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Malaria has been
a problem in India for centuries. Details of this disease can be found even in the ancient
Indian medical literature like the Atharva Veda and Charaka Samhita. In the 30's there was no aspect of
life in the country that was not affected by malaria. During the
latter parts of nineteenth and early twentieth centuries, nearly
one-fourth of India’s population suffered from malaria, with the annual incidence estimated at around 75 million cases in 1953
and about 7-8 lakhs deaths annually, particularly in the states like
Punjab and Bengal.[1] The economic loss due to the loss of
man-days due to malaria was estimated to be at Rs. 10,000 million per year in 1935.
At the time of independence in 1947, of a population of 330 million,
about 75 million people were estimated to be infected with malaria
every year, and the direct mortality due to the disease was
estimated at 0.8 million per annum.[2,3] To combat this menace, the Govt. of India launched the National
Malaria Control Programme in April 1953. The programme proved highly successful and
the number of malaria cases significantly declined to just 100,000
in 1964. Encouraged by this, the programme was
changed to a more ambitious National Malaria Eradication Programme in 1958. By 1961 the
incidence dropped to a mere 50,00 cases a year. But since then the programme
suffered repeated set-backs due to technical, operational and
administrative reasons and the cases started rising again.[3] Early set
backs in malaria eradication coincided with DDT shortages. Later in the 1960s and 1970s
malaria resurgence was the result of technical, financial and operational problems. In the
late 1960s malaria cases in urban areas started to multiply, and upsurge of malaria was
widespread. As a result in 1976, 6.45 million cases were recorded by the National Malaria
Eradication Programme (NMEP), highest since resurgence.
Map (right) showing Malaria Endemic
Areas in India [Source] |
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The
implementation of urban malaria scheme (UMS) in 1971-72 and the
modified plan of operation (MPO) in 1977 improved
the malaria situation for 5-6 years. Malaria cases were reduced to about 2 million. The
impact was mainly on vivax malaria. Easy availability of drugs under the MPO prevented
deaths due to malaria and reduced morbidity. The P. falciparum containment programme (PfCP)
launched in 1977 helped reduce falciparum malaria in the areas where the
containment programme was operated but its general spread could not be contained.
P. falciparum showed a steady upward trend during the 1970s and thereafter. Rising trend of
malaria was facilitated by developments in various sectors to improve the national economy
under successive 5 year plans.
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Malaria, at one time a rural disease, diversified under the pressure
of developments into various ecotypes. These ecotypes have been
identified as forest malaria, urban malaria, rural malaria,
industrial malaria, border malaria and migration malaria; the latter
cutting across boundaries of various epidemiological types. Further,
malaria in the 1990s has returned with new features not witnessed
during the pre-eradication days. These are the vector resistance to
insecticide(s); pronounced exophilic vector behaviour; extensive
vector breeding grounds created principally by the water resource
development projects, urbanization and industrialization; change in
parasite formula in favour of P. falciparum; resistance in
P. falciparum to chloroquine and other anti-malarial drugs; and
human resistance to chemical control of vectors.[4]
Currently, 80.5% of the 1.2 billion population of
India lives in malaria risk areas. Of this, 4.2%, 32.5% and 43.8%
live in areas of high, moderate and low risk to malaria
respectively.[5,6] At present, official figures for malaria in
India, available at NVBDCP,[7] indicate 1.5–2 million confirmed
cases and about 1,000 deaths annually[3,7]. According to the WHO
South East Asia Regional Office estimates, during
2000-2009, malaria incidence remained between the range 2.16 -2.83
millions and malaria deaths between 3188 - 6978 in SEA Region, the
proportion of P. falciparum being 44 – 60% and more than 70%
of these cases being reported from India. During 2009, total 2.7
million confirmed malaria cases (Microscopically and RDT) and
3188 malaria deaths were reported in the SEA Region where as
estimated malaria cases were around 26 -36 million and malaria
deaths between 42300 – 77300. The P. faciparum
proportion remained around 60.5% (including RDT positives). Of
these, the highest number laboratory confirmed cases were reported
from India (1,563,344).[8] However, even these estimates for malaria
in India by the WHO have been recently questioned.
