Malaria situation in India with special reference to tribal areas.

BACKGROUND & OBJECTIVES: In India, malaria is a major public health problem in States having predominantly tribal population. The objective of this analysis was to find out the incidence of malaria in various States/districts having varied proportions of tribal population using National Vector Borne Disease Control Programme (NVBDCP) data. METHODS: States and districts were classified into three categories based on proportions of Scheduled Tribes (ST) population as <10, 10-29.9 and 30 per cent + ST population. Five year average (2008-2012) of all important malaria indicators collected by NVBDCP was taken to normalize the effect of annual fluctuations in malaria incidence. RESULTS: State level analysis revealed that ten States/UTs with 30 per cent or more tribal population comprising only three per cent of total population, contributed 14 per cent of total malaria, 21 per cent Plasmodium falciparum and 29 per cent of deaths due to malaria. Similarly, district level analysis showed that districts with 30 per cent or more tribal population comprising about eight per cent country's population contributed to 46 per cent of total malaria cases, 70 per cent P. falciparum and 47 per cent malarial deaths in the country. INTERPRETATION & CONCLUSIONS: Our analysis showed that the neglect of the ethnic communities in tribal areas would be detrimental to the overall reduction of morbidity and mortality due to malaria. The fight against the increasing burden of malaria in tribal belt requires adoption of multiple approaches and socio-economic development of the tribal communities.

Improving malaria treatment and prevention in India by aiding district managers to manage their programmes with local information: a trial assessing the impact of Lot Quality Assurance Sampling on programme outcomes.

OBJECTIVES: This paper reports the first trial of Lot Quality Assurance Sampling (LQAS) assessing associations between access to LQAS data and subsequent improvements in district programming. This trial concerns India's approach to addressing an increase in malaria-attributable deaths by training community health workers to diagnose, treat and prevent malaria, while using LQAS to monitor sub-district performance and make programme improvements. METHODS: The Ministry of Health introduced LQAS into four matched high malaria burden districts (Annual Parasite Incidence >5) (N > 5 million). In each sub-district, we sampled four populations in three 6-monthly surveys: households, children <5 years, people with fever in the last 2 weeks and community health workers. In three districts, trained local staff collected, analysed and used data for programme management; in one control district, non-local staff collected data and did not disseminate results. For eight indicators, we calculated the change in proportion from survey one to three and used a Difference-in-Differences test to compare the relative change between intervention and control districts. RESULTS: Coverage increased from survey one to three for 24 of 32 comparisons. Difference-in-Differences tests revealed that intervention districts exhibited significantly greater change in four of six vertical strategies (insecticide treated bed-nets and indoor residual spraying), one of six treatment-seeking behaviours and four of 12 health worker capacity indicators. The control district displayed greater improvement than two intervention districts for one health worker capacity indicator. One district with poor management did not improve. CONCLUSIONS: In this study, LQAS results appeared to support district managers to increase coverage in underperforming areas, especially for vertical strategies in the presence of diligent managers.

Antimalarial drug policy in India: past, present & future.

The use of antimalarial drugs in India has evolved since the introduction of quinine in the 17 th century. Since the formal establishment of a malaria control programme in 1953, shortly after independence, treatments provided by the public sector ranged from chloroquine, the mainstay drug for many decades, to the newer, recently introduced artemisinin based combination therapy. The complexity of considerations in antimalarial treatment led to the formulation of a National Antimalarial Drug Policy to guide procurement as well as communicate best practices to both public and private healthcare providers. Challenges addressed in the policy include the use of presumptive treatment, the introduction of alternate treatments for drug-resistant malaria, the duration of primaquine therapy to prevent relapses of vivax malaria, the treatment of malaria in pregnancy, and the choice of drugs for chemoprophylaxis. While data on antimalarial drug resistance and both public and private sector treatment practices have been recently reviewed, the policy process of setting national standards has not. In this perspective on antimalarial drug policy, this review highlights its relevant history, analyzes the current policy, and examines future directions.

Monitoring antimalarial drug resistance in India via sentinel sites: outcomes and risk factors for treatment failure, 2009-2010.

