Indoor Residual spray (IRS) in Malaria Control 1.

Vectors of Malaria

In India malaria is transmitted by nine vector species, six are of primary importance. These are: Anopheles culicifacies: Transmits malaria in rural and peri- urban Areas in plains In urban areas In north eastern states In Andaman and Nicobar Islands In hills and f

Anopheles fluviatilis oothills Anopheles stephensi Anopheles minimus Anopheles dirus Anopheles sundaicus Anopheles annularis Anopheles philippinensis Anopheles varuna

Of these An.culicifacies is responsible for the transmission of 6 -! " and An.fluviatilis, #$-% " ne& cases of malaria in our country. 'ontrol of malaria in India is actually control of An.culicifacies as each year 6 (! " of the allotted bud)et is spent for control of malaria in those areas &here An.culicifacies is the vector species for malaria transmission. The understandin) of the transmission of malaria is further complicated by the existence of species complexes of cryptic species or siblin) species or isomorphic species in this team and also in other malaria vectors. *xcept for An.stephensi all other malaria vector exist as species complexes comprisin) several siblin) species that result in considerable impact on the transmission of malaria includin) susceptibility to commonly used insecticides in public health pro)ramme. 2. Vector Control:

Intervention measures to restrict the transmission of malaria by controllin) the vector population form the main part of the vector control. *ffective vector control strate)ies are based on four facts:

+i, +ii, +iii, +iv,

-no&led)e and understandin) of vector biolo)y .urveillance of vector species Incrimination of vector species /ublic education and implementation of effective control measures.

0ector control pro)ramme in India, as in the case &ith many anti-malaria pro)ramme else&here, in the &orld, mostly rely on usa)e of natural and synthetic chemical molecules, &hich have potential to 1ill the tar)et insects. /resently different formulations of synthetic chemical insecticides are in the use for vector control. 2ettable po&der +2/, formulations are used for indoor residual sprays &hile emulsion concentrate +*', formulations are used for larval control. 3or Indoor 4esidual spray +I4., insecticides in use are 55T $ " 2/, malathion %$" 2/ and synthetic /yrethroid +2/,. .ynthetic /yrethroids include deltamethrin %.$" 2/, 'yfluthrin # " 2/, lambdacyhalothrin # " 2/, alphacypermethrin $" 2/, *tofenprox # " 2/ and 6ifenthrin # " 2/. .ynthetic pyrethroid insecticides are also used for impre)nation of bed nets. 3. Indoor Residual spray (IRS) : 7ost of the insecticides havin) residual effect are sprayed indoors, so that mos8uitoes after havin) bite on an infective person &ill rest in the house and &ill pic1 up sufficient insecticide particles sprayed on the &alls and other indoor surfaces of the house and its lon)evity &ill be reduced so much so that it does not survive to become infective. In areas &here the vectors are stron)ly endophilic, i.e. they tend to rest indoors, indoor residual sprayin) of human d&ellin)s can )ive very effective control. 0ectors that are exophillic i.e. they tend to rest outdoor but tend to feed or rest indoors briefly, can be effectively controlled by indoor residual sprayin) &ith insecticides that have )ood airborne effect. In areas &here vectors are stron)ly exophilic and9or exopha)ic, i.e. they rest and bite outdoors, other control methods, such as use of insecticide treated mos8uito nets or exterior space sprayin) +for emer)ency control,, should be considered. In practice, the effecti eness of house sprayin! for "alaria control depends on adherence to the specified criteria of the insecticide and application procedure, pu#lic acceptance of sprayin!, the a aila#ility of $ell "aintained e%uip"ent, ade%uately trained sprayin! personnel, efficient super ision and stron! financial support. &he si'e of the area depends on local circu"stances and is influenced #y the distri#ution of "alaria and "alaria ectors( distance fro" i"portant #reedin! sites, the fli!ht ran!e of the ectors and de"o!raphic features: :.# &ar!et area: ;enerally, all the interior &alls and ceilin)s are treated. In addition to permanent human d&ellin)s, field huts &here people sleep durin) the plantin) or harvestin) season should be sprayed, dependin) on local vector behaviour. The underside of furnitures, bac1 of the doors, outside caves and porch may need to be treated. It should be noted that the residual effect of insecticides may be short on some surfaces, e.). porous mud &alls, oil painted &ood and al1aline &hite &ash. 2

