National Vector Borne Disease Control Programme😊

• Targets
• Annual Parasite Incidence (API): < 1/1000
• Annual Blood Examination Rate (ABER): > 10%
• Microfilaria Rate: < 1%

• If “V” present → Very active in liver

• Schizont hide in cerebral blood vessel

Immunity Against Malaria

• Duffy & Basigin Antigens.

• Some humans immune- lack Duffy antigens

Immunity scenarios

• SC traits.

• Thal Trait.

• Fetal Hb.

• G6PD deficiency.

• Ovalocytosis.

• Absence of Duffy antigen.

Light Microscopy (IOC)

• 1 microscope / 25,000 population

• Gold standard.

• Peripheral Blood Smear
• Thick Smear:
• Identifies parasite
• For quantification of malaria.
• Sensitivity - 5 parasites /microlitre.
• Thin Smear:
• (tongue-shaped smear)
• Identifies species
• Sensitivity - 200 parasites/ microlitre.

• Stains used - Romanowsky stain.
• JSB: Jaswant Singh Bhattacharji (JSB)
• or Giemsa

• 200-300 OIF (Oil immersion field — 100x) examined
• before reporting negative.

• Vivax and ovale affect and enlarge young RBCs.

• All other plasmodium involve all RBCs.

Other Laboratory Diagnosis

• PCR: Most sensitive test.

• Fluorescent microscopy:
• Rapid screening, expensive.
• Kawamoto technique: acridine orange.
• The screening method of choice.

• Microhematocrit method.
• QBC: Quantitative buffy coat.

• RDT-Rapid diagnostic test/card test.

Malarial pigment:

• Haemoglobin changes to Hemozoin - yellow-brown pigment.
• Property of all plasmodium.

• Under a microscope: Trophozoite, Schizonts and Gametocytes are observed.

QBC: Quantitative Buffy Coat analysis

• Blood is taken and spun
• RBC at the bottom.
• Plasma at the top.
• Tiny middle area - called Buffy Coat.
• All organisms stay at the buffy coat - malaria, filaria.
• Sensitivity is 2 parasites/microlitre blood.
• Fluorescent dye coated tube - Acridine orange stain.

RDT: Rapid diagnostic test/card test

• Principle = Immunochromatography (ICT)

• Sensitivity = 50-100 parasites/microlitre.

• Nitrocellulose membrane.

• Control line — validation line.

Field test:

• All malaria species have aldolase and LDH.
• ALL → Aldolase & LDH

• P.falciparum has histidine rich protein 2— HRP2.

ACT Components:

• Artesunate: 4 mg/kg

• Sulfadoxine: 25 mg/kg

• Pyrimethamine: 1.25 mg/kg

• Artemether: 20 mg

• Lumefantrine: 120 mg

• Mnemonic: NES → Not SP (swayam pongi)

• Mixed Infection
• (P. falciparum + P. vivax)
• Rx: ACT-AL/ACT-SP + Primaquine x 14 days

In Pregnancy:

Complicated / Cerebral Malaria

• IV Quinine

• IV Artesunate

Primaquine

• DOC for Radical Cure For P. vivax

• Given for 14 days

• Tafenoquine is single dose radial cure of P. vivax malaria

• Contraindication (C/I) of Primaquine:
• Pregnancy
• Infants
• G6PD deficiency

Vaccines

• Mosquirix RTS

• S/AS01

Prophylaxis

Indicators

• Incidence → x 1000

• Rate → x 100

• Annual Parasite Incidence (API):

Category	API (State)	API (District)	Classification
3	>1	-	Intensified malaria control
2	<1	Some : >1	Pre-elimination area
1	<1	All : <1	Elimination area
0	0 or negligible	-	Prevention of re-establishment

• Count 3 - 2 - 1 - 0 → kill the mosquito
• Assesses the burden of malaria
• Impact indicator
• Total no of confirmed cases x 1000
  Total population
• Confirmed cases:
• Slides positive OR
• Rapid diagnostic kit positive (Approved only in NES)