OBJECTIVE: To describe India's National Antimalarial Drug Resistance Monitoring System, measure the efficacy of first-line malaria treatments, and determine risk factors for treatment failure. METHODS: In 2009-2010, prospective studies with 28 days of follow-up were conducted at 25 sentinel sites. Patients infected with Plasmodium falciparum were given artesunate plus sulfadoxine-pyrimethamine (AS+SP); those infected with P. vivax were given chloroquine. Polymerase chain reaction was used to distinguish post-treatment reinfection from treatment failure. Isolates of P. falciparum were checked for dhfr and dhps mutations. FINDINGS: Overall, 1664 patients were enrolled. Kaplan-Meier survival analysis showed an efficacy of 98.8% for AS+SP. Most patients with P. falciparum parasitaemia cleared their parasitaemias within 24 hours of treatment initiation, but six, including four with treatment failure, remained parasitaemic after 72 hours. Double mutants in dhfr were found in 68.4% of the genotyped isolates. Triple or quadruple mutants in dhfr and mutations in dhps were rare. A daily dose of artesunate of < 3 mg per kg of body weight, age of less than 5 years, and fever at enrolment were associated with an increased risk of treatment failure. Chloroquine remained 100% efficacious and generally cleared P. vivax parasitaemias within 48 hours. Vomiting (seen in 47 patients) was the most common adverse event. CONCLUSION: India's National Antimalarial Drug Resistance Monitoring System provides wide coverage. The first-line antimalarials used in the country remain safe and efficacious. The treatment of malaria in young children and the relative benefits of age- and weight-based dosing need further exploration.

Absence of lymphatic filariasis infection among secondary-school children in Oman.

The endemicity status of lymphatic filariasis in Oman is uncertain, with only sporadic cases reported, mostly imported. Immunochromatographic card test surveys were carried out to assess the presence of circulating Wuchereria bancrofti antigenaemia as a marker for active infection in children from suspected high-risk areas of Oman (South Batinah and Dhofar). Lot quality assurance sampling surveys were carried out on a minimum of 250 secondary-school children aged 17-18 years in each of 8 districts from February 2004 to March 2004. All tested students were negative for circulating W. bancrofti antigen. Based on these findings as well as previous data, Oman may possibly be classified as a nonendemic country, with no evidence of indigenous lymphatic filariasis transmission.

New perspectives of malaria control in India under World Bank Project.

The World Bank has been assisting Government of India (GoI) for a number of years with development of effective health services for the control of vector borne diseases (VBDs). An Enhanced Malaria Control Project (EMCP) under financial assistance from Bank was implemented in selected tribal states and districts from 1997 to 2005. While most of the project districts did report a decline in malaria incidence, the Implementation Completion Report (ICR) highlighted the need for major reform. Plasmodium falciparum (Pf) malaria, which accounts for almost all malaria related mortality, has been increasing in India and there is widespread resistance to chloroquine. The needed reform would require, first and foremost, updating of policy on malaria case management in public and private sectors. Also needed are innovative approaches for promoting the use of insecticide treated nets (ITNs) and strengthening institutions at the district and state levels for effective implementation of new policies. Several important changes in the policy on diagnosis and treatment of malaria are being implemented in this new project. The most important of these are: Use of artesunate combination therapy (ACT) as the first line treatment for all confirmed Pf malaria cases, introduction of rapid diagnostic kits for quick diagnosis of Pf cases, promotion of long lasting insecticide treated bed nets (LLINs) in vulnerable population. Supervision and monitoring will be strengthened by deployment of Malarial/Kala azar Technical Supervisors (MTS/KTS) and VBD consultants at district level. The project has also envisaged two important components like Environment Management Plan (EMP) for safe use of insecticides and materials and Vulnerable Community Plan (VCP) for the benefit of underprivileged population.

Emergence of drug resistance in India.

Chloroquine resistance in Plasmodium malaria is an emerging problem globally. In India resistance of Plasmodium falciparum to choloroquine, the cheapest and the most used drug was first reported in the year 1973 from Diphu of Karbi-Anglong district in Assam state. Systematic monitoring of drug resistance is being undertaken in the country from 1978 by the Directorate of National Vector Borne Disease Control Programme (NVBDCP) through its 13 Pf monitoring teams. The findings of these drug resistance studies has helped the programme for the revision of the drug policy and update it from time to time thereby facilitating appropriate measures for not only individual cases but also to contain and prevent further spread of resistant foci. This article summarises therapeutic efficacy studies conducted by the Pf monitoring teams in the country between 2001 and 2007 related to efficacy of chloroquine and other antimalarials drugs. As per the results available, the efficacy of chloroquine for treating uncomplicated falciparum at most of the study sites is much lower than the desired cut off levels of 10% (83% studies have shown treatment failure more than 10%). Total of 4273, 168 and 137 P. falciparum cases have been tested against chloroquine, sulphadoxine/pyrimethamine and ACT(AS+SP) combination. During the period under report, 85 new chloroquine resistant PHCs/foci from 64 districts were qualified warranting change of drug policy as per the national guidelines. These studies show that chloroquine resistance in P. falciparum is widespread in the country. To combat the drug resistant in malaria, the use of combination therapy ie, artesunate plus sulfadoxine/pyrimethamine has been recommended for treatment of all confirmed P. falciparum cases in all the qualified areas as per the criteria laid down in National Drug Policy on malaria.