Nets) → API ≥5 areas
    ├── ITNs (Insecticide-Treated Nets) → API 2-5 areas
    └── >80% coverage target in high-risk areas

Malaria Treatment (Drug Policy)

---

(B) FILARIASIS (Under NVBDCP)

FILARIASIS CONTROL STRATEGY
│
├── MASS DRUG ADMINISTRATION (MDA)
│   ├── DEC + Albendazole (annual, single dose)
│   ├── National Filaria Day (synchronised)
│   ├── Drug distributors: ASHAs trained
│   └── ≥5 annual rounds, ≥65% population coverage
│
├── MORBIDITY MANAGEMENT
│   ├── Identify lymphoedema/elephantiasis/hydrocele cases
│   ├── Refer to PHC/CHC
│   └── Train patients in home-based lymphoedema care
│
└── VECTOR CONTROL
    ├── Urban: Antilarval (Chemical + Biological + Environmental)
    └── Rural: IRS (limited scope)

---

(C) KALA-AZAR (Under NVBDCP)

KALA-AZAR ELIMINATION STRATEGY
│
├── CASE DETECTION
│   ├── Quarterly active search ("Kala-azar Fortnight")
│   ├── Door-to-door: fever >15 days → refer to PHC/CHC
│   └── rK39 RDT for diagnosis
│
├── TREATMENT
│   ├── Single-dose Liposomal Amphotericin B (LAMB) 10 mg/kg IV
│   └── Miltefosine oral (DOT) × 28 days
│
├── VECTOR CONTROL
│   ├── IRS: Synthetic pyrethroids (replacing DDT)
│   └── Coverage: up to 6 feet from floor
│
└── ASHA INCENTIVES
    ├── Rs. 300 per KA case identified
    ├── Rs. 100/200 per IRS round ensured
    └── Rs. 500/2000 patient compensation

---

(D) JAPANESE ENCEPHALITIS (JE)

JE CONTROL STRATEGY
│
├── SURVEILLANCE: Sentinel sites at tertiary care institutions
│
├── CASE MANAGEMENT
│   ├── No specific cure → early supportive management
│   └── Minimize complications and deaths
│
├── VACCINATION ← KEY STRATEGY
│   └── Children 1-15 years in endemic areas
│       (SA 14-14-2 live attenuated vaccine)
│
├── VECTOR CONTROL
│   ├── Larvivorous fish in water bodies
│   ├── Personal protection: full-body clothing, bed-nets
│   ├── IRS NOT effective (outdoor resting vectors)
│   └── Malathion outdoor FOGGING for outbreak control
│
├── HEALTH EDUCATION
│   ├── Keep pigs away from human dwellings (especially dusk-dawn)
│   └── Community awareness on signs/symptoms
│
└── ENDEMIC STATES
    AP, WB, Assam, TN, Karnataka, Bihar, Maharashtra,
    Manipur, Haryana, Kerala, Uttar Pradesh

---

(E) DENGUE FEVER / DENGUE HAEMORRHAGIC FEVER

DENGUE CONTROL STRATEGY
│
├── SURVEILLANCE
│   ├── Early case detection and reporting
│   ├── Sentinel surveillance hospitals
│   └── Contingency plan for outbreak response
│
├── CASE MANAGEMENT
│   ├── NS1 antigen test (day 1-5 of fever)
│   ├── IgM/IgG ELISA (after day 5)
│   └── Supportive treatment; no specific antiviral
│
├── VECTOR CONTROL (Aedes aegypti/albopictus)
│   ├── Source reduction: eliminate stagnant water collections
│   │   (coolers, tyres, pots, tanks)
│   ├── Anti-larval: temephos in water storage containers
│   ├── Biological: larvivorous fish in ornamental ponds
│   ├── Personal protection: repellents, clothing, nets
│   └── Fogging: malathion/pyrethroid during outbreaks
│
├── IEC ACTIVITIES
│   └── Do's & Don'ts for dengue prevention (community)
│
└── MONITORING & REPORTING
    └── Weekly reporting to states + centre

---

(F) CHIKUNGUNYA

CHIKUNGUNYA CONTROL STRATEGY
│
├── Re-emerged after 3 decades; added to NVBDCP burden
│
├── Strategies similar to dengue (same vector - Aedes spp.)
│   ├── Source reduction (water stagnation)
│   ├── Personal protection
│   └── Symptomatic case management (NSAIDs, rest)
│
└── Special focus areas: House-to-house survey + IEC +
    capacity building in affected areas

---

4. COMPLETE NVBDCP MASTER FLOW CHART

┌─────────────────────────────────────────────────────────────────────┐
│                          NVBDCP                                     │
│           (Under MoHFW → NRHM → State Health Departments)          │
└───────────────────────────┬─────────────────────────────────────────┘
                            │
         ┌──────────────────┼──────────────────┐
         ▼                  ▼                  ▼
   ┌───────────┐     ┌─────────────┐    ┌─────────────┐
   │ MOSQUITO- │     │  SANDFLY-   │    │ SUPPORTIVE  │
   │ BORNE     │     │  BORNE      │    │ SYSTEMS     │
   └─────┬─────┘     └──────┬──────┘    └──────┬──────┘
         │                  │                  │
   ┌─────┼─────┐            │            ┌────────────┐
   ▼     ▼     ▼       ┌────▼────┐      │ BCC / IEC  │
MALARIA DENGUE FILARIA │KALA-AZAR│      │ PPP        │
  JE  CHIKUN-           └─────────┘      │ M&E        │
        GUNYA                            │ Capacity   │
                                         │ Building   │
                                         └────────────┘
         │
         ▼
  COMMON STRATEGIES
  ├─ Early Case Detection (ACD + PCD)
  ├─ Complete Treatment (Drug Policy per disease)
  ├─ Integrated Vector Management
  │   ├─ IRS (Rural)
  │   ├─ Antilarval (Urban)
  │   └─ ITN/LLIN (Personal protection)
  ├─ Surveillance & Reporting (IDSP linkage)
  └─ Community Involvement (ASHA, VHSNC, MAS)

---

5. KEY INDICATORS FOR MONITORING (NVBDCP)

---

6. ROLE OF ASHA UNDER NVBDCP (Field Level)

ASHA ACTIVITIES IN NVBDCP
│
├── MALARIA
│   ├── Collect blood smears from fever cases
│   ├── Use RDTs for early diagnosis
│   ├── Administer presumptive/radical treatment
│   └── Motivate community for IRS acceptance
│
├── KALA-AZAR
│   ├── Door-to-door fever search (>15 days)
│   ├── Guide suspected cases to PHC/CHC
│   └── Ensure IRS rounds (incentive-linked)
│
├── JAPANESE ENCEPHALITIS
│   └── Identify fever + encephalitis signs → refer PHC/CHC
│
└── FILARIASIS
    ├── Distribute DEC + Albendazole on National Filaria Day
    ├── Identify lymphoedema/hydrocele cases → refer
    └── Train patients in home-based lymphoedema care

---

7. INTERACTION WITH OTHER PROGRAMMES

• IDSP - Weekly fever alerts provide early warning for malaria outbreaks
• RCH/JSY - LLINs distributed to pregnant women at ANC
• IMNCI - Malaria case management integrated into child health protocols
• Overlap areas - Dengue + Malaria (urban); Malaria + Kala-azar (Jharkhand districts); Malaria + Filariasis (Odisha)

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