[Left] Proportion
of P.
falciparum distribution in India
[6] |
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Recent Study Contradicts NVBDCP and WHO Data: A
study conducted by teams from the office of the Registrar
General of India, Centre for Global Health Research at St
Michael’s Hospital and University of Toronto, Canada,
published in The Lancet on 20 November 2010 has reported
that malaria causes
205 000 malaria deaths per year in India before age 70 years
(55 000 in early childhood, 30 000 at ages 5—14 years, 120 000
at ages 15—69 years) with a 1·8% cumulative probability of death
from malaria before age 70 years.
The report says that 90 per cent of the deaths were recorded
in rural areas, of which 86 per cent occurred at home
without any medical attention. It also found that Orissa reported the highest number of deaths — 50,000,
followed by Chhattisgarh, Jharkhand
and Assam. The study, which began in 2002, covered 6,671
areas, each with about 200 households.[9-11] However, WHO
has rebutted these estimates.[12]
Yet other study on the global malaria mortality between
1980 and 2010 by Murray at al, published in The Lancet
in Feb 2012, estimated the malaria mortaliy in India
in 2010 at 46,800.[13]
According to the estimates of a 16-member committee set up
by the National Vector Borne Disease Control Programme (NVBDCP)
to assess India's actual malaria death burden, the total
annual number of cases in India may be about 9.7 million,
with about 30,014 - 48,660 deaths (40,297 on an
average).[14]
Another
paper estimates the malaria burden in India at India at 180 million, with as many as 90 million cases of
P. falciparum malaria per year.[15] |
Positive and P. falciparum Cases
Reported from India from 1995-2007 [14] |
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The biggest burden of malaria in India is
borne by the most backward, poor and remote parts of the
country, with >90-95% cases reported from rural areas and <5-10%
from urban areas; however, the low malaria
incidence in urban areas may be due to almost non-existing
surveillance. The state of Orissa, with a population of 36.7
million (3.5%), contributes about 25% of the total annual
malaria cases, more than 40% of P. falciparum malaria cases
and nearly 20–30% of deaths caused by malaria in India,
followed by Meghalaya, Mizoram, Maharashtra, Rajasthan,
Gujarat, Karnataka, Goa, southern Madhya Pradesh,
Chhattisgarh, and Jharkhand that also report significant
number of malaria cases and deaths.[3,6] The proportion of
P. vivax and P. falciparum varies in different parts of India; P. falciparum accounts for
30–90% of the infections in the forested areas inhabited by
ethnic tribes and <10% of malaria cases
in mostly indogangetic plains and northern hilly states,
northwestern India, and southern Tamil Nadu,[3]
Map (left) Showing High
Risk Towns for Malaria in India [16] |
Unbridled
urbanization, drought, migration of workers, and lax control efforts
are all contributing to the resurgence of malaria in India and
the problem is expected to exacerbate in the years to come. With
increasing global warming, it is projected that in 2050s, malaria is likely to persist
in Orissa, West Bengal and southern parts of Assam,
bordering north of West Bengal, but may shift
from the central Indian region to the south western
coastal states of Maharashtra, Karnataka and Kerala.