:.% Selection of Insecticides: .everal factors need to be considered in the selection of an insecticide sprayin), includin) availability, cost, residual effectiveness, safety, vector susceptibility and excito -repellency. There are lar)e number of insecticides, &hich are used as aduliticides for indoor residual spray. These are 55T, 7alathion and different formulations of synthetic pyrethroids. &he choice of insecticide for areas under the An.culicifacies: ectorial influence of

This species is a vector for malaria all over India. It is a complex siblin) species< A,6,', = 5. All siblin) species are efficient vectors of malaria except siblin) species >6?. A )enetic variant of siblin) species >6? transmits malaria only in 4ames&aram islands. .iblin) species &ere found to differ in their response to insecticides and also in the rate of development of resistance to different insecticides. 6ased on these observations, the follo&in) recommendations have been made in 7alaria Action /ro)ramme +7A/,, #@@$ for indoor residual spray: Areas &here species AA? is predominant: Areas &ith species A6B and A 'B : 7alathion %$" 2/ In most of the areas these .pecies have already developed resistance to malathion. /yrethroids use.

In areas $here o#ser ations a#out si#lin! species )*+, ),+ and )C+ are inconclusi e, use --& ensurin! total co era!e in &i"e and Space #efore s$itchin! o er to Malathion or .yrethroids . The other main vectors of malaria i.e., An.fluviatilis, An.minimus and An.dirus are still susceptible to 55T. Co&ever, susceptibility status should be continuously monitored and if the tests sho& development of resistance coupled &ith loss of epidemiolo)ical impact of spray operations, the follo&in) strate)y should be adopted for chan)e of insecticide. Resistant to 55T 55T and 7alathion 3.3 Chan!e of Insecticide: *lternati e insecticide 7alathion .ynthetic /yrethroids

If the chan)e of insecticide is &arranted, the state ;ovt. should support their choice of alternative insecticide by documentation of data on vector resistance studies and field observations on epidemiolo)ical impact of spray in 3

respect of insecticide in use. The chan)e of insecticide &ill al&ays be decided in mutual consultation bet&een .tate /ro)ramme Officer for N065'/, 4OC=32 and the 5te. Of N065'/ &ith concurrences of .tate and 'entral ;ovts. The proposal for any such chan)e of insecticide should follo& the follo&in) steps: +i, .tate ;ovt. submits the proposal for chan)e of insecticide to 5te. Of N065'/ in the month of Danuary-3ebruary. All technical data on vector resistance, epidemiolo)ical impact of the current insecticide in use, alon) &ith financial outlay, 8uantity of alternative insecticide chosen, &ith comparative cost difference for spray operation should be included in the proposal. The proposal should be discussed in the annual action plan meetin) in 5te.of N065'/. 7utual consultations bet&een the .tate /ro)amme Officer N065'/, 4OC=32 and 5te. of N065'/ in the month of 7archApril and report prepared in this re)ard for submission to Technical Advisory 'ommittee for approval under the chairpersonship of 5;C., ;OI. Approval of 7OC=32 should be obtained in the month of April7ay. Insecticide should be procured for next yearBs spray operations and fixin) of delivery schedule should be ensured so that the insecticide reaches the periphery by 7ay-April next year i.e. &ell before startin) the first round of spray operation.

+ii,

+iii, +iv,

E.

Insecticide for"ulations used under /V,-C.

