Some facts about Malaria

Malaria is re-emerging as the number one infectious killer and is number one priority tropical
disease of the WHO. Malaria ranks third among the major infectious diseases in causing deaths
after acute respiratory tract infections and tuberculosis. Malaria kills over one million people
globally each year and majority of them are children. Malaria kills a child every 30 seconds.
With acute disease a child may die within 24 hours without prompt and effective treatment. In
endemic areas women are more likely to have malaria during pregnancy which can lead to serve
anemia and higher risk of death. Infants born to mothers with malaria are more likely to have low
birth weight, which is the single greatest risk of death during the first month of life. Health
system failure drug resistance, population movement, deteriorating sanitation, climatic changes
and unplanned development activities are contributing to the spread of malaria. Prompt and
effective treatment of suspected malaria fever cases can significantly reduce malaria.
Malaria control in Pakistanan Historic Perspective
Malaria control activities have always been a priority in Pakistan. Development of irrigation,
netweroks, coupled with unprecedented population growth and haphazard urbanization, together
with the existing socio-economic and enviornmnetal conditions has increased the malariogenic
potential of the country.
Phase one:- Malaria Eradication Era
The country has been actively engaged in malaria control activities when Malaria Eradication
Campaign was started in 1961 under the auspices of WHO and with the support of UNICEF and
USAID. As a result of this campaign malaria was nearly eradicated from the country, bringing
reduction from 15% to 0.01% in the positivity rates of slides collected in surveillance operations.
Phase Two:- Malaria control Programme
The relief however proved temporary and malaria begain rising in 1969 when DDT and
Dieldrin/BHC became resistance in Anopheles. The programme collapse subsequentely and
epidemic occur in 1972-73. As a result there initiate five year National Malaria Control
Programme MCP in 1975 agin using vector control as the major intervention strategy. At this
stage the implementation was handed over to the provincial governments and malaria control
programme was integerated with the general Health Services.
Phase 3:- Roll Back Malaria
In view of the deteriorating malaria situation in many countries the WHO in 1998 launched a
global Roll Back Malaria. The main aim of RBM is to
Reduce disease burden by 50% by the year 2010.
Pakistan joined hands with RBM in 2001.
Policy of RBM
Strengthening early diagnosis and prompt treatment of malaria cases including
good supervision and monitoring arrangements.
Strengthening IVM mainly through promoting insecticides treated nets, focal
spraying with insecticides and selective use of larvicides.
 Strenghthning the behavior change communication and community mobilization
for effective malaria control.
Developing partnerships with governments and non governments partners both at
national and international level.
Enhancing the capability to design and conduct operational research on priority
programme issues as well as programme.

SoPs for Quality Assurance of Malaria Microscopy

Early diagnosis and prompt, effective treatment is the basis for the management of malaria and
key to reducing malaria mortality and morbidity in Roll Back Malaria. Demonstration of the
presence of malaria parasites prior to treatment with antimalarial drugs is fundamental this goal,
as clinical diagnosis has poor accuracy and leads to over-diagnosis of malaria with resultant poor
management of non-malarial febrile illness and wastage of antimalarial drugs. While microscopy
remains the mainstay of parasite-based diagnosis in most large health clinics and hospitals, the
quality of microscopy-based diagnosis is frequently inadequate for ensuring good health
outcomes and optimal use of resources. An acceptable microscopy service is one that is cost-
effective, provides results that are consistently accurate and timely enough to have a direct
impact on treatment. This requires a comprehensive and active quality assurance (QA)
programme. The primary aim of malaria microscopy QA programmes is to ensure that
microscopy services are manned by competent and motivated staff, supported by effective
training and supervision that maintains a high level of staff competency and performance
and by a logistics system that provides and maintains an adequate supply of reagents and
equipment.
QA programmes must be:
Sustainable
Compatible with the needs of each country
able to fit into the structure of existing laboratory services.
Characteristics of QA Programmes
A QA programme should appropriately recognize and accredit good performance, identify
laboratories and microscopists with serious problems which result in poor performance,
establish regional or national benchmarks for quality of diagnosis and central reporting of
indicators including accuracy, equipment and reagent performance, stock control and
workload. Without an efficient QA programme, resources spent on diagnostic services are likely
to be wasted and clinicians will have no confidence in the results.
At a minimum, a malaria microscopy QA programme should include the following:-
A central coordinator(s) to oversee QA.
A reference (core) group of microscopists at the head of a hierarchical structure, supported by
an external QA programme and with demonstrable expertise in overseeing programme training
and validation standards.
 Good initial training with competency standards that must be met by trainees prior to
operating in a clinical setting.
Regular retraining and assessment/grading of competency, supported by a well validated
reference slide set (slide bank).
A sustainable cross-checking (validation) system that detects gross inadequacies
Good supervision at all levels.
Good logistical management, including supply of consumables and maintenance of
microscopes.
Clear standard operating procedures (SOPs) at all levels of the system.
An adequate budget is required as an essential part of funding for malaria case management.
Quality assurance
The monitoring and maintenance of high accuracy, reliability and efficiency of laboratory
services. Quality assurance addresses all factors that affect laboratory performance
including test performance (quality control, internal and external) equipment and reagent quality,
workload, workplace conditions, training and laboratory staff support.
Quality control
Measures the quality of a test or a reagent. For malaria microscopy, the most common form of
quality control (QC) is the cross-checking of routine blood slides to monitor the accuracy of
examination. Quality control also encompasses external quality control and reagent quality
control. Cross-checking QCis a system whereby a sample of routine blood slides are cross-
checked for accuracy by a supervisor or the regional/national laboratory. Reagent QCis a system
of formally monitoring the quality of the reagents used in the laboratory.
Microscope
Basic cleaning/maintenance
Correctly set up a microscope (correct illumination)
Correctly use a microscope
Slide Reading
Accurately identify asexual stages
Accurately differentiate between Pf and non-Pf
Identify all the species present in the local region
Identify gametocytes
Quantification
Perform a basic differential count on the thick film neutrophils, lymphocytes, eosinophils
Identify other major local blood parasites
Data
Recording of results in a laboratory register
Regular collation of data
Other
Basic inventory control and stock management
Training in basic quality control
Training in blood safety
Biosafety/waste management
Use of referral system