• Annual Blood Examination Rate (ABER) (> 10%):
• No of slides examined x 100
  Total population
• Indicator for prevalence of fever
• Operational indicator

• Slide Positivity Rate (SPR):
• No. of slides positive x 100
  No. of slides examined
• Best during outbreak

• Recent Malarial Transmission Indicator:
• Infant Parasite Rate (IPR)

• Number of slides examined → always 100

• Spleen Rate
• Number of children from 2 to 10 years showing enlargement of the spleen.
• Measure of endemicity of malaria.
• Holoendemic pattern - seen during 2- 10 years

• Type: Viral zoonotic disease

Endemic Areas:

• 350 districts
• Uttar Pradesh, Bihar, West Bengal
• North-eastern states (NES)
• South India

• Hosts:
• Ardeid Birds: Maintenance host
• Cow, Cattle, Humans:
• Dead end host
• Pig: Amplifying host

Vectors in India:

• Vector: Culex mosquito

• Global: Culex tritaeniorhynchus (world)

• India: Culex Vishnui (INDIA)

Clinical Features:

• Encephalitis (high grade fever, neurological changes, convulsions)

• Peak age: Children/young adults

• Mnemonic: Japanil Cute (culex) girl with Coca (Kokku → ardeid bird) Cola (Kolar vaccine ) kand oru Pig () vannnu → sex cheyyan (pig - amplify) shremich → freezeril (freeze sensitive) puuti itt → Kill ayi (killed vaccine)

• Important Note:
• Nagayama spots → seen in HHV-6 (sixth disease), not JE

Management:

• Diagnosis: RT-PCR

• Treatment: Symptomatic

• Vaccine, vector control, acute encephalitis surveillance

Vaccines Types

• Live: (S/c)
• SA-14-14-2 strain
• (Earlier used in India)

• Inactivated:
• Nakayama and Beijing P1 strains

• Killed (IM)
• JEEV (SA-14-14-2 strain)
• JENVAC (Kollar strain)

Update 2023: JENVAC

• Killed Kolar Strain (Approved for use in immunization schedule)

• 2 doses: 9 months, 16-24 months

• Route: IM

• Dose: 0.5 mL

• Site: Left thigh

• Unimmunized Child: Immunized till 15 years

• Under open vial policy because not using live vaccine

JE Live Vaccine vs JE Killed Vaccine:

• Note: Adult JE vaccines given in high burden areas.

• Live vaccine is difficult
• Reconstitute
• Put in freezer
• No open vial policy

• Mnemonic:
• KLLL → kaLa azar → Leishmaniasis → LAMB
• Pro (Promastigote) causes infection

• Etiology:
• Wuchereria bancrofti (Most common)
• Brugia malayi
• Brugia timori

• Clinical Presentations:

Type	Characteristics
Cutaneous	Most common, darkening of skin
Visceral (Kala Azar)	Hepatosplenomegaly
Mucocutaneous	Most disabling

• Vector: Phlebotomus argentipes (Sand fly)



• Hairy & Lanceolate shaped wings
• Does not fly
• Hopping range: 50 yards
• Painful biter, nocturnal
• Sand fly : Killed by synthetic pyrethroid.

• Infective Form: Promastigote.

• Diagnostic Form: Amastigote.
• L.D bodies → amastigotes.

Sample:

• Spleen → most sensitive

• Bone Marrow → most preferred

• Blood.

• HIV patients
• BAL
• Spleen and liver → are not very commonly involved

Hypergammaglobulinemia tests:

• Napier's aldehyde test.

• Chopra's antimony test.

Diagnosis:

• Montenegro test
• Kala → black → negro

• Media: NNN (Novy-MacNeal-Nicolle) media → shows promastigotes
• NNN media also used for
• T. cruzi.
• Leishmania

• Serology: rk-39 antigen (rapid card test).