The follo&in) formulations9compounds are used under the N065'/ for control of malaria: E.# 55T +5ichloro < diphenyl < trichloroethane,: In India 55T has been in use for malaria control since #@E6. 4ecently there has been a tendency to curb the use of 55T due to its persistence in the environment. It is a fact that if 55T is applied in a)riculture, it contaminate &ater resources, enters the biochain and at each step of the biochain, it )ets more concentrated +bio-ma)nification, till it reaches human bein)s. In human body, it is stored in the body fat and is excreted in the mil1. Therefore it reaches the infants ri)ht from the time of birth. .ince 55T persists for a lon) time in the community, there has been apprehension that it &ill produce adverse impact on human metabolism and )ro&th. Co&ever, in spite of extensive use of 55T in a)riculture, no adverse reaction of 55T on human health has been reported so far. A study )roup on 2CO has recommended that at this sta)e there is no Fustification on toxicolo)ical or epidemiolo)ical )rounds for chan)in) current policy to&ards indoor sprayin) of 55T for vector-borne disease 4

control. 55T may therefore be used for vector control, provided that all the follo&in) conditions are met. a, b, c, d, It is used only for indoor sprayin) It is effective The material is manufactured to the specifications issued by 2CO The necessary safety precautions are ta1en in its use and disposal.

;ovt. of India has constituted a mandate 'ommittee on 55T &hich revie&s the use of 55T in public health and decides its 8uantity to be released for the vector borne diseases control pro)ramme every year. 55T has an added advanta)e. It is comparatively cheaper than the other insecticides and even in those areas &here resistance to 55T has been recoded in studies &ith 2CO test 1its, the epidemiolo)ical impact of )ood spray operations is seen because of its excito-repellent action. Re%uire"ent of --&: #$ 7T per million population for t&o rounds of spray is re8uired. In areas &here third round is proposed in selected villa)es, additional re8uirement of !$ 7T per million population should be estimated. 0.2 1r!anophosphorous co"pounds: 7alathion %$" 2/ is used under the pro)amme in areas &ith 55T resistance. The disadvanta)e of or)anophosphorous compounds is that unli1e their use in a)riculture &here a farmer uses the or)anophosphorous compound for crop protection only once or t&ice a year, the spray s8uads en)a)ed in sprayin) residual insecticide in the human d&ellin)s &or1 &ith these compounds for periods extendin) up to 6 or ! months. This lon) exposure results in acute toxic symptoms and if not controlled properly may lead to mortality. Therefore, the spray staff en)a)ed in sprayin) of or)anophosphorous compounds are to be provided &ith more elaborate protective )arments and their blood cholinesterase level is to be chec1ed periodically to assess the toxic impact of the compound. These compounds are also toxic to domestic pets. Gnder Indian conditions, three rounds of spray &ith or)anophosphorous compounds are )iven as a)ainst t&o rounds of spray &ith 55T. In case of O/ poisonin), the patient should be transported as soon as possible to a doctor to receive an antidote. Or)anophosphate poisonin), 220 "! of atropine should be )iven intravenously +for children .$ to % m) accordin) to &ei)ht,. 5ependin) on symptoms, further doses of % m) should be )iven every #$ minutes for %-#% hours in severe cases. Automatic inFections are available for administration of atropine.

Re%uire"ent of Malathion234 5.: @ 7T per million population for three rounds of spray are re8uired. If in some areas a further round is re8uired in selected villa)es, : 7T per million population for the special round for the population of selected villa)es only 0.3 Synthetic .yrethoids: These are ne& insecticides introduced for control of vector borne diseases in India. The cost of these insecticides is much hi)her than the cost of 55T and 7alathion. 'urrently there are five insecticides of this )roup re)istered &ith 'entral Insecticide 6oard for use in the pro)ramme. These are +i, 5eltamethrin%.$" 2/, +ii, 'yfluthrin # " 2/, +iii, Alphacypermethrin $" 2/ +iv, Hambdacyhalothrin # " 2/ and +v, 6ifenthrin # 2/. In treatin) pyrethroid poisonin) vitamin * oil preparations can be )iven for prolon)ed paraesthesia. Only in cases of definite aller)ic symptoms should corticosteroids be administered. On occurrence of convulsions after sever intoxication, intravenous inFection of $-# m) 5iaIepam +or other benIdiaIepine derivatives, should be )iven. Re%uire"ent of Synthetic .yrethroids: +i, 5eltamethrin %.$" 2/: 6 7T per million population for t&o rounds of spray. In some areas, &here a further round is re8uired in selected villa)es, additional re8uirement of : 7T per million for the population of selected villa)es is estimated. 'yfluthrin # " 2/: #J.!$ 7T per million population for t&o rounds of spray and @.:J 7T per million population for selected villa)es &hich &ould re8uire special round9third round of spray. Hambdacyhalothrin # " 2/: #J.!$ 7T per million population for t&o rounds of spray and for a special round or IIIrd round of spray in selected villa)es, @.:J 7T per million population may be estimated. Alphacypermethrin $" 2/ :!.$ 7T per million population for t&o rounds of spray. 6ifenthrin # " 2/ : #J.!$ 7T per million population for t&o rounds of spray and @.:J 7T per million population for selected villa)es &hich &ould re8uire special round9 third round of spray.

