previous and current situation of malaria in BD, treatment, prevention, national malaria strategic plan 2915 etc.

1. Uncovering Malaria
in Bangladesh

2. 1. Suraiya Ahmed
2. Atikur Rahman Nyeem
3. Mimma Sultana Chandni
4. Reeti Susan Roy
5. Faria Iqbal
6. Sabrina Arafin Tanni
Presented By-

3. Malaria is a mosquito-borne infectious disease of humans and
other animals caused by parasitic protozoans (a group of single-
celled microorganism) belonging to the genus Plasmodium.
The female Anopheles mosquito is the only mosquito that
transmits malaria. It primarily bites between the hours of 9pm
and 5am
What is MALARIA?

4. • Malaria is one of the major public health problems in Bangladesh.
• It is endemic in 13 eastern and northern districts of the country.
• The three hilly districts (Rangamati, Khagrachari and Banderban)
account for 80% of the total burden of malaria.
• During the last decade, 82% of the total annual reported cases were
due to Plasmodium falciparum.
• The remaining cases are due to Plasmodium vivax, and few are due
to mixed infection.
• Over 13.25 million people of Bangladesh are at high risk of malaria,
with the utmost vulnerability of the under-five children and pregnant
women.
• Malaria claims about 0.10% lives annually.
• In 2012, the official number of laboratory confirmed malaria cases in
the country was 29,522 with 11 confirmed malaria deaths.
INTRODUCTION & BACKGROUND

6. • Malaria is caused by the plasmodium parasite. The parasite can
be spread to humans through the bites of infected mosquitoes.
There are many different types of plasmodium parasite, but
only five types cause malaria in humans. They are:
1. Plasmodium falciparum (the most common type of malaria
parasite and is responsible for most malaria deaths
worldwide)
2. Plasmodium vivax
3. Plasmodium ovale
4. Plasmodium malariae
5. Plasmodium knowlesi
CAUSES OF MALARIA

7. • Malaria can cause a number of life-threatening complications
that can result in death. The following may occur:
swelling of the blood vessels of the brain (cerebral malaria)
accumulation of fluid in the lungs that causes breathing
problems (pulmonary edema)
organ failure (kidneys, liver, or spleen)
anemia due to destruction of red blood cells
low blood sugar
Life-Threatening Complications of Malaria

8. The plasmodium parasite is spread by female Anopheles
mosquitoes, which are known as 'night-biting' mosquitoes because
they most commonly bite between dusk and dawn.
If a mosquito bites a person already infected with malaria, it can
also become infected and spread the parasite on to other people.
However, malaria cannot be spread directly from person to person.
Once a person is bitten, the parasite enters the bloodstream and
travels to the liver. The infection develops in the liver before re-
entering the bloodstream and invading the red blood cells.
The parasites grow and multiply in the red blood cells. At regular
intervals, the infected blood cells burst, releasing more parasites
into the blood. Infected blood cells usually burst every 48-72 hours.
Each time they burst, patient will have a bout of fever, chills and
sweating.
Malaria can also be spread through blood transfusion and the
sharing of needles, but this is very rare.
How Malaria Spreads?

10. Shaking chills that are moderate to severe
High fever
Profuse sweating
Headache
Nausea
Vomiting
Diarrhea
Anemia
Muscle pain
Convulsions
Coma
Bloody stools etc.
Symptoms of Malaria

11. Four districts (Mymensingh, Netrakona, Sherpur and Kurigram)
with eight endemic upazilas have low transmission of malaria and
have shown <5% malaria positivity rates (RDT and Microscopy) over
last three years. These districts currently may be considered for
adopting pre-elimination strategies.
There is significant progress in malaria control in Bangladesh during
the period from 2008 to 2013 showing a progressive decline in total
cases and deaths.
Current Malaria Situation in Bangladesh

12. The NMCP had the GFATM support since 2007 and there was an increase in
number of cases due to scaling up of interventions; introduction of RDR for
diagnosis, and ACT for treatment of P. falciparum cases. Thereafter, a steady
decline is noted from 84,690 cases in 2008 to 26,891 cases in 2013, having a
68.2% reduction in case incidence. The total deaths came down to 15 in 2013
as against 154 in 2008 showing 90.2 % reduction.