Elements of Quality Control-Administration

1. Workplace
The laboratory should be organized to allow efficient flow of work. Microscopy area
should be secure, standardized and comfortable work place.
2. Staffing
A staff must receive proper training in malaria microscopy. Staff must have technical
knowledge and skills appropriate for laboratory work.
3. Standard operation procedure
Methods must comply with current international standards e.g microscopy manuals. The
methods in use must be as recommended by the microscopy manual of MCP. The
microscopy manual must be located in the labarorty working area.
4. laboratory register
All work performed such as examination of ACD, PCD,ECS, MBS slides must be entered
and recorded in Malaria Case register from EVA.M-2 Forms on which number, detail of
slides such as name of patient, age, sex, addresses, Name of Union Council, Date of
smears taken.
5. Data collection
 The laboratory must collect and analyze data on workload and results. Malaria case
diagnosis must be entered in Malariomateric monthly record (EVA-M-4) and then G-30
Form(Form-A)
6. Equipment
All laboratory equipments such as Electric, Binocular microscope capable of x 1000
magnification must be maintained to be in working condition.
7. Supplies
Laboratory staff must take responsibility for ensuring there are adequate stocks of
Gimesa Stain, Slides, Slides boxes, Ph Meter, Stock solution of GSS, Xylene, Oil
emersion.
8. Smear Preparation
The smear must be prepared on clean glass slides during Active Case Detection on
EVA.M-2 Forms containing all the relevant information of PUO and suspected malaria
patient by CDC Supervisors in the field. PCD(Passive Case Detection) form in RHC,
THQ and DHQ Hospital available for recording of malaria patients.
9. Microscopy and reporting
Results must be graded whether plasmodium vivax, plasmodium falciparum, plasmodium
ovale, plasmodium malariae or mix type of infection. Where practicable positive slides
should be verified by another worker before reporting. Results must be reported to doctor
as soon as possible.
10. Workload
Workload should not exceed 50 slides per microscopists per day.
11. Decentralization of malarial microscopy centres
In Punjab, each Rural Health Centres, Tehsil Headquarter Hospital and District
Headquarter Hospital Malarial microscopy centres are available where trained
Microscopists/ Lab. Assistants /Lab. Technicians perform malarial microscopy.
12. Malarial Microscopy centre at District Officer Health Office
In each district of Punjab there is malarial microscopy centre at DoH Health office where
20 percent of checked slides are re-examined for quality assurance.
13. Provincial Reference Lab at Directorate General Health Services Punjab Lahore
Five percent quota of slides checked from whole of 36 districts is sent to Provincial
Reference Lab and all positive slides are also sent to PRL at Directorate level.
14. Mechanism of on site visits
Monthly visits of the District Lab. Supervisor or Sr. Microscopists is required to each
malaria diagnostic centre and he report significant discrepancies to District Officer Health
as well as Incharge Rural Health Centre. Quarterly visits of the Sr. Microscopist of
Province Reference Lab should visit each District or peripheral laboratories. The main
purpose of the on site visit is to check that the laboratory, under routine conditions, is
operating according to the standards set down by Malaria Control Programme. It is also
essential that the observations, in the broader sense, should cover both administrative as
well as technical aspects.
15. Slide Storage
Ideally, all laboratory slides should be kept for more than 12 months or at least six
months.
16. Acceptable smears
Blood smears must be made according to malaria microscopy manual. There must be
proper thickness of both thick and thin smear, it must be properly labeled with serial
number, date and union council, adequate size, free of debris and properly stained.
17. Wastage and disposal of slides
Broken and wasted slides must be incerinated or properly disposed off.

SoPs for malaria case management

The history of malaria dates back to 1700 B.C. Malaria is a common and serious public
helath problems in many parts of the world, including Pakistan. Malaria is ranked among
the leading causes of mortality due to communicable diseases, killing globally one
million people each year, majority of the children. There is an evidence of worsening
global malaria situation mainly due to resistance to anti malarial drugs. Malaria is major
constraint to economic and social development of countries and as a result a global
partnership emerged as Roll Back Malari IN 1998. The main objective of RBM is to
reduce the global malaria burden significantly through intervention adopted to local
needs and strengthening of the health sector. Early detection and prompt treatment of
malaria cases is the key element of the global and national RBM strategy package. Other
key elements include early detection and response to malaria epidemics, multiple
prevention measures including ITN Promotion and community awareness.
The Malaria Control Programme has developed national policies and strategies for
countrywide implementation of standardized case management. In order to minimize the
variation in case management practices, there is Standard Operating procedure for case
management of complicated and uncomplicated malaria cases. The main purpose of
malaria case management is to train doctors on the national guidelines for managing
malaria patients and to increase their skills in malaria diagnosis, prescription, education,
recording, reporting and follow up of malaria cases.
1. Malaria Causative Agent and its life Cycle
Malaria is an infection of RBS (Red Blood Cells) by a singled celled parasite. It is
spread by the bite of infected female Anophelen Culicifacies mosquitoes. Potentially
malaria can also occur after transmission with contaminated blood or an injection
with a infected needle with blood having parasites of malaria.
2. Causative agents
There are four species of the parasite
i. Plasmodium vivax
ii. Plasmodium falciparum
iii. Plasmodium ovale
iv. Plasmodium malaria,
 However in Pakistan first two parasites are commonly found.
3. Life Cycle of Female mosquitoes i.e Anopheline Culicifacies
Eggs, Larvae, pupae and adult mosquitoes are four stages.
4. Life Cycle of the Parasite
i. Upon ingestion of infected blood by mosquito, the parasites reproduce in its
gut and then move to the salivary glands.
ii. On biting of female mosquito of anophelene the parasite injected along with
saliva into peripheral blood.
iii. Inside human, parasite move to liver where they multiply and mature over a
period of two to four weeks.
iv. After maturation parasites enter the blood stream and infect RBC and multiply
in them and RBC rupture and at this stage rigors chills and fever occur.
v. The released parasites infect new RBC and thus repeating the cycle several
times.
vi. In blood sexual parasites called gametocytes of the parasites is formed and
when ingested by the mosquito are reproduced there thus completing the full
life cycle of the parasites.
vii. The incubation period is variable---usually between two to three weeks for
P.vivax.
Early Diagnosis and prompt Treatment of Malaria Case
PCD (passive Case Detection is the main strategy for the detection of malaria cases.
However restricted use of ACD (Active Case Detection) would be continued in the areas
of high epidemiological importance such as flood affected areas during epidemics and out
breaks.
The patients with symptoms of uncomplicated malaria, visitng health facilities or getting
in contact with community based health workers such as LHW/CDC Supervisors would
be clinically assessed as per MCP Guidelines.
The patients with symptoms/signs of complicated/Severe malaria, visiting helath facilties
would be clinincally assessed and referred to Hospital.
The microscopy services would be offered at District and Tehsil level as well as RHC and
selected BHUs.
The trained microscopists at the facility would be responsiable for collecting the blood
smears, preparing thick and thin smears, recording and reporting the results.
The patients attending therse health facilties should get the Malaria patients MP results on
the same day basis to ensure prompt treatment.
If microscopy services are accessible, the probable malaria case is sent for smear
microscopy. The confirmed cases are treated according to the type of malaria in
accordance with MCP Case management guidelines.
Those not confirmed on microscopy but clinincally judged as malaria, would be treated
as clinincal malaria cases, as per MCP Case Management guidelines.
 If Microscopy services are not accessible, the malaria case is assessed clinincally and
treated as clinical malaria as per MCP Case Management Guidelines.
Uncomplicated Malaria
Fever for severl days i.e 2 to 3 days with one or more of the following
Chills/shivering
Headache
Generalized body aches and pains
Malaise
Vomiting or diarrhea
Poor or loss of appetite
Body weakness and dizziness
Diagnosing uncomplicated malaria with laboratory facility
Doctor fills the investigating request form for each patient requiring MP
examination
Preparation of thich and thin blood smears by microscopists.
Staining of blood smears slides
Examination under microscope
Reporing the results to the doctor on the investiong requiest form whether
Plasmodioum Vivax, Plasmodium falciparum or negative or malaria parasite
not seen.
Deciding treatment for clinical and confirmed malaria cases
Essential Mode of action Dosage Common drug
Antimalarial drugs preparation
Chloroquine Blood Schizonticidal 25 mg/kg body weight Tablet 150 mg/ Syrup
for 3 days 50mg/5ml
Primaquine Pv:- Tissue 0.25 mg/kg bw for 14 Tablet 15 mg
Schizonticidal days
Pf:- gametocytocidal 0.75 mg/kg bw single
dose
Sulfadoxine + Blood schizonticidal 25 mg/kg bw Tab. Sulphadoxine
pyrimethamine sulphadoxine 500 mg
1.25 mg/kg bw Tab. Pyrimethamine
pyremethamine 25 mg
Artesunate Blood schizonticidal 4mg/kg bw Tablet 50 mg and 100
mg
Quinine Schizonticidal 10 mg/bw Tablet 300 mg
Injection of 1 ml
injection

