(a) State the vision, goals and objectives of the National Framework for Malaria Elimination in India, 2016-2030. What are the…

(a) National Framework for Malaria Elimination in India, 2016–2030

Vision. To eliminate malaria from India and so contribute to better health, quality of life and the alleviation of poverty.

Goals. To achieve zero indigenous malaria cases throughout the country by 2030, and to maintain malaria-free status in areas where transmission has stopped and prevent re-introduction of the disease.

Objectives. To eliminate malaria from low- and moderate-transmission states and union territories; to bring the incidence down in high-burden areas; to strengthen the health system and surveillance; and to promote research and partnerships.

Milestones and targets: By 2022: elimination (zero indigenous cases) in the 26 states and union territories of Category 1 and 2, with a fall in national incidence. By 2024: incidence below 1 case per 1000 population in every state and union territory. By 2027: interruption of indigenous transmission throughout the country, including the high-burden states (Odisha, Chhattisgarh, Jharkhand and the north-eastern states). By 2030: sustain the elimination and prevent re-establishment of transmission, for certification of the country as malaria-free.

Broad strategies: Categorise states and districts by transmission and plan elimination in phases, with the district as the unit of planning. Early diagnosis and complete treatment: rapid diagnostic tests and microscopy, artemisinin combination therapy, and radical cure of P. vivax with primaquine after G6PD testing. Surveillance: case-based reporting, focus investigation and rapid response, with active case detection in high-burden areas. Vector control: long-lasting insecticidal nets, indoor residual spraying, larval source management and environmental measures. Health system strengthening and capacity building, behaviour change communication and community involvement (ASHA). Intersectoral and cross-border coordination, public-private partnership, operational research, and monitoring. The programme is run by the national vector-borne disease control programme with the states.

(b)(i) Grading of anaemia in pregnancy (WHO)

Anaemia in pregnancy is a haemoglobin below 11.0 g/dL in the first and third trimesters, and below 10.5 g/dL in the second. Mild anaemia: 10.0 to 10.9 g/dL. Moderate anaemia: 7.0 to 9.9 g/dL. Severe anaemia: below 7.0 g/dL. (Indian guidelines call below 4.0 g/dL very severe anaemia.)

(b)(ii) Complications of anaemia in pregnancy

Maternal: weakness, breathlessness and cardiac failure; pre-eclampsia; preterm labour and abortion; poor uterine action with prolonged labour; postpartum haemorrhage, with poor tolerance of blood loss; puerperal sepsis and subinvolution; poor lactation; thromboembolism; and maternal death. Fetal and neonatal: intrauterine growth restriction, low birth weight, prematurity, stillbirth and perinatal death, neonatal anaemia and infection, and later poor neurodevelopment.

(b)(iii) Management of a woman with severe anaemia in labour

Admit and treat in a facility with blood bank and operative facilities, in a semi-reclined position, with oxygen and pulse and blood pressure monitoring. Send Hb, blood group and cross-match; start an intravenous line and do not give much fluid, because of the risk of cardiac failure. Transfuse packed red cells slowly (one unit over 4 hours) with a diuretic (frusemide) cover, as the first priority when Hb is below 5 g/dL, or 5 to 7 g/dL with decompensation near term. Allow vaginal delivery and shorten the second stage with forceps or vacuum; caesarean section only for an obstetric indication. Active management of the third stage with oxytocin to prevent haemorrhage; keep blood available; antibiotics for prevention of sepsis. After delivery, recheck Hb, treat the cause (hookworm, malaria, nutrition), and give iron (oral or intravenous iron sucrose or ferric carboxymaltose) and folic acid, with contraception advice and breastfeeding support.

(c)(i) Therapeutic indications of splenectomy

Trauma: rupture of the spleen not controlled by non-operative care. Haematological: hereditary spherocytosis; immune thrombocytopenic purpura not responding to medical treatment; autoimmune haemolytic anaemia; thalassaemia major with hypersplenism; refractory thrombotic thrombocytopenic purpura. Hypersplenism and massive splenomegaly: portal hypertension, myelofibrosis, Gaucher disease, lymphoma or hairy cell leukaemia. Splenic lesions: abscess, hydatid or non-parasitic cysts, tumours, splenic artery aneurysm, torsion, and splenic vein thrombosis with gastric varices. En bloc removal during gastrectomy or distal pancreatectomy for cancer.

(c)(ii) Overwhelming postsplenectomy infection (OPSI)

Aetiology. Streptococcus pneumoniae causes most cases (50 to 90%), followed by Haemophilus influenzae type b and Neisseria meningitidis, and also Capnocytophaga canimorsus (dog bite), Escherichia coli, and malaria and Babesia. Pathogenesis. The spleen filters blood and clears encapsulated bacteria. After splenectomy, the macrophages of the red pulp are lost, so opsonised bacteria are not removed; marginal zone and memory B cells are lost, so IgM antibody to capsular polysaccharide falls; and tuftsin and properdin levels are low. A small inoculum then multiplies fast, leading to septicaemia and DIC with purpura (purpura fulminans) and adrenal haemorrhage; mortality is 40 to 70%. The risk is highest in the first two years and in children, but lasts for life; it is higher after splenectomy for haematological disease.

Prophylaxis: Vaccines: pneumococcal conjugate vaccine followed after 8 weeks by polysaccharide vaccine, Hib, meningococcal ACWY and B, and yearly influenza vaccine; given at least 2 weeks before an elective operation, or 2 weeks after an emergency one, with revaccination for pneumococcus every 5 years. Antibiotics: daily oral penicillin V (250 to 500 mg twice daily in adults, 125 mg in young children) for at least 2 years or until age 16, and lifelong in high-risk patients; a standby supply of amoxicillin-clavulanate to start at once at the first fever. Education: warn the patient that any fever is an emergency, carry a card or bracelet, and take malaria prophylaxis and care after animal bites. Spleen preservation where possible (non-operative treatment of trauma, partial splenectomy, splenorrhaphy).