Also the northern states, including Himachal Pradesh
and Arunachal Pradesh, Nagaland, Manipur and
Mizoram in the northeast may become malaria prone.[17]
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Incidence
of Malaria in India (Sources
1,2)
[For latest update, see
http://nvbdcp.gov.in/malaria-new.html]
|
Year |
Total cases |
P. falciparum |
Deaths |
1947 |
75 million |
? |
8,00,000 |
1961 |
49151 |
? |
-- |
1965 |
99667 |
? |
-- |
1976 |
6.47 million |
0.75 million |
59 |
1984 |
2.18 million |
0.65 million |
247 |
1985 |
1.86 million |
0.54 million |
213 |
1986 |
1.79 million |
0.64 million |
323 |
1987 |
1.66 million |
0.62 million |
188 |
1988 |
1.85 million |
0.68 million |
209 |
1989 |
2.05 million |
0.76 million |
268 |
1990 |
2.02 million |
0.75 million |
353 |
1991 |
2.12 million |
0.92 million |
421 |
1992 |
2.13 million |
0.88 million |
422 |
1993 |
2.21 million |
0.85 million |
354 |
1994 |
2.51 million |
0.99 million |
1122 |
1995 |
2.93
million |
1.14
million |
1151 |
1996 |
3.04
million |
1.18
million |
1010 |
1997 |
2.66
million |
1.01
million |
879 |
1998 |
2.22
million |
1.03
million |
664 |
|
1999 |
2.28
million |
1.14
million |
1048 |
|
2000 |
2.03
million |
1.05
million |
932 |
|
2001 |
2.09
million |
1.01
million |
1005 |
|
2002 |
1.84
million |
0.90
million |
973 |
|
2003 |
1.87
million |
0.86
million |
1006 |
|
2004 |
1.92
million |
0.89
million |
949 |
|
2005 |
1.82
million |
0.81
million |
963 |
|
2006 |
1.79
million |
0.84
million |
1707 |
|
2007 |
1.51
million |
0.74
million |
1311 |
|
2008 |
1.53
million |
0.77
million |
1055 |
|
2009 |
1.56
million |
0.84
million |
1144 |
|
2010 |
1.49 million |
0.78 million |
767 |
|
Orissa,
Chhattisgarh, West Bengal, Jharkhand and Karnataka contribute
the most number of cases of malaria in India [6]
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Economic Burden: Sinton estimated a
loss of Rupees 42 crores at 1935, based only on the financial
loss in the community in terms of lost wages. In 1994, Shiv
Lal and others estimated that, if there were no control
activities and malaria was allowed to transmit from the 1947
level, there would have been an expenditure of Rupees 76,600
million (US$1,670 million) for medication, medical advise,
hospitalization, and absenteeism. If the estimates of the
Malaria Research Center, Delhi were taken into account for
calculation of economic loss, the cost would have been Rupees
68,600 million (US$1,508 million) versus expenditures of
Rupees 3,467.9 million (US$76.2 million) for control. Thus,
the net savings due to malaria control was estimated at Rupees
65,132.1 million (US$1,431 million). These authors inferred
that every Rupee invested in malaria control has produced a
direct return of Rupees 19.70. The estimated man-days saved
were 1,328.75 million per year.[3]
Realising the
difficulties in controlling/eradicating malaria, the National Malaria Eradication
Programme has been now renamed as National Anti Malaria Programme. (See
National Vector Borne Disease Control Programme
Website)
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Malaria in Karnataka |
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|
Incidence of Malaria in Karnataka State and Dakshina Kannada District |
Year |
Karnataka State |
Dakshina Kannada District |
| |
Total |
P. falciparum |
Total |
P. falciparum |
| 1994 |
266682 |
37934 |
4744 |
21 |
| 1995 |
285883 |
39700 |
9221 |
1694 |
| 1996 |
219198 |
32639 |
12481 |
1749 |
| 1997 |
181447 |
46517 |
10057 |
989 |
| 1998 |
118685 |
26369 |
8834 |
685 |
|
1999 |
96156 |
21523 |
4438 |
295 |
|
2000 |
107999 |
27934 |
2653 |
122 |
|
2001 |
196306 |
47200 |
4441 |
449 |
|
2002 |
132609 |
29675 |
5069 |
874 |
|
2003 |
100218 |
23425 |
10275 |
2051 |
|
2004 |
81314 |
20579 |
17347 |
4292 |
|
2005 |
83181 |
21956 |
21059 |
6135 |
|
2006 |
62864 |
16446 |
16473 |
4957 |
|
2007 |
49355 |
11295 |
8685 |
1768 |
|
2008 |
47344 |
9864 |
6452 |
675 |
|
2009 |
36559 |
5723 |
5850 |
682 |
|
2010 |
44122 |
7771 |
7025 |
984 |
Source:
NVBDCP Data Available at
http://nvbdcp.gov.in/Doc/Malaria-situation-upto2011(P).pdf
and data from District Malaria Officer, Mangalore and Malaria
Cell, Mangalore City Corporation |
Malaria
in Dakshina Kannada District: Dakshina Kannada district is located on the western coast
of Karnataka State. It was relatively free from malaria until early 1990 with only
sporadic case reports. But since 1990, with a sudden spurt in industrialisation and
construction activities, malaria has made a dramatic comeback here. The table below gives
the details of the incidence as per the data available with the District Malaria Officer.