+ii, +iii, +iv, +v,

0.0 Insecticide for"ulations and dosa!es for IRS2

S./o. /a"e of Insecticide .reparation of suspension in $ater -osa!e per s%."etre of acti e in!redient Residual effect in $ee6s *rea to #e co ered #y 17 lit.of suspension to !et correct dosa!e $ s8.m %$ s8.m $ s8.m $ $ $ $ s8.m s8.m s8.m s8.m.

#. %. :. E. $. 6 !.

55T $ " &p # 1)9# Hit 7alathion %$" &p % 1)9# Hit 5eltamethrin %.$" E )m9# Hit &p 'yfluthrin # "&p Hambdacyhalothrin # " &p Alphacypermethrin $"&p 6ifenthrin # " 2/ #%$ )m9# Hit #%$ )m9# Hit %$ )m9# Hit. #%$)9# litre

# )m % )m % m) %$ m) %$ m) %$ m) %$ m).

# -#% 6-J # -#% # -#% # -#% # -#% # -#%

0.3

Insecticide Resistance in Malaria ectors:

/resently insecticides belon)in) to different )roups, namely, or)anochlorine +55T,, or)anophosphate +7alathion,, and synthetic pyrethroid are used for public health spray. Insecticides belon)in) to the carbamate )roup have yet not been introduced for public health sprays in India. .trate)y for the chan)es in the insecticides has al&ays been reactive. .uccessive chan)es in insecticide &ere made after the failure of the control by the on)oin) insecticide intervention. A subse8uent chan)e in the insecticides has lead to se8uential selection pressure of insecticides resultin) in multiple insecticide resistant malaria vectors. 7alaria vectors in India are resistant to 55T alone or double resistant to C'C or triple resistant to 55T, C'C, malathion and 8uadruple resistant to 55T, C'C, malathion and 5eltamethrin +synthetic pyrethroid,. C'C has been phased out of the pro)ramme in #@@!. Of the six principal vector species, t&o, namely An.culicifacies and An.stephensi have sho&n &ide spread resistance. Other vector species are mostly susceptible to these insecticides. 5evelopment of resistance to synthetic pyrethroid &arrants a caution of impendin) possibility of &ide spread resistance to other compounds of this )roup that are introduced in public health pro)ramme for indoor residual spray as &ell as insecticide treated bed nets.

0.8

Strate!ies of -elay9* oid the onset of Resistance:

The most important aspect of the mana)ement of resistance is to either avoid or delay. The onset of resistance by effectively manipulatin) or influencin) the factors responsible for the development of resistance. The methods include avoidance of use of insecticide, that induce broad-spectrum resistance mechanisms and confer cross resistance to chemically related and un-related insecticides and se8uential use of insecticides in rotation is preferred. .ossi#le $ays of a oidin! de elop"ent of insecticide resistance in field 0.: Avoid indiscriminate use of insecticides Avoid use of insecticides that simultaneously select resistance to other chemically related insecticides. Avoid use of insecticides that induce development of more than one type of resistance mechanism of broad spectrum of resistance. Avoid use of the same insecticide both a)ainst adults and larvae. Gse of non chemical control methods, e.). biopesticides, larvivorous fish. Gse of syner)ist &ith insecticides to reduce physiolo)ical resistance. Insecticide spray operations:

The indoor residual spray of human d&ellin)s is as important for malaria control in the community, as is the early case detection and prompt treatment for an individual cure, therefore, it is essential that residual insecticidal spray should be planned and implemented &ith sound technical s1ill under expert )uidance . It should not #e entrusted to non2technical personnel li6e contractors, oluntary #odies etc. In the revised approach to malaria control, it has been decided to spray human d&ellin)s and mixed d&ellin)s. Cattle sheds are not to #e sprayed &ith a vie& to conserve insecticide, improve covera)e of human d&ellin)s and the present diversion of mos8uitoes from sprayed cattle sheds to human d&ellin)s. 0.; .lannin! for spray operations:

The plannin) of spray operations &ill be done by the 5istrict 7alaria Officer. Ce involves the 7edical Officer inchar)e of the /C's in this process. The epidemiolo)ical data should be thorou)hly analyIed in this process. A meetin) of 7edical Officer inchar)e /C's should be convened by '7CO957O for this purpose. Gnder the 7/O, the spray operations are to be carried out in all area &ith A/I % or above. Co&ever, the priority of spray &ill be )iven to Ci)h 4is1 areas all over the country. Therefore, in >hi)h ris1? areas the population of AsubcentreB 8ualifyin) under the criteria laid do&n by the expert committee is considered. The population is obtained from the epidemiolo)ical data collected from each of 8

the /C's of the district. The 7edical Officer inchar)e of /C' should brin) this information in the meetin) at district CK in the follo&in) format. The 5istrict 7alaria Officer should consolidate the information for the district in the follo&in) format .<C and su#2centres of =<i!h ris6> areas for spray operations S./o. /a"e of hi!h ris6 .<C .opulation of .<C /o. of hi!h <i!h ris6 ris6 su#2 population centres in for spray .<C Re"ar6s

In sub-centres &ith A/I % above +excludin) the hi)h ris1 sub-centres, population of 8ualifyin) sub-centres only to be considered for spray in a /C' is se)re)ated in the follo&in) format : ..No. Name of the /C' /opulation of /C' Number of sub-centres havin) A/I % = above /opulation of sub-centres havin) A/I % = above 8ualified for spray 4emar1s

2hile plannin) for spray, the epidemiolo)ical data of precedin) three years are considered for selectin) the population to be protected. 0.? Spray &echni%ue

The re8uired 8uantity of insecticide should be issued to the s8uads each day by the supervisor after chec1in) balance stoc1s available from previous dayBs supplies. The insecticides used under the National 0ector 6orne 5iseases 'ontrol /ro)ramme +N065'/, are available as &ettable po&ders. The preparation of the spray suspension is made Fust before the start of the spray operations every day. It is important that the suspension is made correctly so that the correct dosa)e is applied on the sprayed surfaces. The procedure for the preparation of the suspension is the same irrespective of the insecticide. Co&ever, the 8uantity of the insecticide used per # litres of &ater &ill depend on the insecticide used. The re8uired 8uantity of the insecticide is measured &ith a plastic mu) and poured into a #$ litre buc1et. A paste is made &ith a small 8uantity of &ater. The remainder of &ater is then poured slo&ly into the buc1et and the insecticide &ater mixture is stirred vi)orously to obtain a uniform suspension. The suspension is then poured into another buc1et throu)h a cloth sieve to remove any particulate matter that mi)ht clo) the noIIle of the spray pump. 9

The barrel of the stirrup pump is put in the buc1et containin) the spray suspension. One man operates the pump and the other man sprays. The spray lance should be 1ept E$ cms +#J inches, a&ay from the &all surface. The s&ath should be parallel. .pray is applied in vertical s&ath of $: cm +%# inches, &ide. .uccessive s&aths should overlap by !.$ cm +: inches,. .pray is done from roof to floor, usin) do&n&ard motion, to complete one s&athL then steppin) side&ays and sprayin) up&ards from floor to roof. 5o not let the spray drip to the floor. .prayin) is done on inner surfaces includin) eaves and roofs. The dischar)e rate should be !E to J$ ml per minute. To obtain the above dischar)e rate, the pump man should )ive % to %6 stro1es per minute &ith # -#$ cms plun)er movement at a pressure of # /.I + .! 1)9s8.cm, at the noIIle tip. .prayin) into a buc1et for one minute and measurin) the 8uantity of the suspension in a )raduated mu) should chec1 the correct dischar)e rate +!E to J$ ml9minute,. The noIIle tip should be discarded if the dischar)e rate exceeds J$ ml per minute. If the spray stops due to a bloc1a)e in the noIIle, the noIIle cap be unscre&ed to remove the bloc1a)e and replaced &ith a ne& one. The bloc1ed noIIle should be put in a container &ith &ater for a fe& hours before the bloc1a)e is removed &ith a finer &ire. A )ood 8uality spray should lead to uniform deposit on &alls and other sprayable surfaces. This is easy to verify for 55T and malathion sprays as the insecticide deposits are clearly visible. 5eposits of synthetic pyrethroids are visible on &ooden structures. The supervisor throu)h physical verification should verify the 8uality and covera)e of spray randomly. It ta1es about $ minutes to spray a house &ith an avera)e surface area of #$ s8. metres. A daily summary of spray operations should be maintained by the field supervisor and verified by the health &or1ers sho&in) the areas covered, percenta)e room covera)e and insecticide consumption in the tables as belo&: Villa!es Selected @or Inter ention Measures A Spray 1perations Spray 1perations *t Su#centre 1n 2222222222222222222222222222222 Villa!e &o #e Sprayed Sprayed <ouses Roo"s <ouses Roo"s Boc6ed9Refused

10

-aily Consu"ption Record 1f Insecticide Spray 1perations *t Su#centre 1nCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCC Insecticide Issued +Kty.&p, 6alance insecticide available from previous day Number of buc1ets +$ litres,

/repared

'onsumed

0.17

SD.ERVISI1/, .R1CESS */- .ER@1RM*/CE I/-IC*&1R

.upervision of spray operations is a very important activity to ensure that spray operations are carried out accordin) to correct technical procedures, &hich is essential for ta1in) corrective action, and achieve the pro)ramme )oals. .upervision is carried at all levels of pro)ramme implementation. It can be concurrent or consecutive. A stratified sample should be ta1en up for supervision. Concurrent super ision The follo&in) should be chec1ed durin) such inspections: 5ate of advance notification and the maintenance of time table for spray operations Turn out of spray cre& NoIIle tip dischar)e rate 'onditions of spray pumps /reparation of insecticide suspension Actual sprayin) operation includin) the techni8ue, speed and covera)e etc. *xtent of refusal to accept spray and the numbers and percenta)e of loc1ed houses 7aintenance of spray records 'onsumption of insecticide as determined by the 8uantity issued and stoc1 in hand 5ate and time of chec1in) of the s8uad by Inspectors9 .upervisors and other supervisory personnel and their remar1s, if any Arran)ements for moppin) up 3uture pro)ramme and time schedule 11

Consecuti e super ision The follo&in) is to be chec1ed in consecutive supervision *vidence of insecticide deposit on sprayable surface particularly on the ceilin) and &ooden material li1e &indo&s etc. 5ispersal of the insecticide deposits on the &alls to verify uniformity of deposits Number of rooms in each house sprayed satisfactorily, partially and not at all /ercenta)e of refusals and loc1ed houses 3actors responsible for not sprayin) any area as elicited throu)h en8uiries from the residents Attempts made for moppin) up operation in the event of hi)h refusal *xtent of mud plasterin) on the &alls, if any and other relevant matters. 0.11 Co""unity participation

Involvement of /anchayats in successful indoor residual insecticide spray is an essential aspect of the pro)ramme. /anchayats9villa)e9 local bodies9 villa)e heads9 6loc1 5evelopment Officers9 7ahila 7andals, reli)ious )roups etc., are to be informed about the spray schedule at least before a fortni)ht. This advance information must be mopped up by .urveillance 2or1ers97alaria Inspectors9 5istrict 7alaria Officer so as to facilitate the villa)ers to extend full cooperation in )ettin) actual spray inside of human d&ellin) &ith the obFective of full covera)e of tar)eted population. It is not the insecticide but the supervision and re-supervision of the spray operations, &hich matter in the control of vector borne diseases. *nsure hi)h covera)e of insecticide spray in terms of time = space.

12