Status of Malaria in India

Introduction

During the British ruling in India, the period 1932 to 1941, fever accounted for 58% of the average annual deaths. Malaria was the largest single cause of fever deaths during this period. Morbidity directly due to the disease and also due to lowered immunity and mortality was recognized in the country. The annual mortality due to  Malaria was to the tune of  around 2.4million;  ie. 8 per 1000 population. This account for 37% of total mortality annually in India. Out of this, 1.25 to 1.50 million deaths was directly due to malaria. The infrastructural  developmental activities including building of roads, railways, and irrigation projects lacked design concepts that would prevent water logging whereby increasing chance for mosquito breeding.  

Distribution of the disease was depicted in 5 geographically as:

1.      Moderate to high intensity endemic area where malaria is prevalent and endemic but almost static. This include the coastal areas and Gangetic valleys.

2.      Forested hilly terrains of Sub-Himalayas, NorthEast & Western Ghats, the Chittagong Hill Tracts, in Assam, the Chota Nagpur Hills of the Central Provinces etc were considered as Hyperendemic areas.

3.      The relatively dry tract including the Sind, Rajputana, the south western portion of the United Provinces, a large part of Central India, Gujarat, Bombay, Hyderabad and Mysore with varying degrees of endemicity depending on irrigation.

4.      Areas such as Punjab, Delhi and North west were considered as prone to fulminant epidemic malaria.

5.      Areas such as Tanjore, spots in Orissa & Bengal were considered as non-hilly hyperendemic areas.

The Central Malaria Bureau and the Entomology Section of the Central Research Institute, Kasauli, that was found in 1926, was designated the task of Malaria Survey of India. This center was later changed to the Malaria Institute of India. In 1940, the Government of India took over this institute. The institute actively participated in public health works especially in investigating and preparing strategies for managing the disease. Training was provided for medical officers in the community, medical professionals in the defense including Army Navy and Air-force. This was mainly during the war that control of malaria became very important. Training for para-medical staff including sanitary inspectors and engineers, science graduates etc was also provided through the system. Through the provincial organizations, the central institute could also spread its activities including investigation, control etc through various ways in addition to the training and research activities.

Bhore Committee found that the provision for the treatment in the country quite inadequate. The distribution system of Quinine, the main drug of choice at that time was not enough to meet the requirement. It recognizes that the province’s effort of just managing epidemics would not suffice as far as malaria control is concerned. Poor organization structure, staffing, remuneration etc has made the program not a big success eventhough the disease was controlled to some extend in some areas. The dis-continuous efforts of the provinces also were the reason for the failure in spite of initiating research and training along with conducting field investigations and entomological studies etc. There were other external factors such as poor administration and war etc that was affecting the program. Thus Bhore committee identifies Malaria as an important disease that has to be taken care of actively.

Present status of Malaria in India

Presently, malaria control in India is implemented by the National Vector Borne Disease Control Programme (NVBDCP) by providing technical and operational support to the state and also sharing the cost. Implementation is through the PHCs with the participation of community and multi-purpose workers. Early detection & treatment, prophylaxis, behavior changes, integrated vector control, strengthening of MIS, multi-sectoral coordination etc are the key strategies. Drug distribution centers and fever treatment depots located in hard to reach areas to improve coverage. The program is receiving financial assistance from the World Bank and the Global Fund for AIDS, TB & Malaria (GFATM).

Around 70% of malaria in the South East Asian Region of WHO is contributed by India with an annual report of about two million cases and about 1000 deaths attributable to malaria. Currently in India, there is an increasing trend in malaria caused by plasmodium falciparum according to the available data from NVBDCP both in cases and in mortality in the post resurgence phase. This now account for 45% of the total reported cases. The clinical presentation pattern of severe malaria also has changed where multi-organ failure is more frequently seen with falciparum malaria. The ethnic tribes living in the forested pockets of the states like Orissa, Jharkhand, Madhya Pradesh, Chhattisgarh and the North Eastern states contribute to the bulk of mortality and morbidity attributable to malaria. 15% of the total malaria cases reported in India are in the urban areas which could be associated with construction activities and migration of people from endemic areas and the lower status of living. Majority of the malarial deaths reported in India are from Orissa and other forested areas occupied by ethnic tribes. As per the National Vector Borne Disease Control Program (NVBDCP), about 2 million parasite positive cases are seen in India in a year. Several independent studies suggest that the prevalence of malaria and the mortality is under reported. Studies by the Indian Council of Medical Research also prove that malaria incidence is hugely under-estimated. Considering the existing gaps in reported and estimated morbidity and mortality, need for estimation of true burden of malaria has been stressed. However, NVBDCP is providing all guidance to states for malaria control through implementing malaria drug policy, surveillance and research. The efforts of control of malaria are rather complicated by poverty and other adverse social determinants of health. To quote an example, in 2000, 88% of P. falciparum malaria was contributed by those states with population exceeding the national average of 26.1% population below poverty line (BPL). The Global Malaria Eradication Program of WHO that was launched in 1950s showed a big success where there was a significant decline in cases. From about 75 million cases and 8,00,000 deaths in 1947, it dropped to 49,151 cases (annual parasite incidence per thousand [API]: 0.13; slide positivity rate [SPR]: 0.38% and Plasmodium falciparum [Pf]: 34.9%) and no deaths in 1961. But there was a resurgence of the disease in different parts of the country which is attributed to contentment, administrative, operational and technical problems like resistance in vectors to commonly used insecticide DDT and resistance in parasites to chloroquine and overall low priority malaria enjoyed in the post control period. However, a modified plan of operation (MPO) was implemented in 1977 after which malaria cases declined and ranged between 2-3 million per annum in the subsequent years. There were further outbreaks in 1996 reporting an increase in cases to 30,35,588 and mortality of 2803. In 2006, the reported number of cases was 16,69,333 (API: 1.57; SPR: 1.63% and Pf:45.3%). As per the reports from WHO, presently, about 80.5% of the Indian population lives in malaria risk areas. Out of this, 4.2%, 32.5% and 43.8% live in areas of high, moderate and low risk to malaria respectively. However, preventive measures such as spraying of newer insecticides like synthetic pyrethroid, biological control measures through larvivorous fish like Gambusia and Guppy etc are being used recently along with mass awareness programs and extensive distribution of mosquito nets impregnated with insecticides in the risk areas.