• PCR → definitive test

Treatment:

• Liposomal Amphotericin B: DOC (single dose)

• Alternatives
• Miltefosine
• Paramomycin

• Etiology:
• Wuchereria bancrofti (Most common)
• Brugia malayi
• Brugia timori

• Vectors:
• Culex:
• Bancroftian filariasis (most common)
• Mansonia:
• Brugian filariasis
• Mnemonic: Mansoonil (Mansonia) cutex (culex) itt irunnapo manthu () vannu

• Epidemiology:
• Microfilaria enters culex mosquito → Undergoes Cyclodevelopmental Change (no multiplication) → Only change in form → Forms the Infective form: 3rd stage larva of developing microfilaria (L3)
• Portal of entry: Skin
• Localization: Inguinoscrotal lymphatics
• Reservoir: Humans with microfilaria in blood

• Clinical Presentation:
• Asymptomatic
• Acute Dermatolymphangitis (ADL)
• Lymphedema
• Hydrocoele
• Causes Chyle in urine (Chyluria).

Diagnosis:

• USG scrotum for filarial dance sign.

• Antibody tests: non-specific.

• Antigen tests: specific.
• ELISA for ADI12Ag.
• ELISA for OgD4C3Ag9
• ogod D4 (dancing) 3 filaria - aadi

• Transmission assessment survey

Peripheral Blood Film:

• Diagnostic, surveillance

• Sample collected from 10 PM till 2 AM

• Concentration Method: (Most sensitive)
1. Membrane filtration
• Most common
2. Centrifugation / Knott method (2% formalin)
• Blood sample lysed in 2% formalin (knott’s technique)
• Not (knott) in form (formalin) for 2 (2%) days

DEC Provocation Test:

• Clinically diagnostic

• 100 mg oral DEC → 1 hr → Peripheral blood smear

Treatment:

• DEC: 12 doses at 6 mg/kg/dose, total 72 mg/kg

Prevention:

• Best Method for Control of Filariasis:
• Deweeding of large water bodies

• Target: Elimination by 2027

Strategy:

• Mass Drug Administration (MDA)
• IDeA



• DEC medicated salt:
• 1-4 gms DEC/kg
• All filaria DEC except onchocerca → ivermectin
• Fila → Iver

Indicators:

1. Microfilarial Rate:
• No. of people with slide positive
  Total slides examined in population
• Indicates microfilaria (Mf) in blood.

2. Filarial Endemicity Rate:
• % people showing Mf in blood or disease presentation or both.
• Indicates disease prevalence in area.

3. Microfilarial Density:
• No. of Mf per unit volume of blood (20 cu.mm).
• Indicates intensity of infection.

Elimination of Lymphatic Filariasis Criteria

• Two criteria

• Children born after initiation of ELF programme
• Free from circulating antigenemia

• Microfilaria carriers
• < 1%

Complication:

• Mazzotti Reaction:
• Hypersensitivity to DEC in onchocerciasis (River Blindness)
• Black fly
• C/f: Urticaria, skin rashes
• Not seen in India so we dont check for mazotti reaction
• Because Onchocerciasis is not seen
• Mnemonic: Mazootti → Blind () aalu black fly () ne kollan Vetti Vetti (mazootti) → oru desk vetti (DEC)

Brunners Classification (Stages)

• Leg become Bun (B Runners) like

• Subclinical (Latent):
• Excess interstitial fluid
• no visible signs.

• Stage I:
• Pitting edema.

• Stage II:
• Non-pitting edema.

• Stage III:
• Edema with irreversible skin changes.
• Stemmer’s Sign:
• Inability to pinch skin (diagnostic).
• Hard like stem → cannot pinch
• Buffalo Hump:
• Loss of ankle contour.

Investigations

• Gold Standard:
• Water plethysmography (measures limb volume).
• Mild: < 20% volume increase.
• Moderate: 20-40% volume increase.
• Severe: > 40% volume increase.

Management

• Skin Care:
• Protect skin during activities (chopping, gardening).
• Never walk barefoot.
• Use electric razors for hair removal.
• Prevent dry skin.
• Treat cuts promptly with antibiotics.
• No blood sampling from affected limb.
• Use sunscreen.

