Subscribe to our newsletter Edit profile Unsubscribe
Newsletter Logo Newsletter Header
Malaria India

Malaria in India

About 95 % of India’s population lives in areas, where malaria transmission is possible However, the interaction between climate, environment, vectors and people determines a high degree of variability (figure 1).

 


fig. 1

The following major eco-epidemiological types can be distinguished:

  • Forest, forest-fringe and hill-tract malaria found in the eastern and north-eastern states.  Transmission is intense and perennial.  The populations are often “tribes” living in or near forests with a more or less nomadic life-style.
  • Rice-field malaria which is often highly seasonal with low to moderate transmission.  In the arid north-west, rice-field malaria declines to epidemic-prone desert-fringe malaria.
  • Urban malaria has been a steadily increasing problem in India since the 1950s and is largely related to changing urban ecology with construction activities, which attract workers from poor rural endemic areas. Malaria related to development projects, e.g. road-building, is conditioned by similar factors.

 

At the time of independence in 1947, there were an estimated 75 million malaria cases and 0.8 million deaths annually. National Malaria Eradication Programme was launched in 1958, based mainly on widespread DDT spraying. The number of reported cases was reduced to about 100,000 by 1965-66. After global eradication was called off in 1969, funding decreased steeply, and by 1976 reported cases peaked at 6.47 million.  In 1977, a Modified Plan of Operation was launched with the immediate objectives of preventing deaths and to reduce morbidity due to malaria. The programme was “integrated with primary health care”.

The blanket approach of insecticidal spraying was changed to selective  indoor residual spraying targeting with Annual Parasite Incidence (API) of 2 per 1000 per year and above. The number of cases declined to 1.91 million in 2004 (figure 2). However, the proportion of cases due to P. falciparum has risen steadily in the 1980s.  In the face of a generally decreasing case-load, this is a sign of worsening resistance to the treatment being used.

 


fig. 2

The latest review of the national programme was carried out in early 2007 as an international collaborative Joint Monitoring Mission following a sample survey in households and health facilities of malaria control implementation carried out by the National Institute of Malaria Research, New Delhi. The main problems identified were:

  • The malaria burden in the country is unknown despite an elaborate surveillance system.  The number of officially reported malaria deaths is about 1000 per year, but a study of  medically certified deaths in the country suggest that the real figure is at least 40 times as high (Rastogi unpublished.)
  • Although surveys over the last 5 years countrywide have consistently found that more than 25% of P.falciparum infections are resistant to chloroquine, this drug has been maintained as first-line treatment.
  • Until recently, primary health care has not been systematically developed in rural areas of India, especially the eastern states with high burden. Malaria disease management in the periphery has therefore mainly been in the hands of malaria volunteers.  As these have little to offer, except a prick in the finger and some chloroquine tablets, patients increasingly seek the assistance of private providers, whose services are also highly inadequate and not always accessible for poor remote populations.
  • The targeting of indoor residual spraying is based on loose criteria, it is carried out with poor quality and often sabotaged by the population.
  • Insecticide-treated nets have been distributed mainly by NGOs and based on poverty criteria rather than malaria burden.  There has therefore been no measurable impact, despite good results in controlled trials in some areas and high population acceptance in many (but not all) rural areas.


All of these problems can be addressed. The National Rural Health Mission launched in 2005  signals a new commitment to quality health care in rural areas based on collaboration between national and local government, civil society and the populations in need, which has proven productive in parts of the country.  India is also in a unique situation by being a lead producer of antimalarial medicines and diagnostics and probably in the near future long-lasting insecticidal nets.  A State like Gujarat has developed a dynamic GIS-linked communicable disease surveillance system that would be the envy of many richer countries.

 

Allan Schapira