Treatment choices for uncomplicated malaria

Condition First line drug Second line drug Third line drug
Clinical malaria Chloroquine Sulhadoxine- --
pyrimethamine
Vivax malaria Choloroquine+primethamine --
Falciparum malaria Choloroquine + primaquine Sulhadoxine- Quinine
1 Dose pyrimethamine
Artesunate +SP ----- Quinine
(Combination therapy when
available)

Severe or complicated Malaria

Severe or complicated malaria is defined as severe manifestation of malaria that may
contribute to major organ dysfunction or failure e.g coma, renal failure or pulmonary
edema or even death if treatment is not properly done. Severe or complicated malaria
caused by plasmodium falciparum.
Diagnosis of severe malaria
The diagnosis of severe malaria is based on clinical assessment, microscopic
examination and other supplementary lab. Investigation such as rapid diagnostic tests
RDTs, blood examination and urine examination.
Prescribing anti malarial drugs to the patients with severe malaria
In severe malaria, the WHO recommends parenteral antimalarial administration
because gastointetesintal absorption of anitmalarial drugs may be unpredictable
during sever malaria. Oral drug administration can be given once the patient is able to
swallow. If not swallow then rectal or IM Route can chosen. IV route should be
selected If the facilities for maintaining IV exist.

SOPs for Chemical Interventions against vectors of Malaria

Before first starting the unit the operator must be firm with the safety instructions.
Only educated and authorized persons are allowed to work with the unit.
The operator must follow the actual rules for the prevention of accidents,
when working with fuel and fuel driven units like TF 35 etc.
1. Smoking is strictly forbidden, while working with fuel. Nearby to the fuel open
flames or other hot thermal sources should not exist.
2. Do not fill the fuel into the fuel tank, as long as the temperature of the
unit is still high. Danger of fire and explosion exist.
3. Do not spill fuel, when filling the fuel tank. Use the funnel with strainer
provided by the company. In case of spilling fuel, use a dry cloth and take residual
fuels away from the unit.
4. Never operate the unit, when combustible materials or gas are nearby.
Danger of fire and explosion exists, because there is an open flame inside of
the fogging tube. Avoid direct between the hot fogging tube and other materials,
because will be damaged due to the high temperature.
5. It is forbidden to fog in rooms with finest combustible dust particles ( I. grain
silo), because danger of dust explosion exists.
6. It is forbidden to fog into enclosed rooms where open flames, candle light, hot
engines or electrical appliances exit, because of danger of fire.
7. When fogging in enclosed rooms, take into account that fogging can lead
to fire and explosions if the concentration of fog in a room exceeds a crucial value.
This is due to the combustible additives of such a fog. Do not fog longer than
allowed into enclosed rooms. Make your self familiar with the dosage of
combustible additives in enclosed rooms. Calculate the maximum quantity of
combustible additive depending on room size, nozzle size and fogging time,
before you start fogging into enclosed rooms.
8. It is not allowed to transport the unit in a closed vehicle, as long as the unit is hot.
Wait until the unit has cooled down.
9. Do not leave the working unit unattended in closed rooms.
10. Comply with the specifications of manufacturers regarding safety instructions
and dosage of formulations. Do not spill solution, when filling the solution tank.
Use the funnel with strainer. In case of spilling solution, use a dry cloth and take
residual solution away from the unit. In case of etching formulations wear protective
gloves and protective spectacles. Store and depose residual formulations carefully
according to legal regulations.
11. Wear suitable ear protectors when operating the unit. The noise level of the unit
exceeds 90 DBA.
12. Wear a breathing mask and protective clothing when fogging in enclosed
spaces. Use suitable filters against organic fumes and solvents. When etching
formulations are used for fogging, and then wear a full protection including
breathing mask, protective clothing and protective gloves.
13. In stationery operation the unit must stand horizontal and stable on a rigid
base. Unstable positions of the unit are not allowed. Do not leave the working unit
unattended in closed rooms.
14. In mobile operation carry the unit by means of the carrying belt. When
carrying the unit, Tanks show to your body. Do not put the carrying belt onto hot
areas of the unit. Carry the belt at the same shoulder side which has to carry the unit,
that means do not put the belt over your neck.
15. Do not touch hot areas of the unit, because touching leads to harmful
burns on hand and fingers. Especially the fog tube, the combustion chamber
and adjacent part gets extremely hot. During operation the protective covers
and the heat deflector shield heats up due to temperature radiation. Avoid
touching those parts.
16. Repair the unit after the unit has cooled down. After repair do not forger
to reattach heat deflector shield and protective covers.
17. Do not fog if the unit does not work properly.
18. Do not fog directly against persons, walls or other objects. During operation keep
distance or minimum 3 m.
19. If the unit stops running due to malfunction or due to missing fuel. Close
immediately the solution taps (lever shows upwards). Slightly incline the fog tube
downwards, so that liquid solution flows out of the fog tube.
Attention: Liquid solution is inflammable. Use a suitable metal receptacle for
collection of liquid solution.
20. Never start the unit, if the swirl vane is detached from the maxing chamber
(carburetor) but still connected with the ignition. If fuel tank is open, ignition sparks
cold inflame fuel or fuel vapour. Dangers of fuel vapour explosion exist.
21. A reconstruction of the unit without written permission of manufacturing
company is not allowed. Use only original spare parts and accessories from
company.
22. If you fog into enclosed rooms, those rooms must be marked as forbidden areas
and must be protected against access, especially children.
23. Make sure that a fire extinguisher is available, before you start working with TF
35 etc in enclosed rooms.
24. Before the unit is stored for longer periods, remove residual fuel, residual
formulation and batteries out of the unit.
25. Store formulations, fuel and the unit itself at places where they are not accessible
to children and other persons, who may not be aware of dangers involved.
26. Regard the unit as your personal fogger. Keep the unit always under your
responsibility. Read and follow the operating and service instructions by the
respective company.
27. To avoid chemical reaction when mixing different active substances, the
instruction of the manufacturer must be followed.
28. When solution tank is filled, the instructions of the chemical manufacturer must
be followed regarding transport storage etc.
29. Danger of burn / Burning by stumble.
30. Walking direction should be contrary to the fogging direction. Pay
attention to sufficient sight.
31. Walking direction should be contrary to the fogging direction. Pay
attention to sufficient sight.
Dosage Schedule of Insecticides for thermal fogging
A. Permethrine 25EC (25g/L):
250 ml of insecticide will be mixed with 10 L Diesel.
01 hectare (10000 m ) area will be covered with whole prepared mixture (10- 50 L).
B. Deltamethrine 1.5 EC (1.5 g / L):
333 ML to 666 ML insecticide will be mixed with 10 to 50 L Diesel.
01 hectare (10000 m ) area will be covered with whole prepared mixture (10-50L).
LARVICIDING.
Larviciding should be considered as complementary to environmental management
In larviciding, strict precautionary measures should be observed, Including:
daily washing of overalls.
use of cloth face masks, broad-brimmed hats
shoes or boots.
Mixers and baggers handling the concentrate should also wear rubber boots,
gloves and aprons.
Any concentrate that gets onto the skin should be washed off at once. Clothes that
are wetted with the insecticide should be changed immediately.
Operators should not be exposed to the insecticide for longer than the
predetermined working hours (usually 56 h).
Transport should be arranged to minimize delays between the end of a days
operations and return to base for showering, which should be mandatory.
Once a week, all personnel exposed to the insecticide should be examined and
their cholinesterase activity determined. Operators should be withdrawn from
exposure if their cholinesterase activity decreases to 50% or more of that before
exposure. The simple tintometric method is suitable for determining blood
cholinesterase activity.
Stay out of the house during spraying, prevent children from re-entering the house
until the floors have been swept or washed.
Dosage Schedule of Insecticides for Larviciding
A. Fenthion 2 % Granules B. Temephos (Abate) 50% EC

Sr. No depth dosage

1 01 to 15 Cm 0.55 gram / m
2 16 to 25 Cm 1.10 gram / m
3 26 Cm and above 1.65 gram /m
INDOOR RESIDUAL SPRAY
INSTRUCTIONS.
Spraying staff should be provided with at least two uniforms to allow for frequent
changes.
Washing facilities with sufficient water and soap should be made available in the
field at appropriate locations.
All working clothes must be removed at the end of each days operations and a
shower or bath taken.
Working clothes must be washed regularly, the frequency depending on the
toxicity of the formulation used.
Particular attention should be given to washing gloves, as wearing contaminated
gloves can be more dangerous than not wearing gloves at all.
Dosage of Temephos 50 EC
Sr. No depth Dosage
1 01 to 15 Cm 0.04 ML / m
2 16 to 25 Cm 0.08 ML/ m
3 26 Cm and above 0.12 ML/m
Spray operators must wash before eating.
Eating, drinking and smoking during work must be strictly forbidden.
When work involves insecticides of relatively high toxicity, the hours of work
must be arranged so that exposure to the material is not excessive; transport should be
arranged so that there is not a long delay between the end of the daysoperations and
return to base for washing.
Operational procedures
Spraying staff will inevitably be exposed to insecticide spray, and absolute protection
of the skin and respiratory tract would impose physical limitations that would make
such work impossible in hot climates. The skin can be protected to a considerable
degree by cotton clothing and by regular washing with soap and water.Inhabitants of
houses that are to be sprayed should be informed of the purpose and the times of
insecticide applications and should be given clear instructions as to what to do before
and after their houses have been treated: e.g. remove all foodstuffs and cooking
utensils, stay out of the house during spraying, prevent children from reentering the
house until the floors have been swept or washed. Appropriate facilities must be
provided for handling pesticide concentrates, both as water-dispersible powders and
as emulsifiable concentrates. Workers must use protective clothing and equipment as
indicated below. When workers are weighing insecticide powder and preparing the
suspension, they should avoid contact with the powder and should stand in such a
position that the wind blows the dust away from them and not onto other workers. If
the concentrate comes into contact with skin, it should be washed off atonce. Work
should be performed away from food and cooking utensils. Any spillage of
insecticide onto the ground during mixing should be removed, in particular for the
protection of chickens and domestic animals. Concrete surfaces should be washed. To
clean earth surfaces, damp earth should be scooped up and then buried. Large
numbers of insects, such as flies, moths and bedbugs, might be killed and fall on the
floor during indoor spraying operations, presenting a hazard, particularly to chickens.
Floors should therefore be carefully swept and the sweepings safely disposed of.
Staff spraying organophosphates should wear clean, regularly washed overalls, broad-
brimmed hats and shoes or boots (not sandals) while spraying. Mixers and baggers
and any other personnel handling the concentrate should also wearprotective clothing
and rubber gloves while working. They should wash, preferably under a shower, at
the end of a days work.
INSTRUCTIONS FOR MIXING OF INSECTICIDE FOR INDOOR
RESIDUAL SPRAY & SPRAY ACTIVITY.
Prepare homogenous insecticide in a bucket by mixing 125 gms of Deltamethrine
5%WP powder in 10 liters of water.
 Decant the solute before filling up the tank of spray pump.
Make a pressure in spray pump upto 55 psi (per square inch pressure). If it
reduces to 25 psi, repressurize upto 55 psi before restarting the spray.
The spraying speed should be 19m 2 area per minute.
Distance of nozzle tip from the surface should be 18. The nozzle should be
angled at 90 and the layer be overlapping.
Spray should cove whole room including side walls, roof & floor, area
behind curtains, under the beds and corners behind the doors & windows. The
utensils from the kitchen be removed & proper preparation be done prior to start of
spray. Shake the spray pump at each corner to avoid sedimentation of insecticide.
Deposit rate of Deltamethrine 5% WP must be 0.025 gms/m
10 liter suspension of insecticide is enough for 210 to 220 marea ( 4-5 rooms).
Door marking after spray of house as T-Total, P-Partial, X-not sprayed,
date of sprayed houses be recorded on form.
Dosage Schedule of Insecticides for Indoor Residual Spray
Name of Insecticide: Deltamethrine 5 % WP
125 gram of the powder will be mixed with 10 L water.
All rooms (complete walls, roof, curtains, below furniture) must sprayed
completely and room should be closed for one hour after spray.
Area of 210 to 220 square meter (3 to 4 rooms) will be sprayed with 10 L
mixture (01-spray pump).
Deposit rate of insecticide used for IRS must be 0.025 gms/m

SoPs for vector surveillance and its control

Selection and procurement of insecticides

All kinds of insecticides are selected and procured strictly as per protocol of WHOPES
(World Health Organization Pesticides Evaluation Scheme)
For Instance
Product Specifications: Temephos 1% Sand Granules(Active Component/ingredient should be
within range of 5%)(95%-105%), Original Pack of maximum of 25 kg Net.
New strong plastic container/cotton bag with the inner polyethene bag
with the nominal thickness of 0.1 mm with the marking on the container/bag the following:-
Labeling:
Orginal lable of the manufacturer with following informations
Name of insecticide (Generic and Brand (if applicable), equally prominent in English/ Urdu
Name of active ingredient
Contents of active ingredient(Gm/Kg or % W/W)
Net content of unit pack (e.g Liter, grams, Kg)
Date of manufacture/formulation
Date of expiry
Batch Number
Registration No. In country of origin
Precautionary pictograms
First Aid and medical advice/Antidote
Name, address and contact number of Manufacturer and Supplier
Manufacturer company logo, if any
Warning or caution statements(Required Signal word such as, Danger, Warning, or Caution
and the statement, Keep out of reach of children must appear on the front panel
and the front label of the labelled insecticide must contain the following namely
: the word POISON in Red on a contrasting background
The word DANGER
Stamped or printed, NOT FOR SALE , PUNJAB GOVERNMENT PROPERTY
Note:- The company will provide detail information about
Materials safety data sheet
Test report of the product conducted at the lab of the manufacturer
Certificate of country of origin

Trade Name of the Offered Product

Country of Origin

Enlistment at WHO official website/ (WHOOPES)

Import documents of sample provided
confirmation with the specification/ WHO approved manufacturers/WHO Specified
products.