Apart from income status and nutrition, individual vulnerabilities such as gender roles, aging, family size etc has made women as a more vulnerable group. Increased incidence of maternal mortality, still births, miscarriages, infant mortality etc in certain areas could also be attributed to the prevalence of malaria among these vulnerable women . Sensitization of the health services providers and policy makers is essential in this regard to further achieve the goals of malaria control and ensuring justice.

Drug resistance, insecticide resistance, lack of knowledge of actual disease burden along with new paradigms of malaria pose a challenge for malaria control in the country. Several social determinants of health are also playing their part as such as socio-economic, gender etc.  Administrative, financial, technical and operational challenges faced by the national programme has to be taken into account. Approaches and priorities that may be helpful in tackling serious issues confronting malaria programme has to be outlined.

The favourable changes in Malaria control that have occurred and the reasons for these changes.

Favorable changes were found with a reasonable control over the deaths due National Malaria Control Program (NMCP), a comprehensive program to control malaria was started in 1953 following endorsement of the Bhore Committee report by the Planning Commission. The broad objectives were to bring down malaria transmission to a level at which it would cease to be a major public health problem and to hold down the malaria transmission at low level indefinitely. A big success of NMCP after effectively covering a population of 165.6 million in 1957, urged the Government of India to change the strategy from control to eradication. Thus, in 1958, National Malaria Eradication Program (NMEP) was launched. Epidemiological surveillance was initiated in 1961 and by these efforts at the national and state level, many parts of the country were practically under control and entered into a technically maintenance phase by 1966. However, this was followed by outbreaks in several parts of the country. From 1968 onwards there were setbacks, 1976 recorded the highest ever post-eradication incidence of 6.47 million cases. 

A Modified Plan of Operation was implemented in 1977 with a good success to follow. The reasons for this were the change in strategy and approaches that included

i)                    Decreasing morbidity and mortality due to malaria

ii)                  To preserve the achievements of the country from green revolution etc

iii)                Fortnightly blood smear collection by domiciliary visits, from fever cases, their examination and treatment with antimalarial drugs.

iv)                Decentralisation of laboratory services to the PHC level.

v)                  Establishment of Drug Distribution Centres (DDCs)/ Fever Treatment Depots (FTDs).

vi)                Insecticidal spray with appropriate insecticide during the transmission period in rural areas recording Annual Parasite Incidence (API) 2 or above. In urban areas, through recurrent antilarval operations.

vii)              Health Education and Community Participation.

All these strategies of MPO helped to bring down the number of case significantly with a downward trend. The situation remained almost static for a decade from 1984 where the deaths due to malaria crossed the 500 mark. Malaria due to P.falciparum was also on the rise after 1994. Focal outbreaks were also found in some parts of the country from then onwards. 100% central assistance was provided to all the north-eastern states since December 1994. Other activities included

1.      Information, Education and Communication (IEC) components were Intensified by observing anti-malaria month throughout the country for increasing the awareness of malaria and its control among the community to ensure their participation.

2.      Accelerated urban malaria scheme was implemented in the problematic towns as urban malaria was seen on the increase due to developmental activities and migration.

3.      NMEP drug policy has been revised in view of rising incidence of P. falciparum malaria.

4.      An Enhanced Malaria Control Project with World Bank assistance was launched in 1997 to provide additional inputs for the control of malaria in the 100 identified hard-core tribal predominant districts of Andhra Pradesh, Bihar, Gujarat, Madhya Pradesh, Maharashtra, Orissa and Rajasthan. 19 problematic towns have also been included under this project. This Project, provided newer technologies like insecticidal spray with synthetic pyrethroids, bio-environmental methods for vector control including use of larvivorous fish and  biolarvicides, and rapid diagnostic methods for prompt detection of P. falciparum cases. Injectable artemisinine for the treatment of severe and  complicated malaria was made available.

