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G.P. CHATTERJEE MEMORIAL AWARD LECTURE 2003-2004 Malaria Control in India by Dr. V.P. Sharma 91 st Session of the The Indian Science Congress Session Chandigarh 4 th January 2004 Burden of Malaria in the World 300-500 million malaria cases in the world 1.5 to 2.7 million deaths due to malaria

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G.P. CHATTERJEE MEMORIAL AWARD LECTURE 2003-2004Malaria Control in IndiabyDr. V.P. Sharma91st Session of the The Indian Science Congress SessionChandigarh4th January 2004


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Burden of Malaria in the World

  • 300-500 million malaria cases in the world

  • 1.5 to 2.7 million deaths due to malaria

  • 90% disease burden in Africa, South of Sahara


Estimated burden of disease in disability adjusted life years dalys who report 2001 l.jpg

Region

%

World

40,213,000

-

Africa

35,748,000

88.89

The Americas

111,000

2.76

1,945,000

4.83

Europe

21,000

0.052

Western Pacific

5,16,000

1.28

South East Asia

1,874,000

4.66

India

1,311,800

Estimated Burden of Disease in Disability Adjusted Life Years (DALYs)(WHO Report 2001)

Total DALYs

Eastern Mediterranean

(70% of SEAR DALYs)


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SITUATION ANALYSIS OF MALARIA IN INDIA

  • 1 BILLION POPULATION AT RISK OF MALARIA

  • 10 MILLION POPULATION UNDER SP TREATMENT

  • 2 MILLION CASES REPORTED BY NAMP

  • 800-1000 MALARIA DEATHS REPORTED BY NAMP

  • 6 MAJOR VECTORS-RESISTANT, EXOPHILIC AND OR ENDOPHILIC BEHAVIOR

  • NEW MALARIA ECOTYPES IDENTIFIED

  • SPRAYING PRODUCES TRANSIENT CONTROL

  • WIDESPREAD MONO-DRUG RESISTANCE, MULTI-DRUG RESISTANCE IN P. falciparum

  • INADEQUATE RESOURCES

  • 1 BILLION US DOLLARS LOSS DUE TO MALARIA


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HUMAN MALARIA PARASITES

  • Plasmodium vivax

  • Plasmodium falciparum

  • Plasmodium malariae

  • Plasmodium ovale


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Chronology of drug resistance in SEA Region

  • CHLOROQUINE

  • 1962 Thailand 1969 Myanmar 1970 Bangladesh 1973 India Indonesia 1981 East Timor 1984 Nepal Sri Lanka 1985 Bhutan

  • SULFADOXINE-PYRIMETHAMINE

  • 1979 India Indonesia 1980 Myanmar Thailand 1985 Bangladesh 1997 Nepal

  • QUININE

  • 1983 Thailand 1986 India

  • MEFLOQUINE

  • 1989 Thailand


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DEATHS DUE TO ARF/ARF COMPLICATIONS IN SEVERE MALARIA IN ISPAT GENERAL HOSPITAL, ROURKELA, ORISSA

1995-97 2000-03

Total Deaths in Severe Malaria Cases

61/431 (14.15%) 236/996 (23.69%)

Deaths Due to ARF/ARF Complications

14/62 (22.58%) 117/265 (44.15%)

Deaths Due to Complications without ARF

47/369 (12.74%) 119/731 (16.28%)


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MALARIA TREATMENT COST OF

AN ADULT IN INDIA

DrugsCost (Rs.)

Chloroquine 3.50-10.00

Chloroquine injection + fluids 200.00

Sulfadoxine Pyrimethamine 7.00-30.00

Mefloquine 240.00-300.00

Artemether injections 390.00-1000.00

Arteether injections 275.00

Artesunate injections 1120.00

Quinine tables + Tetracycline 270.00-210.00

Quinine injections+IV fluid+Tetracycline 800-910

*Antipyretics @ Rs. 5.00-10.00 per treatment

I/V fluid may be required during Artemisinin treatment


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6.5 m +s

CQ 400 mt

2m +s

CQ 61 mt

140 mt SP

MALARIA INCIDENCE AND DRUG CONSUMPTION IN INDIA


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Malaria in Pregnancy

  • Pregnant women attract twice the number of mosquitoes than non-pregnant women

  • There is a greater susceptibility to P. falciparum than P. vivax during pregnancy

  • Low birth weight babies in malarious areas are 2 to 4 times more likely to experience failure in school.