Samples conformity with t he prescribed specifications

Chemical Analysis Report of imported sample provided at maunfacturer lab.

Chemical Analysis Report of imported sample provided at Pesticide Lab Faisalabad.

Bioassy Results/Report at IPH
 BIoassy Results/Report at University of Agriculture Faisalabad.
GST No
IT No
Any Black Listing

Vector Control Methods

For vector control operations, these SOPs mainly focus on following main vector
control methods;
Residual insecticides application (Spraying and dust application of insecticides)
Breeding sites treatment (Larviciding)
Personal protection measures that include the use of;
Repellants
Insecticides Treated bed nets(ITNs/LLINs)
Cloth Treatment
Protective cloths
Screening of houses
Space spraying or fogging
Environmental management that includes;
Source reduction
Sources management
Elimination of hiding places
 Health Promotion Campaign
Integrated Vector Management (IVM)
Physibility of Aerial application
Details of strategic directions for implementation of each intervention are as under;
Residual insecticides application
Selective Indoor Residual Spraying (SIRS)
Generally, SIRS is a valuable option for vector (s)control, particularly when applied in right
circumstances, time, with full coverage and with proper application method. Pakistan,
since eradication era solely dependent on residual insecticides spraying for vector control.
However since late1980s this intervention is being carried out on limited scale. Currently the
total areas in the country covered by Indoor Residual Spraying is not more than 5-10% which is
extremely low as compared to required one i.e. 80% of target areas. Since IRS is not highly
recommended intervention after the outbreak of disease, therefore this activity must be
completed well before the start of transmission period and all resting places of vector (s) should
be sprayed thoroughly using right equipments.
Strategic directions for SIRS
Following key points should be considered for vector (s) control through SIRS;
Only the insecticides of WHOPES (World Health Organization Pesticides Evaluation Schemes)
tested and recommended insecticides should be used for spraying.
For routine operation, spraying should be started at least 1 month before the onset of the
transmission season (mostly July-August).
Spraying activities should be finished in shortest possible period of time by employing
more number of people if manageable.
Special mobile squads (Entomologists, Malaria Superintendent, M. Supervisors, CDC
Officer etc) should be raised to carry out vector density surveys in district by
involving district government staff and logistics.
The target areas must be covered up to >80% through residual spraying.
The insecticides with longer residual efficacy should be preferred.
The recommended dose of Deltamethrin and Alphcypermethrin should be 10-20
and 20-40 and milligrams/m of active ingredient respectively for plastered smooth surfaces. In
case of mud walls, dose should be doubled.
Always use equal distribution (E type) nozzle for indoor spraying.
Verandas, porches and all sleeping rooms, stores, bath rooms and animal sheds should be
sprayed thoroughly.
Ceilings of rooms particularly if made of straw must also be sprayed along with walls.
Doors and windows from inner side and undersides/behinds of furniture boxes should
also be sprayed.
Treatment of curtains with insecticides particularly from backside will also be useful to control
endophilic vectors.
After spraying, room should be closed for at least one hour.
 Keep the children and animals away from room during this period.
Never leave any food item inside room during spraying and always transfer food item
insides at least after two hours of spray.
Never clean (broom) the wall after spray.
In case of displaced population or deployment of armed forces, spraying of tents from
inside will also be very effective and spraying operation should be done before mid of the day.
After spraying, close the tent for at least half hour.
Spraying must be done after the transportation and installation of tents.
Hang a black cloth sheet (CHADDAR) in rooms (preferably in corners) and spray it
thoroughly. This will give maximum mortality of vectors resting inside the room during
day time.
There is no need of spraying in open air/sunlight,on water or on debris/garbage.
In areas with long transmission period (>4 months), there should another round of IRS and in
case of transmission around the year there should be 3rd round of application of residual
application (depending upon the residual efficacy of insecticides).
Breeding sites treatment (Larviciding)
The best and most effective method of vector (s) control is to find, treat or eliminate their
breeding places. Generally larval control includes use of chemical, environmental
management, biological control, etc. However in Pakistan the use of chemical has always
been given top most priority. For mosquito control,larvicides should be used in breeding
sites that cannot be drained, filled or where other larval control methods are too expensive or
impossible to use. Generally larval control operations should be used during dry
months(May-June) when there are manageable breeding sites. For effective control of flies,
breeding sites i.e.garbage, heaps of animal dung etc should be repeatedly treated with chemicals
at interval of2-3 weeks particularly after monsoon rains.
. Strategic directions for treatment of breeding sites
Mosquito control
Larviciding should be done during Dry months i.e.May & June when there will be limited and
manageable numbers of breeding places.
For routine operations, larviciding should be carried out very carefully after proper
Breeding Sites Assessment Surveys (BSAS), mapping and marking as Fixed and Non-
Fixed breeding sites.
Larvicides should be applied in water bodies havingdensities of;
Anopheles(Malaria control) 1-2 anopheline larvae per dip.
Aedes(Dengue control) 0.5-1 Aedes larvae per dip.
Culex(Nuisance mosquito control) 2-3 culicines larvae per dip.
Organically polluted water should only be focused for control of nuisance mosquitoes
(Culex) by using granular larvicides (Fenthion2%) while clean water for control of anophelines
mosquitoes by using Temephos50%.
In case of drinking water the recommended larvicides are Abat/Temephos,
Methoperene/Altosid (XR Briquets), Bacillus Thuringienesis (BT), Diflubenzuron (Dimlin).
 Strictly follow the dose criteria of manufactures,particularly when use for drinking water.
Generally larviciding should be focused only to those water bodies which are close to human
dwellings (within 1-2 kilometer radius).
Granulars (Fenthion 2g) should be sprinkled (usingsieve) along the 2-3 feet from margin @ 75
g/100 m
2 of stagnant water (a.i. 22-112 g/h)
Liquids larvicides (Temephos 500E) should be sprayed along margin up to 2-3 feet
@ 1.5 lit/5hec (a.i. 56-120 l/h). Details of doses have been given at table 2.
No larviciding should be done beyond these limits (2-4 feet) from margin or in the center of
water bodies.
Larviciding during rains and floods (flowing water) should be strictly prohibited.
Larviciding should be carried out at least 2-3 weeks of cessation of rains (permanent
water bodies).
Larviciding should be focused in water bodies lessthan 100 sq. meters of size.
In case of very large water bodies >100 m 2 larviciding (if very necessary) should be confined
to areas where there are emergent vegetations along pond margin and also towards
downwards of wind direction.
Ideally larviciding should be carried out at 2nd and 3rd stage/instars of development stage of
mosquitoes.
For spraying of larvicides, hallow/solid cone nozzles are only recommended.
Direct mixing of liquid larvicides should be strictly prohibited.
For most efficient larviciding program, treatments must be repeated after 7-10 days depending
upon larval density and availability of resources (3-4 cycles per month).
Larviciding operation should be carried out for at least 2 months.
In case of unserviceable water bodies (even for animal use), used mobil oil should be sprinkled.
Similarly mixing of animal dung (15-20 kg/100 m 2) in such water bodies will also give a
significant control of nuisance mosquitoes Larvicides can be applied with a watering cane
or a sprayer as emulsions, suspension or solutions @ sufficient to wet the upper 10-15 cm of
the substrate i.e. 0.5-5 liters/m2
In case of heavy infestation (after rainy season or in refugees camps), application of dust
formulation to garbage, heaps of animal dung, etc should also be a top most priority intervention
for significant flies control.
Simple dusting of Calcium carbonate (Chunna) on such sites can be effective if
insecticides is not available.
Personal Protection
Personal Protection includes different methods used by an individual or small group of
people to protect themselves from biting insects and diseases they may carry. Personal
protection measures act as a barrier between human and vector (s). However, these
methods have no significant impact of reduction of diseases incidence. Personal
Protection measures which includes the use of repellants, LLINs, cloth treatment,
protective cloths etc are top most priority interventions after heavy rains and subsequent
floods resulting in an increased vector densities or threat of VBDs outbreak. These
measures are also most important in emergencies, displaced population and for armed forces
particularly when they deployed in forests. Similarly if IRS operation could not be done and
there is a threat of an outbreak, again the priority should be given to Personal Protection than
IRS.
Following are the main methods of Personal Protection for vector (s) bite control;
Repellents
Repellents are among the most commonly used methods to prevent blood sucking pests from
biting. They are applied directly on skin or to cloths and they evaporate much quickly than
insecticides. Insecticides last longer and actby killing or knocking down vector when come in
contact, where as repellent act by preventing human-vector contact only. The duration of
protection by repellents applied to skin varies from 15 minutes to 8 hours whereas on
clothing the effects last much longer.
Strategic directions on use of repellents
The repellents containing N, N-Diethyl-m-toluamide (DEET) and PICARIDIN/ICARIDINE
(odorless and more advance form of repellants) etc are highly recommended. However
Benzyl benzoate, dimethyl phthalate, dimethyl carbamate and ethyl hexanediol can also be
recommended.
Repellents should be applied particularly to exposed body parts (foot, arms, face) to prevent
vector bites.
Repellents should not be sprayed directly to the face; spray the repellent onto hands and then
apply to face. Sensitive areas like the eyes, mouth and nasal membranes should be avoided.
Children <5 and pregnant women (PW) should use repellents at time of sleeping, particularly
when sleeping outsides. During emergencies particularly when population displaced, the
repellents must also be used by children and PW even when they are not sleeping.
Clothing can also be treated with P./ICARIDINE or DEET, etc to repel vectors.
The repellents (DEET) containing concentration above 30-35% will be quite effective.
However, effect will last for up to 4 hours.
For children repellents with lower concentrations (<10%) should be preferred.
Repellents should not be used for children <2 years. However in case of extreme need, it
should not be applied to their hands and/or faces, preferably to their clothing.
The repellent which gives at least 8 hrs should be preferred (PICARIDIN/ICARIDINE),
particularly during emergencies/outbreaks.
In case of hot and sweating days, application of repellents should be repeated
particularly when repellents have short duration (2-4 hrs)
Repellents must be used according to label directions to avoid misuse or overuse of repellents.
Prolong use of repellants for more than 2 months should be consulted with doctor.
Natural repellants like Garlic, basil (niaz boo) onion, neem, Cedar, Eucalyptus spp,
cloves
oils, can also be used during peak breeding times during/after monsoon or complex
emergencies.
 In case of tent during emergencies, burn the leaves of neem, Eucalyptus spp (smoke only)
in a tin/metallic container inside and close the entrance for at least 15 minutes. This
practice should be done under close supervision and at least1-2 hours before sleeping.
Insecticidal Treated Nets (ITNs/LLINs)
The use of ITNs/LLINs should be the one of the major intervention particularly for children<5
and pregnant woman (PW) and also for those people living outdoor during peak vector
breeding season. However during outbreak, emergency or among displaced population the
use of Long Lasting Insecticidal Treated nets (LLINs) become best choices for the control of
vectors of public health importance.
Strategic directions on use of LLINs
Following are the major instruction for better use of LLINs for control of vector (s) bites;
ONLY WHO-Recommended LLINs (PermaNet, Olyset, Dawa plus, Yarkool, Interceptor,
Net Protect, and DuraNet) should be promoted and used.
In case of prolong rainy season (floods) and when there is risk of outbreak of disease,
whole population at risk should be protected by LLINs. However, priority should be given
to PW and children <5 year.
2 bed LLINs per household should be provided to cover entire family.
Armed forces particularly when deployed in forest must use LLINs
All patients of vector-bone diseases (malaria, anddengue etc) must be kept under LLIN to
decrease risk of further spread of diseases.
After opening of packet, LLIN should be spread under shade for 1 hrs before use.
Dont leave the net in sun or in rain after use.
Dont fold the net but hang it in room or tent (preferably in corners) during day time when it is
not in use.
The use of LLINs as curtain will also give significant control of vector densities and in tents
particularly, LLINs should also be used as curtains at entrance.
Before sleeping tuck the hanging edges of LLIN under bed sheet/mattress.
Normally LLINs should be washed after at least 3-4months. However it should not be washed
during peak transmission, rainy days, emergency/epidemic/N disasters.
Washing should not be done in lakes, well and other drinking water resources.
Make sure the 100% coverage of target population particularly children <5 and PW.
If there is any hole in bed net it must be replaced with new one. However, if new one is not
available it must be repaired immediately.
Screening of tents/houses.
In case of house, vector-proof screens on doors and windows should be promoted to prevent the
entry of vector (s) particularly mosquitoes.
Screen of mesh size 150-170/ inch 2 or 25-30/cm2 should be used to prevent entry of vectors.
In case of tent, net with same mesh size should be hanged at entrance.
In case of any damage to screen, it should be repaired quickly.
Space Spraying/Fogging
The space spraying is not recommended for routine vector control operations in Pakistan.
It should be considered as Epidemic Contingency Measure particularly during outbreak or
complex emergencies. Space spraying is usually designed to provide a rapid knockdown effect
on exophillic vectors during peak breeding season or during outbreak after monsoon
season.
Strategic directions for Space spraying
Following are the key points for effective implementation of this intervention;
. Indoor Fogging
For endophilic vectors control during emergencies situation or outbreak as a result of
heavy monsoon, indoor thermal fogging should also be an important component of VBDs control
operation. Personnel conducting this activity require training on following safety measures
to be applied;
Switch off all electricity at main/master switch.
All heating and cooking equipments including pilotlight (and allow them for a cool down) must
be turn off before operation.
To reduce the risk of fire, water-diluted productsshould be used.
All foodstuff and water containers must be properly protected.
For indoor fogging a team of 2 persons should target 75-100 houses per day.
The person operating should move backwards and away from fog to minimize the exposure.
Other persons should assist in moving furniture, exposing hidden sites and guide the spray man
through tight spaces.
For small single-storey house, the spray can be delivered from front door or through
open window without having entry to every room, provided that adequate dispersal of
insecticides have achieved.
For large single-storey building, fogging should be carried out from room to room beginning
at back of building and moving towards the front.
For multi-storey buildings, operations should be started from top floor to ground and
from back of the building to front.
Before fogging, windows and doors (tents also) should be closed and keep them closed for at
least 15-30 minutes to ensure the maximum efficacy.
Residents and pets should move out.
Before entry of home, ventilation of home/building must be ensured.
Size of an average household/building (in m2) first should be estimated and volume
of diluted spray required should be prepared according to manufacturers label
recommendations. The Flow Rate of machine (ml/minute) should be checked so that average
time required to treat the home/building should be calculated and fog machine operator should be
informed and trained.
A fog must be dry before going in to house/building. To check it place the machine
on ground and check the area immediately infront of nozzle is not wet. To reduce the production
of large wetting droplets, obtain the correct balance between flow rate and combustion
temperature, usually by reducing the flow rate.
. Outdoor fogging
For outdoor fogging operation, advance route planning should precede which may require
combination of vehicle-mounted and hand carrier or knapsack equipment particularly for area
with difficult or limited vehicle access. Consideration must be given to following;
One day before operation, there should be an announcement about operation in area and
community should be advised to keep open doors and windows during outdoor fogging
operation.
Space spraying must be conducted at the time of peak activity of adult vector (s).
It should be implemented in a compact community and should be within 1000-2000 meter
radius of affected areas.
First prepare plan with respect to layout of streets and wind directions.
Fogging should be done perpendicular to the wind direction. While using vehicle
mounted fog machine, speed of vehicle must be maintain at 5-8 km/hr.
The downwind side of spray area should be treated first, working systematically from
downwind to upwind.
To avoid driving into spray cloud, dead-end road must be sprayed only on the way out.
During outbreak, fogging should be done (preferable at dawn) on alternate days during
first week of outbreak and later on 3rdday for next two weeks.
Finally there should be 4 cycles/month during the epidemic/emergency situation and operation
should be continued for at least next 2 months.
For vehicle-mounted equipment, in areas where the roads are narrow and houses are close to
roadside, the spray should be directed from Backwards from vehicle.
In areas with wide roads and building far from the roadside, the spray should be
directed at an Angle(downwind) to the road rather directly behind the vehicle.
The nozzle of vehicle-mounted cold fogger may be directed upwards when there is
barrier that impede airflow. However, for thermal fogger the nozzle should be
directed horizontally.
Spray must be turned off when vehicle is stationary.
In case of outdoor fogging, the operation should not be carried out when; wind speed is >10
km/h.
Day time heat is >280C wind speed is less than 3 km/h relative humidity is >85%
(during/immediately after rains)
Follow the dose criteria of manufacturer mentioned on label i.e. 1 liter insecticides in 160 liters
of kerosene oil or diesel which will be sufficient for 700,000 800,000 sq. m area. In case of
Ultra-Low Volume (ULV) there should be 1 liter insecticides for 50 liters of kerosene oil or clear
water which will be sufficient for an area of 250,000-300,000 sq meters.
N.B: Blood cholinesterase must be monitored on regular basis, if organophosphates
compounds are used.
. Integrated Vector Management (IVM)
Vector control has proven highly effective in preventing disease transmission around the globe.
However, for complete prevention of disease, vector control intervention (s) should be
supplemented by drug-based interventions. Similarly implementation of single vector
control intervention will not give its desired results and ideally one or two even more
interventions should be used simultaneously. This approach called Integrated Vector
Management(IVM) which is now being endorsed as the recommended strategy to exploit the
preventive power of vector control in cost-effective, sustained and ecologically sensitive
ways. IVM relies on packages of evidence-based interventions, tailor-made for local settings, and
provides a way to coordinate and refocus resources for vector control, while at the same time
reducing reliance on insecticides. This approach aims to control, manage and monitor VBDs at
all relevant points in the life-cycle and transmission-cycle of the vector.

SOPs for Geographical Reconnaissance

Geographical Reconnaissance is the collection of base line data for planning,
implementation and execution and evaluation. In Malaria Control Programme, the main
purpose of GR is to collect data in the form of number of houses, rooms, type of
structures, premises and residential areas along with population so that plan of action may
be prepare for vector interventions and control the vectors and treat the malaria cases.
Information collected in GR
Base line data are collected and recorded on GR-4 FORMS in the form of geographical
location of each houses or premises residential or commercial, population of inhabitants
of each house, rooms, owner of the house and in this way whole surveys done in union
councils of the district and at the end of surveys consolidated.
Where information used
Information are useful in calculating quantity of insecticides, spray able surface
area, equipments and human resource, kinds of walls like plasters mud walls etc,
to determine the breeding sites of larvae their exact location and area and
larvicides require .
In GR locality or village map is prepared after measuring the area of village and
on scale area and distance are represented.
Cardinal points are recorded on map like east, west north south.
Conventional signs, grid lines, directions and other land marks are being
represented.
List of conventional signs include international boundaries, district boundary,
tehsil boundary, UC boundary.
Classification of maps are small scale maps, medium scale maps, large scale
maps.
Other kinds of maps are topographic maps, revenue maps, planimetric maps.
GR is updated annually and consolidated at district level and at provincial level.

SoPs for Entomological surveys

 1. Entomologists in district as well as at provincial level conduct following kind of studies/
Entomological and Epidemiological surveys in the field.
a. Vector Density Tests.(Anopheline adult survey record of fixed station and random
stations) EVA=E/16 Form
The test conducted to check positive rooms for female anophiline mosquitoes
b. Susceptibility tests (EVA-E/22)
The test conducted to check efficacy of insecticides use in public health for control of
vectors.
c. Parous/nulliparus tests on female anophelen mosquitoes
The test conducted to check oogenisis in female mosquitoes and sporozite dissection.
d. Anopheles larvas survey (EVA-E/17) Form
The test conducted for checking larval density in the ponds and puddles and other
potential sites.
e. Consolidated record of adult anopheline EVA-E/19 Form
Whole record of inlet, outlet, zoophilic, bait traps, light traps conducted for checking
behavior of vectors
f. Night observation and dissection record of malaria vectors (EVA-E/18) Form
Test conducted to check behavior of vectors endophilic or exophilic.
g. Epidemiological surveys such as ECS (Epidemological Contact Surveys). Survey is
conducted where two plasmodium falciparum and five plasomodium vivax cases are
diagnosed in the locality and around positive house fifty houses are surveys and blood
smears are taken of each inhabitant are taken.
h. Mass Blood surveys conducted in that locality which remain negative throughout the
year in order to check and confirm parastemia in the locality.

SOCIAL MOBILIZATION FOR MALARIA

Social Mobilization is one of core strategies in achieving the goal of dengue prevention &
control.

Social Mobilization strategy document for prevention & control has clearly defined
focus on community participation & social communication. It provides equal impetus
to grass root and community level social mobilization activities in addition to mass
media campaign. Capacity to plan, monitor and implement Social Mobilization will
have to be built at provincial, district, tehsil and union council levels.

SOCIAL MOBILIZATION
Social mobilization is bringing together all feasible and practical collaboration of different
sectors, departments and individuals to raise peoples awareness for malaria prevention and
control, and to strengthen community participation for sustainability.

Steps of social mobilization

1. Information dissemination
2. Motivation
3. Increased awareness
4. Community mobilization
5. Total awareness

Medium for social mobilization

The media for organizing social mobilization are:

Use of Friday Khutbaz and prayer gatherings

School morning assemblies, sports and class events.
Local fairs, festivities and street theatres
Local Baithaks and Deras where people gather in the evening and discuss their problems.
Traditional music concerts
Posters, leaflets, banners, signboards, billboards
Rallies, walks
Health House meetings and meetings of community at health facilities.
Radio, Television, Cinema, Newspaper
Popular drama, puppet shows, theatre, stage
Transport branding

Social mobilization is achieved through the dissemination of certain key message, developed by
the technical experts adopted in the local languages and communicated in a way acceptable to
local communities.

Communication for behavioral impact (COMBI)

It is not enough that people are aware, or are knowledgeable about disease prevention and
control or are even convinced; they need to act.

It is clear that informing and educating people is not sufficient for behavioral response.
Behavioural changes will result only with effective social mobilization and communication
programs.
COMBI (Communication for Behavioural Impact) is social mobilization directed at the task of
mobilizing all societal and personal influences on an individual and family to prompt individual
and family actions.

COMBIs Integrated Actions:

Public relations/advocacy/administrative mobilization: Using media to communicate

particular healthy behaviour - news coverage, talk shows, celebrity spokespersons, discussion
programs, meetings/discussions with various categories of government and community
leadership.

Community mobilization: Use of group meetings, partnership sessions, school activities,

traditional media, music, songs and dance, road shows, community drama, leaflets, posters,
pamphlets, videos, home visits.

Interpersonal communication/counseling: Use of appropriate informational literature and

additional incentives, listening to peoples concerns and addressing them.

Point-of-service promotion: Emphasizing easily accessible and readily available vector control
measures and fever treatment and diagnosis.

Behavioural challenges in Malaria Control

A major obstacle to effective implementation of selective, integrated mosquito control has been
the inability to mobilize and coordinate the resources needed to achieve and sustain behavioral
impact among populations at risk of Malaria fever and Cerebral Malaria.

Knowledge is not enough

Just providing knowledge is not enough.

People know that malaria is caused by mosquitoes and that mosquitoes breed in water ponds and
puddles ,yet they fail to apply what they know how to remove water bodies, larvicide and Indoor
Residual Spray

So instead of bombarding people with complex knowledge and too many messages we need to
provide action oriented education.

Behaviour changes in gradual stages

Unfortunately, people do not change behaviour all of a sudden or remain changed from that
moment onwards. Rather, people move through subtle stages of behaviour change

HICDARM AND BEHAVIOUR ADOPTION

First, we H ear about the new behaviour

then, we become I nformed about it

and later C onvinced that it is worthwhile.

In time

We make the D ecision to do something about our conviction

And later we take A ction on the new behaviour.

We next await R e-confirmation that our action was a good one

And if all is well, we M aintain the behaviour

When we want to teach a preventive behavior to a learner, we certainly cannot expect people to
do it correctly just after we have explained it theoretically. Most people learn: 10% of what they
read, 20% of what they hear, 30% of what they see, 50% of what they see and hear, 70% of what
they talk over with others, 80% of what they use and do in real life, 95% of what they teach
someone else. When we want to teach people how to eliminate mosquito breeding sites (ponds
and puddles), we can just explain it orally, but their learning certainly will be greater when they
see the procedure. And if we can provide them learning by doing, it will be more permanent and
better.

COMMUNICATION SKILLS

Health communication encompasses the study and use of communication strategies to inform
and influence individual and community decisions that enhance health. It links the domains of
 communication and health and is increasingly recognized as a necessary element of efforts to
improve personal

COMMUNITY MOBILIZATION

Community mobilization requires the use of group meetings, partnership sessions, school
activities, traditional media, music, songs and dance, road shows, community drama, leaflets,
posters, pamphlets, videos and home visits.

A. Steps of Community Mobilization

Conducting a Community Assessment

Conduct a community assessment to learn where community currently stands. Assess the level of
basic knowledge and information about the disease and its control, their willingness to be
involved in dengue control efforts. An assessment has to be done about who is currently
involved, what has been accomplished, and what has not happened, what are the opportunities,
barriers and gaps, etc.)

Formation & Activation of Committees

Field staff will activate the existing Health/Mohallah committees in the community. Where these
committees are not present they will try to organize a group/committee which will include
opinion leaders and key informants (Imam Masjid, school teachers, counselors and other
notables in the community).

Selecting a strong leader

Appropriate leadership is key to the success of community mobilization, whether it is

a person with political background or a member of community group. This person
should have the ability to influence and mobilize the community.
Stakeholders Roles How to approach Resources

Schools Provide education to Through education School has hall/

school children department, school classrooms that
regarding symptoms governing body or could accommodate
of malaria and its through the dramas, meetings,
prevention & control principal. workshops etc.
Identify malaria Have existing
cases. relationship and
 Mobilize children to trust of children and
be involved in parents so easy to
malaria campaigns. access a large group
Assist in being of people and gain
volunteers for their attention.
identifying breeding
places (ponds and
puddles in rural areas
in and outside houses
for children/ teachers.
Assist in raising Peer groups Community leaders
Traditional awareness about Political/community with influence can
healers Malaria and cerebral leaders encourage members
(Hakeems, malaria. Community groups for prevention and
homeopaths, Have good relation- Personal contacts control methods.
spiritual ships with the
healers) community so have
high influence.
Identify malaria
patients and refer
them to health
facilities.
Encourage people to
control Malaria and
Cerebral Malaria
through their
individual efforts

Political/comm Assist in raising

unity leaders awareness about Community groups Political/Community
Malaria leaders with
Have good influence can
relationships with the encourage members
community so have to work for malaria
high influence. prevention & control

Religious Leaders to send out Approach religious Human resources.

leaders messages and share leaders for their Financial resources.
information regarding involvement Buildings and
Imam Malaria. through community facilities for
masjids Encourage persons or mohallah meetings,
Imam coming to say prayers committee or by workshops, fund
barghaas & Jumah prayers, Aukaaf department. raisers.
Priests in Members of church Religious leader
the churches groups & mandirs to gets support of
adopt hygiene other leaders as
 Pandits and practices and to well, and they
gurrus in become involved in develop a
mandir malaria prevention & communication
control activities strategy to mobilize
people.