• Decongestive Lymphedema Therapy (DLT):
• Phase 1 (Intensive):
• Supervised
• MLD: manual lymphatic drainage
• MLLB: multilayer bandaging
• Phase 2 (Maintenance):
• Self-care.

• Exercises:
• Beneficial: Slow, rhythmic isotonic (e.g., swimming).
• Worsens with: Vigorous, anaerobic, isometric exercise.

• Surgery:
• TOC
• Lymphovenous anastomosis (creates bypass).
• Debulking (reduction procedures):
• Not done

• Vector: Aedes mosquito

• Seen in household water collection

• Serotypes:
• 4 types (DEN 1-4)
• DEN-2 = most dangerous (M/c)
• DEN-5 found in Bangkok (2013)

• WHO approved vaccines
• Dengvaxia
• Age: 9 - 16 years
• Dose: 3 doses, 6 months apart
• Prerequisite: Must be seropositive
• (Avoid in seronegative as it causes severe primary infection)
• TV003
• Age: 2 - 59
• Live attenuated
• For Seronegative / Seropositive
• Protect against all 4 dengue viruses

Clinical Features:

• ↓↓ platelet count (may need transfusion)

• Haemoconcentration (↑ haematocrit from plasma loss)

• AST/ALT >1000: Danger sign

Danger signs

• Lethargy

• ↑↑ hematocrit with Rapid ↓ Platelet count

• Abdominal pain, tenderness

• Vomiting - persistent

• Fluid accumulation: Ascites, pleural effusion

• Mucosal bleed

• Hepatomegaly >2 cm

Dengue Fever (Bone Break Fever):

• Bimodal fever:
• 2 peaks
• 1st: 2-3 days
• 2nd: 5-7 days

• Retroorbital pain: Characteristic

• Arthralgia, myalgia

Dengue Hemorrhagic Fever:

• Rise in hematocrit rise > 20% of baseline

• Platelets is not in criteria

• Tourniquet Test:
• > 20 petechiae/sq. inch: Positive
• < 10 petechiae/sq. inch: Negative

Dengue Shock Syndrome:

• Systolic BP: < 90 mmHg

• Note: Platelet count is not a criterion

Repeat Infection:

• Increased severity

• no cross immunity

• Cause:
• Occurs in individuals with pre-existing non-neutralizing heterologous dengue antibodies
• From previous infection with a different serotype
• Or passively acquired maternal antibodies in children

• Course:
• Initially resembles classical dengue fever
• Later, condition worsens

Lab Diagnosis:

• < 5 days: NS1 antigen, virus isolation, RT PCR

• > 5 days: IgM (MAC, ELISA)

Indicators for Dengue (Aedes Larval Surveillance):

Treatment in Dengue with Warning Signs

• Primary modality:
• IV fluid (crystalloid)

• Platelet transfusion:
• Indicated only if:
• Severe thrombocytopenia (<10,000)
• Active bleeding present

• FFP & cryoglobulin:
• Not preferred

Criteria for Discharge in Dengue

• Absence of fever for >24 hours without antipyretics

• Platelet count >50,000

• Return of appetite

• Adequate urine output

• Visible clinical improvement

• Minimum 2–3 days after recovery from shock

• No respiratory distress from pleural effusion or ascites

• Breteau index: For Dengue & Chikungunya
• (B → C → D)

• Neil Mooser Reaction/
  Tunica Reaction (in guinea pigs):
• R. Prowazekii:
• Negative reaction.
• R. Typhi: Positive reaction
• scrotal inflammation

Note

• He is Macho (Machiavello stain), Gym (Giemsa stain) and on Custody (Castanada stain) → Weli chaadi (Weil felix reaction) → using proteins (Weil felix → Use Proteus)

• Scrub cheyyunnavan says ok to everything (OXK positive on Weil felix)

• Eats egg (Yolk sac) → Yoyo CAR Mnemonic

Sandfly does not transmit: