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Malaria - Complete Guidelines for PSM Exam

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1. DEFINITION & CAUSATIVE AGENTS

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2. VECTOR

• 45 Anopheline species in India; only a few are vectors
• An. culicifacies - most important vector in rural areas
• An. stephensi - most important vector in urban areas
• Other vectors: An. fluviatilis, An. minimus, An. philippinensis, An. sundaicus, An. maculatus

• Critical density: minimum vector density needed to maintain transmission
• Extrinsic incubation period (EIP): 10-12 days (vector must live longer than this to transmit)
• Endophily (indoor resting): basis of malaria eradication strategy using IRS
• Anthropophily (preference for human blood): determines vectorial efficiency
• Vectorial capacity: combined effect of density, susceptibility to infection, life span, and probability of feeding on man

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3. EPIDEMIOLOGICAL INDICES / MEASUREMENT

Pre-Eradication Era (Classical Malariometric Measures)

Eradication Era (Current Parasitological Parameters)

Endemicity Classification by Spleen Rate

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4. DIAGNOSIS

• Microscopy (gold standard) - blood smear (thick and thin)
• RDT (Rapid Diagnostic Test) - monovalent (Pf only) or bivalent (Pf + Pv)
• As per Revised Drug Policy 2013: No presumptive treatment - diagnosis must be confirmed before treatment

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5. TREATMENT GUIDELINES (India 2013 - NVBDCP)

A. UNCOMPLICATED P. vivax MALARIA

• Primaquine is contraindicated in: infants, pregnant women, G6PD deficient patients
• Relapse rate in India is ~30%
• Primaquine must be given under supervision

B. UNCOMPLICATED P. falciparum MALARIA

• ACT-SP = Artesunate (3 days) + Sulphadoxine-Pyrimethamine (1 day/single dose)
• Plus single dose Primaquine 0.75 mg/kg on Day 2 (as gametocidal)

• Artemether (20 mg) + Lumefantrine (120 mg) - co-formulated tablet, age-specific dose
• Not recommended in: 1st trimester of pregnancy, children < 5 kg

C. MALARIA IN PREGNANCY

• Primaquine is CONTRAINDICATED in all trimesters of pregnancy

D. MIXED INFECTIONS (Pf + Pv)

• Treat as P. falciparum malaria

E. DRUG RESISTANCE

• Suspect resistance if: full treatment given, no vomiting/diarrhoea, and patient does NOT respond within 72 hours clinically and parasitologically
• Treat with: Quinine + Tetracycline/Doxycycline

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6. SEVERE MALARIA - CLINICAL FEATURES

1. Impaired consciousness / Coma (cerebral malaria)
2. Repeated generalized convulsions
3. Renal failure (serum creatinine > 3 mg/dl)
4. Jaundice (serum bilirubin > 3 mg/dl)
5. Severe anaemia (Hb < 5 g/dl)
6. Pulmonary oedema / ARDS
7. Hypoglycaemia (plasma glucose < 40 mg/dl)
8. Metabolic acidosis
9. Circulatory collapse/shock (systolic BP < 80 mm Hg in adults, < 50 mm Hg in children)
10. Abnormal bleeding and DIC
11. Haemoglobinuria (blackwater fever)
12. Hyperthermia (temperature > 106°F or 42°C)
13. Hyperparasitaemia (> 5% parasitized RBCs in low endemic; > 10% in hyperendemic areas)

Treatment of Severe Malaria

• Emergency - parenteral treatment must be started immediately
• Artesunate IV/IM - drug of choice
• Start parenteral dose (artesunate or quinine) BEFORE referring the patient
• Complete treatment with ACT orally once patient can swallow

• Fever persisting after 24 hours of treatment
• Continuous vomiting / inability to retain oral drug
• Increasing headache; severe dehydration
• Change in sensorium (confusion, drowsiness, disorientation)
• Convulsions; bleeding disorder; jaundice; suspected severe anaemia

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7. CHEMOPROPHYLAXIS

• All prophylactic drugs must be continued 4 weeks after last possible exposure
• Long-term chloroquine (>5 years): screen for retinal changes every 6 months

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8. CONTROL STRATEGIES (NVBDCP)

A. Surveillance and Case Management

1. Case detection (passive and active)
2. Early diagnosis and complete treatment
3. Sentinel surveillance

B. Integrated Vector Management

1. Indoor Residual Spraying (IRS) - based on endophilic behavior of vectors
2. Insecticide Treated Bed Nets (ITNs) and Long Lasting Insecticidal Nets (LLINs)
3. Antilarval measures including source reduction

C. Epidemic Preparedness and Early Response

D. Supportive Interventions

• Capacity building; Behavioural change communication
• Intersectoral collaboration; Monitoring and evaluation
• Operational research

Antilarval Methods

• Larvivorous fish (Gambusia, Lebistes) in ponds, wells, water bodies
• Oil spray on breeding sites
• Paris Green - larvicide (oldest)
• Temephos (Abate) - modern larvicide
• BTI (Bacillus thuringiensis israelensis) - biological larvicide

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9. NATIONAL PROGRAMMES - HISTORICAL MILESTONES

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10. NATIONAL FRAMEWORK FOR MALARIA ELIMINATION 2016-2030

Categories of States:

• Category 1 (Elimination phase): API < 1 per 1000
• Category 2 (Pre-elimination phase): API 1-2 per 1000
• Category 3 (Intensified control phase): API > 2 per 1000

Targets:

• By 2022: Interrupt transmission in all 26 States/UTs (categories 1 & 2 in 2014) - zero indigenous cases
• By 2024: API < 1 per 1000 in all states; 31 states/UTs achieve zero indigenous cases
• By 2027: All states/UTs to eliminate malaria
• By 2030: Eliminate malaria from the entire country

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11. URBAN MALARIA SCHEME

• Launched in 1971
• Covers cities with > 50,000 population and SPR ≥ 5%
• Currently protects 130 million population in 131 towns in 19 states/UTs
• Vector: An. stephensi (breeds in man-made containers - overhead tanks, water coolers, cisterns, tyres)
• Methods: Intensive antilarval measures + drug treatment
• Larvivorous fish (Gambusia); larvicides (Temephos, BTI) for unsuitable water bodies

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12. KEY DEFINITIONS (PSM Exam Favourites)

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13. MALARIA VACCINES

• RTS,S/AS01 (Mosquirix) - first malaria vaccine; approved by WHO in 2021 for children in sub-Saharan Africa
• R21/Matrix-M - newer vaccine; higher efficacy reported

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• No presumptive treatment since Drug Policy 2013 - confirm by microscopy or RDT first
• Primaquine CI: G6PD deficiency, infants, pregnancy (all trimesters)
• Infant parasite rate = most sensitive index of recent transmission
• An. culicifacies = rural vector; An. stephensi = urban vector
• NVBDCP (2002) covers: Malaria, Dengue, Chikungunya, Japanese Encephalitis, Lymphatic Filariasis, Kala-azar
• Park's Textbook of Preventive and Social Medicine, pp. 299-315, 469-472