13. • The table below shows District-wise epidemiological data of the 13 endemic districts
for three consecutive years for a comparison based on total cases, Pf %, and Annual
Parasite Incidence (API). The five districts (3 CHT districts and Chittagong and Cox’s
Bazar) had reported API 7.36, 4.02 and 3.77 respectively in 2011, 2012 and 2013.
Stratification of Malaria Endemic Districts

14. • The total population at risk of malaria in the 13 endemic districts is
approximately 13.25 million. (Ref: NMCP Routine Surveillance data) and
the List is attached as Annex-1. About 80% of the cases of malaria in
Bangladesh are reported from the three CHT districts with a total
population of about 1.6 million. The indigenous population constitutes
about 50% of the total population in CHT districts.
• There is a high degree of heterogeneity in malaria cases distribution
between the sexes and across age groups in Bangladesh. During the
2008-2013 periods, males consistently show more positive diagnoses
than females and with increasing trends over the years(Figure
4).Pregnant women constitute 1% of malaria cases in recent years.
Population at Risk
Fig: Age Distribution of
malaria cases

15. • Malaria affects all age groups and both males and females; however, adult
males are commonly affected mainly due to occupations and behavior that
put them at risk of being bitten by malaria vectors. Pregnant women and
children <5yrs are biologically at higher risk and they tend to develop more
severe malaria due to low level of immunity. Thus, in high transmission
areas, these groups should be given priority for interventions. High risk
populations, thus includes:
i) Young children, particularly under <5 yr children,
ii) Pregnant women,
iii) Travelers from non-endemic areas,
iv) People from non-endemic areas residing for a long time and
returning home,
v) ‘Jhum cultivators’ and forest goers, Tea estates;
vi) Refugees and mobile population, and
vi) People with HIV/AIDS and TB (for co-infections, if any).

16. Historically, the malaria control programme in Bangladesh had four
phases:
1. Malaria Eradication Programme (in early 1960s;
2. Malaria Control Programme (1977-1994);
3. Revised Malaria Control Strategies (RMCS-1994); and
4. Continuation of RMCS with updated strategies until today.
Malaria control program

17. Malaria is usually confirmed by-
• the microscopic examination of blood films or
• by antigen-based rapid diagnostic tests (RDT).
• RDT started to use in a mass scale from 2008 under the support of
GFATM funding under round 6. At the community level
‘ShayasthoKarmi’ (health worker) and ‘Shayastho Shebika’ (community
volunteer) of NGOs are responsible for diagnosis and treatment of
uncomplicated malaria. The GoB Health Workers are also responsible
for diagnosis and treatment of uncomplicated malaria using Pan RDT.
Diagnosis and Management of Malaria
The blood film is
the gold standard for
malaria diagnosis

18. Pan RDT

19. An insecticide-treated net (ITN) is a net
(usually a bed net), designed to block
mosquitoes physically, that has been treated
with safe, residual insecticide for the
purpose of killing and repelling mosquitoes,
which carry malaria.
A long-lasting insecticide-treated net
(LLIN) is an ITN designed to remain effective
for multiple years without retreatment. The
insecticide is cleverly bound within the fibers
that make up the netting and is 'slow
released' over a 4-5 year period.
LLIN and ITN Coverage for Malaria Prevention

20. • HEED Bangladesh signed in agreement with GFATM one of the
principle recipients BRAC in May, 2008 to implement Malaria
Control Project in Jaintapur Upazila in Sylhet district with a view
to contribute in reducing malaria burden nationally by June,
2015.
Use of LLIN and ITNs

21. • Bioassay test conducted in various sites as a routine entomological
surveillance. The results of the bio-assay test on LLINs and ITNs
dipped with K-O-Tab1,2,3 mortality rates of mosquito nets at
Durgapur, Jheenaigati, Kolmakanda, Lama, Rangamati Sadar and
Jointapur upazila.
Bio Assay Test