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Endless Vicious Cycle of Malaria

  • Malaria is the leading cause of anemia

  • Malaria affects cognitive development and learning abilities of children

  • Malaria is a risk factor of neuro-sensory and behavioral development in children

  • Malaria-one clinical febrile episode of malaria consumes 5,000 k Cal.


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Malaria Vectors

Disease Potential

Total malaria cases (%)

Pf cases (%)

Rural & Urban Vector

An. culicifacies

+

65

55

An. stephensi

++

12

5

Regional Vector

An. fluviatilis

++

15

30

An. minimus

+++

5

5

An. dirus

+++

3

5

Coastal Vector

An. sundaicus

++

0.4

0.001

Role of Vectors in Malaria Transmission in India

Broad categorization based on 1996 NAMP data. + Low ++ Medium +++ High


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Status of Insecticide Resistance

in An. culicifacies

Status of Insecticide Resistance

in An. culicifacies


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Distribution of An. culicifacies species A,B,C,D and An. fluviatilis Species S,T, and U


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Biological Behaviour

An. culicifacies Sibling Species

A

B

C

D

E

Anthropophilic index (%)*

0-4

0-1

0-3

0-1

80

Biting Activity

All night

All night

All night

Till mid-night

-

10-11 pm

10-11 pm

6-9 pm

6-9 pm

-

Vector Potential

Vector

Vector

Vector

Vector

Sporozoite Rate

0.51

0.04

0.3

0.4

20

Resistance to DDT

Slow

Fast

Fast

-

-

Fast

Fast

Fast

-

-

Resistance to Malathion

Slow

(9-10 yrs.)

Medium

(6-7 yrs)

-

-

Biological Variations Among members of An. culicifacies Sibling Species Complex

Peak Biting Time

Non-vector

Resistance to HCH

Fast

(4-5 yrs.)


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RURAL MALARIA

URBAN MALARIA

FOREST MALARIA

IRRIGATION MALARIA

PROJECT MALARIA

MIGRATION MALARIA

BORDER MALARIA

MAJOR MALARIA ECOTYPES FOUND IN INDIA


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Reproduction rate

vivax

falciparum rate

5

215

Over 300

10

155

220

20

110

160

50

80

120

100

65

100

Time taken in days (approx) for 50 per cent of the human population to become infected at different reproduction rates with an initial parasite rate of 0.1 per cent


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  • FACTORS THAT WILL INCREASE MALARIA

  • Irrigation

  • Urbanization

  • Industrialization

  • Migration

  • Natural disasters

  • Resistance in vectors and parasites

  • Global warming

  • Malaria control costs

  • Political instability/war


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“Everything about malaria is so molded by local conditions that it becomes a thousand epidemiological puzzles. Like chess, it is played with a few pieces but is capable of an infinitevariety of situations.”

- L.W. Hackett (1937)


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PERSISTENT ORGANIC POLLUTANTS that it becomes a thousand epidemiological puzzles. Like chess, it is played with a few pieces but is capable of an infinite

Eight Pesticides

Aldrin, chlordane, DDT, dieldrin, endrin, heptachlor, mirex and toxaphene

Two Industrial Chemicals

PCBs and hexachlorobenzene

Two unwanted by-products of combustion and Industrial Processes

Dioxins and furans


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TIMES OF INDIA that it becomes a thousand epidemiological puzzles. Like chess, it is played with a few pieces but is capable of an infinite24 November 1944(On the introduction of DDT on December 2, 1944)

“It should be stressed that it is a re-enforcement and not a substitute for existing well tried systems of malaria control, which should on no account be relaxed. But we believe that DDT is going to have a big future in the fight against malaria and dysentery in post-war India”


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Million Hectares that it becomes a thousand epidemiological puzzles. Like chess, it is played with a few pieces but is capable of an infinite

IRRIGATION IN INDIA


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An.culicifacies that it becomes a thousand epidemiological puzzles. Like chess, it is played with a few pieces but is capable of an infinite Breeding Sites on the Margins of Bargi Dam, M.P.


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Malaria Outbreak in Bargi Dam area in Narayanganj PHC, M.P. that it becomes a thousand epidemiological puzzles. Like chess, it is played with a few pieces but is capable of an infinite

Dam impounded

Dam

Dam completed


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SSP Command area in Gujarat that it becomes a thousand epidemiological puzzles. Like chess, it is played with a few pieces but is capable of an infinite


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Stagnant Water in Canals of the that it becomes a thousand epidemiological puzzles. Like chess, it is played with a few pieces but is capable of an infiniteSardar Sarovar Project


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