The data is based on the study of only peripheral smears examined at the district
laboratory and the primary health centres and it is generally a gross understatement. (QBC
Technique is not accepted by the National Malaria Eradication Programme for diagnosis of
malaria and hence data from private labs is not included).
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Incidence of malaria in
Dakshina Kannada District
[Source:
District Malaria Officer, Mangalore]
|
| Year |
Population |
Slides examined |
Total Positive |
P. vivax |
P. falciparum |
| 1991 |
2582500 |
287171 |
340 |
334 |
6 |
| 1992 |
2638100 |
298658 |
992 |
968 |
24 |
| 1993 |
2690600 |
325512 |
4588 |
4584 |
24 |
| 1994 |
2746700 |
315493 |
4744 |
4723 |
21 |
| 1995 |
2772800 |
358312 |
9221 |
7527 |
1694 |
| 1996 |
2792600 |
418110 |
12481 |
10732 |
1749 |
| 1997 |
2834500 |
369120 |
10057 |
9068 |
989 |
| 1998* |
1675300 |
255506 |
8834 |
8149 |
685 |
| 1999 |
1716982 |
214487 |
4438 |
4143 |
295 |
|
2000 |
|
221479 |
2653 |
2531 |
122 |
|
2001 |
1888680 |
266661 |
4441 |
3992 |
449 |
|
2002 |
1926626 |
282905 |
5069 |
4195 |
874 |
|
2003 |
1955500 |
325690 |
10275 |
8224 |
2051 |
|
2004 |
1963278 |
290947 |
17347 |
13055 |
4292 |
|
2005 |
1964500 |
328862 |
21059 |
14924 |
6135 |
|
2006 |
1965278 |
288950 |
16473 |
11516 |
4957 |
|
2007 |
2084612 |
281558 |
8685 |
6917 |
1768 |
|
2008 |
2084612 |
297954 |
6452 |
5777 |
675 |
|
2009 |
2146746 |
305719 |
5850 |
5168 |
682 |
|
2010 |
2146746 |
310007 |
7025 |
6041 |
984 |
* In 1998
the district was bifurcated into Dakshina Kannada and Udupi districts, hence the numbers
Most of these cases in Dakshina Kannada
have occurred in the city of Mangalore, its head quarters.
It has been observed that
the incidence of malaria increases with the onset of the monsoon (June to October), when
the water logging helps mosquito breeding and thus transmission of the disease.
Annual Distribution of
Malaria Incidence in Karnataka and Dakshina Kannada for the year 1998
| 1998 |
Jan |
Feb |
Mar |
Apr |
May |
Jun |
Jul |
Aug |
Sep |
Oct |
Nov |
Dec |
| Karnataka |
8112 |
7360 |
8915 |
8495 |
9775 |
10077 |
10684 |
11067 |
13395 |
12296 |
11056 |
7456 |
| Dakshina
Kannada |
772 |
587 |
569 |
434 |
493 |
658 |
874 |
1081 |
974 |
898 |
851 |
643 |
Chemoprophylaxis for
travelers to India:
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Most parts of India have a
high transmission of P. vivax malaria and Chloroquine resistant P. falciparum
is reported from the North-Eastern states of India. The high altitude states of Jammu and
Kashmir, Himachal Pradesh and Sikkim are free from malaria. Malaria transmission is low or
very low in areas at an altitude >2000 metres.
For visitors to most parts of India, Doxycycline
100mg daily is advised as chemoprophylxis for short term and
Mefloquine 250mg weekly is advised for long term.
For details, click on your destination
over the map at left
Also see: Malaria in Asia; Malaria in Mangalore
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Further Reading:
- Richard Tren. Malaria and Climate Change. Working Papers Series: Julian Simon Centre For Policy Research. October 2002. Full Text at
http://www.libertyindia.org/pdfs/malaria_climatechange2002.pdf
- Shiv Lal, Sonal GS, Phukan PK. Status of Malaria in India. Journal of Indian Academy of Clinical Medicine. 2000;5(1):19-23. Full Text at
http://medind.nic.in/jac/t00/i1/jact00i1p19.pdf
- Ashwani Kumar, Neena Valecha, Tanu Jain, Aditya P. Dash. Burden of Malaria in India: Retrospective and Prospective View.
Am J Trop Med Hyg. 2007;77(6_Suppl):69-78. Full Text at
http://www.ajtmh.org/cgi/reprint/77/6_Suppl/69
- Sharma VP.
Re-emergence of malaria in India. Indian J Med Res 1996 Jan
103 26-45
- Dash AP, Valecha N, Anvikar AR, Kumar A. Malaria in India: Challenges and opportunities.
J. Biosci. 2008;33:583–592. Full Text at
http://www.ias.ac.in/jbiosci/nov2008/583.pdf
- A Profile
of National Institute of Malaria Research. Estimation of True
Malaria Burden in India. pp 91-99. Available at
http://www.mrcindia.org/MRC_profile/profile2/Estimation of true
malaria burden in India.pdf
- Malaria situation. National Vector Borne Disease control Programme. Available at
http://nvbdcp.gov.in/Doc/Malaria%20Situation_Sep.pdf
- WHO: Regional office for
SEA. Malaria: Disease burden in SEA region. Available at
http://www.searo.who.int/en/Section10/Section21/Section340_4018.htm
-
Dhingra N et al. Adult
and child malaria mortality in India: a nationally representative
mortality survey. The Lancet. 20 November
2010;376(9754):1768-1774. doi:10.1016/S0140-6736(10)60831-8. Full Text
at
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)60831-8/fulltext#
- Hay SI, Gething PW, Snow
RW. India's invisible malaria burden. The Lancet. 20 November
2010;376(9754):1716-1717. doi:10.1016/S0140-6736(10)61084-7. Available
at
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)61084-7/fulltext
- Indian Express. 2 lakh
in India die of malaria annually: Lancet. Available at
http://www.indianexpress.com/news/2-lakh-in-India-die-of-malaria-annually--Lancet/700930
- WHO Stands By Its
Malaria Death Estimates. Available at
http://blogs.wsj.com/indiarealtime/2010/10/21/who-questions-lancet-on-india-malaria-death-numbers/
- Murray CJL et al. Global malaria
mortality between 1980 and 2010: a systematic analysis. The
Lancet. 2012;379(9814):413-431.
doi:10.1016/S0140-6736(12)60034-8. Available at
http://www.lancet.com/journals/lancet/article/PIIS0140-6736(12)60034-8/fulltext
- Kounteya Sinha. India to raise malaria
toll figure 40-fold. Times News Network. Feb 4, 2012. Available at
http://articles.timesofindia.indiatimes.com/2012-02-04/india/31024354_1_malaria-deaths-malaria-like-high-fever-malaria-infection
- Brooks MI, Singh N,
Hamer DH. Control measures for malaria in pregnancy in India. Indian Journal of Medical Research.
Sep 2008. Available at
http://findarticles.com/p/articles/mi_qa3867/is_3_128/ai_n32060546
- Malaria
Country Profile India (1995-2007). Available at
http://www.whoindia.org/LinkFiles/Malaria_Country_Profile-Malaria.pdf
- Bhattacharya
S, Sharma
C, Dhiman RC, Mitra AP. Climate change and malaria in India.
Current Science. 10 Feb 2006;90(3):369-375. Full text at
http://www.ias.ac.in/currsci/feb102006/369.pdf
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