22. • Antimalarial medications, also known as antimalarials, are
designed to prevent or cure malaria
• In the South Asian region, Plasmodium vivax and Plasmodium
falciparum are the predominant species causing human malaria.
For the last decade, chloroquine-resistant P. falciparum has
spread explosively in sub-Saharan Africa, Southeast Asia, and
South Asia
• Control of falciparum malaria is becoming a challenge especially
in Multi-Drug Resistant (MDR) areas.
• P. falciparum is also responsible for complications like cerebral
malaria etc, prompting more than one million deaths per year.
• The other species of mosquito responsible for malaria (P. vivax,
P. ovale and P. malariae) also produce high morbidity but are
usually susceptible to chloroquine, which is a good blood
schizontodicidal drug.
Antimalarial medication

23. • In Bangladesh, 60% of the malaria cases are P. falciparum. Malaria
is also a health problem in the southern belt of 30–50 km and a
few valleys in Bhutan, where 50% of the cases are P. falciparum.

24. Resistance has been documented in all class of antimalarials, including
artemisinin derivatives and it is a major threat to malaria control. Wide
spread and indiscriminate use of antimalarials exerts a strong selective
pressure on malaria parasites to develop high levels of resistance.
Resistance can be prevented by ensuring very high cure rate through full
adherence of correct dose regimen.
Chloroquine and Salfadoxine/Pyrimethamine both are resistant. So these
drugs should not be used in malaria cases.
Mefloquine, a highly efficacious drug for P. falciparum but it is not
recommended to use as a single drug.
Artesunate for uncomplicated malaria is highly effective for P. faciparum
but single drug use is not recommended due to chance of development
of resistance.
Artesunate, Melfoquine combination is highly effective in P. falciparum
cases (Alternate regime)
Drug resistant malaria

25. • Resistant strains are able to
efflux the drug by an active
pump mechanism.
• pfcrt gene  encodes a
transporter in the membrane of
acidic digestive vacuole 
causing efflux of chloroquine
from the food vacuole
• :K76T Mutation
• There is an increase in the
surface area of the resistant
parasites, permitting more
efficient pinocytosis.
Mechanism Of Resistance

27. • Pharmacotherapy of uncomplicated
P.Falciparum Chloroquine resistant
malaria with Artemisinine Combination
Therapy.
WHY ACT FOR CHLOROQUINE
RESISTANT MALARIA?
• The Artemisinins produce rapid clearance of
parasitaemia and rapid resolution of symptoms
• High cure rates (>95%)
• Combination therapy prevents resistance.
• Shorter T ½ so only problem is Recrudescence.
The partner medicine have different mechanisms
of action , longer half-lives and must
independently be sufficiently efficacious in
treating malaria.

28. • WHO Recommends following Artemisinin based combination
regimes for the management of Chloroquine resistant
P.Falciparum malaria.
1. Artesunate-sulfadoxine + Pyrimethamine(AS-S/P)
2.Artemether-Lumefantrine(AS/LF)
3.Artesunate/Mefloquine(AS/MQ)
4. Artesunate-Amodiaquine(AS/AQ)
5. Dihydroartemisinin(DHA)-Piperaquine
ARTEMISININ COMBINATION THERAPY (ACT)

31. Elimination of mosquito breeding
places
National improvements on health and
hygiene
Use of mosquito nets, treated with
Pyrithrin
Clothing with sleeves and long
trousers
Use of mosquito repellents
Young children and pregnant women
should avoid traveling to areas where
malaria is common
PREVENTION & CONTROL

33. The types of drugs and the length of treatment will vary, depending on:
Type of malaria parasite
Severity of the symptoms
Age
Pregnancy
Medications
oThe most common antimalarial drugs include:
oChloroquine (Aralen)
oQuinine sulfate (Qualaquin)
oHydroxychloroquine (Plaquenil)
oMefloquine
o Doxycycline (available generically)
oCombination of atovaquone and proguanil (Malarone)
TREATMENT (VACCINE & MEDICATIONS)

34. Malaria vaccines are an area of intensive research. Emergence
of artemisinin and multi-drug resistant strains of especially P.
falciparum are driving research. Current approaches are
focusing on recombinant protein and attenuated whole
organism vaccines. Various vaccines have reached the state of
clinical trials; most demonstrated insufficient immunogenicity.
 The malaria vaccine candidate RTS,S/AS01. RTS,S/AS01 is the
most advanced vaccine candidate against the most deadly form
of human malaria, Plasmodium falciparum.
VACCINE

35. • Tu Youyou (1930) is a Chinese medical scientist and pharmacist. She is
best known for discovering artemisinin (also known as qinghaosu)
and dihydroartemisinin, used to treat malaria, which saved millions of
lives. Tu received the 2015 Nobel Prize in Medicine for discovering this.
• She collected 2000 candidate recipes, ancient texts, and folk remedies
for possible leads for her research. By 1971, her team had made 380
extracts from 200 herbs, and discovered the extracts
from qinghao (Artemisia annua, sweet wormwood) looked particularly
promising in dramatically inhibiting Plasmodium growth in animals.
Recent Research

36. • Existing Strategic Plan (2008-14)
The existing National Strategic Plan 2008-2015 envisaged 60% reduction
of malaria morbidity and mortality (compared to baseline 2005) by 2015
with the specific objectives of:
i) providing early diagnosis and prompt treatment (EDPT) with effective
drugs to 90% of malaria patients;
ii) ensuring effective malaria prevention to 100% population at risk in
five high endemic districts and 80% in the remaining eight districts;
iii) providing pre-referral treatment and timely referral of 90% of severe
malaria cases;
iv) promoting community participation, partnership with NGOs and
private sector and
 v) strengthening management capacity, M&E and Procurement and
Supply Management (PSM) systems in the National Malaria Control
Programme.
National Malaria Strategic Plan 2015-2020

37. • The Malaria Strategic Plan (2015- 2020) provides the framework and
technical guidance for the National Malaria Control Programme (NMCP)
to plan and implement interventions for achieving pre-determined
goals, objectives and targets. The goal is ‘To have achieved ‘zero
indigenous transmission’ and ‘zero death’ aiming malaria elimination in
Bangladesh, by 2020.
Malaria Strategic Plan (2015-2020)

38. Vision: Malaria-free Bangladesh
Mission:
The National Malaria Control Programme (NMCP), Bangladesh aims
to achieve malaria elimination (‘zero indigenous transmission’ and
‘zero deaths’) by ensuring equitable and universal accesses to effective
preventive and curative services to all ‘at risk population’ through
concerted efforts of the GoB, NGOs, Private sectors, and the
community.
Goal: By 2020, to have achieved ‘zero indigenous transmission’ and
‘zero death’ aiming malaria elimination in Bangladesh
The goal aims at attaining a status of malaria elimination by 2020,
referring to reorientation of the control interventions in phased and
stratified manner for:
i) addressing four low endemic districts (Kurigram, Sherpur,
Mymensingh and Netrakona);
ii) expansion to the moderate endemic districts; and
iii) intensified efforts in high endemic districts; for achieving eventual
malaria elimination status in Bangladesh.

39. Conclusion
Malaria remains a major public health problem in the
tropic.
Prompt diagnosis is essential for timely initiation of
appropriate therapy.
Multi-drug resistant malaria is a public health threat.
Chloroquine drug resistant is high so it should not be
used in malaria.
ACT (Artemisinin combination therapy) should be used.
In cerebral malaria i/v Artisunate is preferable than i/v
Quinine when available.
Preventive measures is one of the major aspects to
strengthen malaria control programme.

40. http://www.theindependentbd.com/printversion/details/912
3
http://knoema.com/WHOWMS2014/who-world-malaria-
statistics-2014
http://reliefweb.int/report/bangladesh/malaria-bangladesh
http://www.healthline.com/health/malaria#Long-
TermOutlook7
https://en.wikipedia.org/wiki/Malaria
http://wwwnc.cdc.gov/travel/yellowbook/2016/infectious-
diseases-related-to-travel/yellow-fever-malaria-information-
by-country/bangladesh
http://www.ncbi.nlm.nih.gov/pubmed/23434288
https://www.k4health.org/sites/default/files/1757-7604-1-
pb.pdf
REFFERENCES