The National Vector Borne Disease Control Programme (NVBDCP) was launched in 2004. where all the vector borne diseases were integrated under one umbrella to coordinate better implementation. Health being the state's responsibility, malaria control is carried out by the states, under the overall guidance of the NVBDCP. The program organizes interventions surveillance to monitor the impact and to detect malaria cases by examining fever cases in the entire country. In rural areas, blood smears are collected by multi-purpose workers at fortnightly intervals through Active Case Detection (ACD). Blood samples are also collected at the Primary Health Centres (PHCs) i.e. Passive Case Detection (PCD). In urban areas, PCD is carried out at the malaria clinics. Radical treatment is given, as per the policy of the NVBDCP to those found positive. The data thus obtained is used in calculating epidemiological indices at the various levels of health services. Assessing drug resistance using strict guidelines with support of monitoring teams, line of management is  decided at various levels and such information is passed on to the persons concerned.  Such thirteen NVBDCP teams routinely monitor P. falciparum drug sensitivity in the country. These teams are located in various regions so as to cover the entire country. Malaria Drug Policy (2007) of the NVBDCP provides treatment guidelines countrywide. It is understood that the vector causing malaria differs in different parts of the country and its susceptibility to larvicides etc also is not the same across the country. Hence, a recommendation has to be made for each state or regions which is done through the monitoring teams. Provision for presumptive treatment for fever cases in high risk areas to prevent mortality due to malaria was introduced. The new national drug policy was for malaria was  implemented in 2010. This has helped the country in bringing down the case load of malaria significantly and the resulting deaths. However the issue of drug resistance and increasing p.Falciparum malaria is posing new challenges.

Aspects of Malaria that have not undergone much change and the possible reasons for that.

There were several challenges that were faced during the effort of controlling the disease. There were hence many aspects that needed change in order to succeed in the mission. However, there were reasons for the flaws that could be rectified in the future. Some of these are,

Insecticide resistance in vectors

Resistance of vectors to insecticides and larvicides are increasing. This is also due to the injudicious use of insecticides and not identifying resistance in certain areas. There has been several insecticides that was found useful but later withdrawn due to ban. Latest used are the synthetic pyrethroids, but resistance has also been documented with them. There is also documented evidence of triple and quadruple resistance in certain parts of the country including the central part of India. Provision of nets impregnated with insecticide was a better option but there are still many pockets where awareness is not coupled well with distributing the nets resulting in under-utilisation of these expensive nets.

Drug Resistance

Chloroquine has been the mainstay of treatment of malaria for decades. This cost effective and safe drug has become resistant to most of the malarial cases in the country especially falciparum malaria. Quinine is effective but is reserved for treating complicated malaria owing to its adverse reactions and long duration of treatment. Mefloquine, eventhough useful in treating multidrug resistant falciparum malaria, due to its long duration of action, it is vulnerable for development of resistance. Artemisinin group of drugs are highly effective but safety in pregnancy, concern about neurological side effects due to short duration of action still debated. Drug resistance became an issue due to variety of reasons such as

1.      Incomplete treatment and non confirmation of diagnosis

2.      No standard guideline was been efficiently implemented especially in the lower socio economic regions

3.      Emperical and non-judicious use of medicines over the counter and by traditional healers

4.      lack of monitoring for drug resistance and network with researchers etc

Control of regular outbreaks

Proper control of regular outbreaks in some urban, rural and large project areas has not been possible as control of An. stephensi, the principal malaria vector in urban areas is becoming difficult. The vector is expanding its distribution southward that is resulting in the recent malaria outbreaks in Goa, Mangalore and recently in Kasargod district of Kerala state which is by and large free of malaria. This is also one of the reason for the observed under reporting of the cases mentioned elsewhere in this assignment. NGOs working in the field with their available limited knowledge are treating in the hard to reach areas of the country and lack proper guidance and monitoring.

Counterfeit drugs

Owing to the rapid development in the pharmaceutical manufacture sector along with relaxation of regulations and surveillance, counterfeit drugs are still in market. Counterfeit drugs are one of the major contributors for drug resistance. Currently since the medicines are more subsidized in india, counterfeiting has decreased but however, regulatory checks and pharmacovigilence has to be strengthened. Empowering drug controllers for regular monitoring could be a solution.

Effects of migration

Migration could be work work opportunity or could be due to famine, poverty or natural disasters etc. There is currently no action that is efficient to control of malaria through such migration. Those labourers migrating to non malaria endemic areas from endemic areas pose serious risk for spreading the disease. This is one of the reasons for the incidence of cases in certain project sites such as agriculture, construction projects etc. The migration of people to the forest fringes can result in something called as the forest malaria.

Socio-economic determinants

Social determinants of health have not been an agenda during discussions for controlling the disease. Unless such determinants such as poverty, marginalization, gender issues, faiths and local healer interactions, socio-cultural practices, living environment/ hygiene etc are taken into account, the aim of an effective control of malaria cannot be achieved. It is only recently that the social determinants of health are looked into as more public health professionals try to see through a non-medicalised lens.