(Poster presented at Oxford 2000- New Challenges in Tropical Medicine and
Parasitology Conference held on 18th September to 22nd September, 2000)
B.Srinivas Kakkilaya, Assistant
Professor of Medicine, B. Motha, Professor of Community Medicine, Regional Research
Centre for Communicable Diseases, K.S. Hegde Medical Academy, Deralakatte; P.P.
Venugopalan, Professor of Community Medicine, A. Rajeev, Assistant Professor of
Community Medicine, Kasturba Medical College, Mangalore; I. Karunasagar, Professor
of Fishery Microbiology, College of Fisheries, Mangalore
Key Words: Malaria, voluntary
initiative, community participation, integrated strategy, eco-friendly, biolarvicides
Introduction1,2: Half a
century ago, malaria was one of the biggest scourges affecting mankind and owing to the
concerted global action under the guidance and leadership of the World Health
Organization, there was a perceptible decline in the incidence of malaria in most parts of
the world. But now, malaria has made a dramatic comeback and all countries are at the risk
of importing malaria. The re-emergence of malaria is blamed on various factors like human
complacence, technical failures, emergence of drug resistance in the parasite and
insecticidal resistance in the mosquito, administrative short comings and environmental
factors like global warming, urbanization, movement of human population etc.
The Global Malaria Control Strategy
endorsed by the WHO in 1992 has emphasized the need to develop sustainable control
programmes adapted to local needs. The strategy involves promotion of early diagnosis and
prompt treatment, planning and implementation of selective and sustainable preventive
measures, including vector control, early detection, containment or prevention of
epidemics and strengthening basic and applied research to promote the regular assessment
of etiological, social and economical determinants of the disease5.
Malaria in Mangalore:
 |
|
Mangalore is a
picturesque city in Southern India, on the shore of the Arabian Sea. It is the
headquarters of Dakshina Kannada district. The annual incidence of malaria in Dakshina
Kannada district was 5106 in 1976, with 5064 (99.17%) cases of P. vivax. By 1989, only 29
cases of P. vivax were reported. But the trend was reversed in 1990 when 114 cases of
malaria were reported. By 1995, there was alarming increase in the cases of
P. falciparum
malaria and first deaths were reported by April that year. |
The Voluntary
Initiative for Malaria Control: Alarmed by these events, a voluntary initiative was
organized in Mangalore with the following objectives:
-
To study the epidemiology of malaria in
Mangalore
-
To design an integrated, community
centered, eco-friendly malaria control strategy based on local conditions
-
To implement the control strategy and to
assess its impact
Epidemiology of malaria in Mangalore:
I. Collection of data (by activated
passive surveillance and active surveillance) and analysis:
 |
1. There was a
distinct clustering of the cases in certain localities of the city, like Falnir, Attavar,
Bunder, Kudroli, Balmatta, Lady Hill, Lalbagh and Bejai (The Hot Spots, see Figure). These
areas also had many apartments, hostels and hotels as well as new construction projects. |
-
Significant numbers of affected patients
were construction workers. Many of them were immigrant labourers from endemic areas of
northern Karnataka State and some parts of northern India. Among the local population,
people living/working in apartments, hotels, hostels and orphanages near the construction
sites were the worst affected.
-
The incidence of P. falciparum malaria
increased steadily from 1991 to 1995. The P. falciparum Percentage increased to 18.37% in
1995 from 1.79% in 1991. The Slide Falciparum Rate increased to 0.47 in 1995 from 0.002 in
1991. By 1995 April, first deaths were reported.
II. Mass screening was carried out
in construction sites, hotels, hostels and orphanages to identify asymptomatic carriers.
Results of mass
screening at high prevalence areas in Mangalore (August 1995)
| Sex |
Total
Screened |
Total
Positive |
P.
vivax |
P.
falciparum |
Mixed |
| Male |
1631 |
95 |
82 |
12 |
1 |
| Female |
565 |
43 |
35 |
8 |
0 |
| Total |
2196 |
138 |
117 |
20 |
1 |
Of the 138 positive cases
on mass screening at high prevalence areas, 58 were asymptomatic (42% of all positives and
2.64% of all screened).
Imported labour force
at construction sites (among screened) N=332
| State |
Karnataka
other than DK |
Bihar |
West Bengal |
Madhya
Pradesh |
Tamil Nadu |
Andhra
Pradesh |
| Total
Screened |
161 |
91 |
35 |
23 |
14 |
8 |
| MP Positive |
41 |
28 |
9 |
2 |
|
|
Among the 332 workers
screened, 80 (24%) were found to be positive.
III. Entomological studies: (With
the help of the Vector Control Research Centre, Pondichery).
-
Anopheles stephensi
was identified as the
vector for malaria in Mangalore
-
The principal breeding sites identified
were: used and unused wells; stagnant water at the construction sites like the water left
on the concrete surface for curing the concrete; water collected inside containers, tender
coconut shells, tyres, flower pots; water in the overhead tanks and tanks that are not
covered; paddy fields etc.
-
The highest density of the vector was
found in the localities identified as ‘hot spots’ of malaria
IV. Other contributory factors:
1. Rainfall:
Rainfall
and Malaria : 1995-1997 |
It was observed
that the incidence of malaria increased after two weeks of rainfall. The maximum incidence
was observed in the months of July to October. |
 |
2. Increase in
constructions and import of labour force: On the one hand, construction sites provided
ideal conditions for the breeding of anopheles mosquito and on the other, lack of hygiene,
poor living conditions and lack of medical facilities of these workers helped transmission
of the parasites.
3. Perils of Urbanization:
| Urban styling |
 |
Flat concrete
roofs in place of traditional tiled roofs |
| Water Supplied
by City Corporation |
|
Wells
became defunct |
| Water Supply
erratic |
|
Water stored in
open tanks/ containers |
| Beautification |
|
Ornamental
tanks, fountains |
4. Apathy and
inaction of the administration:
-
Lack of scientific data on the incidence,
prevalence and distribution of malaria in Mangalore and lack of a methodical approach for
malaria control
-
Lack of inspiring leadership
-
Lack of knowledge and lack of dedication.
-
Scarcity of staff, equipment, chemicals
and vehicles.
-
Lack of credibility.
-
Lack of communication with the public, the
media and the private medical services.
5. Lack of information among patients
and doctors: Malaria was unknown in Mangalore until 1990. This sudden outbreak of the
disease caught the doctors unawares and lack of exposure to the various problems in
malaria and its treatment made things difficult for them. Due to lack of awareness,
patients suffering from malaria were not prepared for the blood tests. All this resulted
in delayed diagnoses and improper and incomplete treatment, thus helping the spread of the
infection.
Dynamics of malarial epidemic in
Mangalore:
Increased Parasite Load |
- Increased Construction activities
- Imported labour force from malaria endemic
areas of Northern Karnataka and Northern India
- Poor living conditions at the construction
sites helping transmission
|
 |
Mosquitogenic Conditions |
 |
- Construction sites- curing, toilets, tanks
- Flat RCC roofs
- Water stored in open tanks
- Defunct wells
- Recklessness-discarded bottles, cans,
tender coconut shells, tyres
|
|
Spread to local workforce / neighbouring apartments / hostels /
hotels / orphanages |
|
Spread to local population
EPIDEMIC |
Development of control
strategy:
Based on these data, an integrated,
community centered, eco-friendly malaria control strategy was developed, involving the
following measures:
-
Activated passive and active surveillance
-
Promotion of Early diagnosis and Prompt
treatment (EDPT)- by media campaigns, CME programmes, Fever Treatment Depots
-
Mass media campaigns and audio-visual
presentations on malaria for the target groups and general public about EDPT, source
reduction, personal protection
-
CME Programmes for medical practitioners,
integrating private practitioners with Anti Malaria Progaramme - stress was on EDPT,
presumptive treatment, management of complications, case reporting etc.
-
Training of laboratory technicians
-
Fever treatment Depots for conducting
peripheral smear examination and administering presumptive and radical treatment free of
cost
-
Indoor spraying of residual insecticides
(Deltamethrin) in high prevalence areas and weekly anti larval measures in all areas -
done only in the first two years of 1995 and 1996
-
Breeding and distribution of Guppy fish
into the used and unused wells of Mangalore city
-
Promulgation of by-laws to tackle the
builders and hoteliers who did not abide by the instructions regarding malaria control.
Priority: Minimizing mortality,
promoting EDPT
Implementation of the malaria control
strategy:
To implement this malaria control
strategy for Mangalore, the Malaria Control Action Committee (MCAC) was constituted by the
Deputy Commissioner of the district.
Composition of Malaria Control Action Committee, Mangalore |
|
|
Impact of Voluntary
Initiative for Malaria Control:
The Voluntary Initiative for
Malaria Control in Mangalore was started in July 1995. The programme has been sustained
thus far and is being further strengthened. The highlights of the programme have been:
-
Providing inspired leadership to the staff
of the National Anti Malaria Programme
-
Providing technical and logistical support
to the Government machinery
-
Encouraging community participation by
involving the different sections of the society in the anti malaria programme - hoteliers,
builders, students, aquarists, representatives of the media, social workers, religious
leaders etc. were all involved,
-
Active campaign to educate and involve the
private medical practitioners in the Anti Malaria Programme
-
Organizing self-financing ward committees
-
Source reduction measures-destroying
artificial water collections, observing 'dry-day-a-week' etc.
-
Sparing use of chemical insecticides and
thrust on biolarvicides
-
Making the programme eco-friendly and
sustainable
After the formation of the Malaria
Control Action Committee and initiation of the control measures in July 1995, there has
been a decrease in the annual incidence of malaria and in the mortality. The total cases
have dropped to 4438 in 1999 from 12481 in 1996 (decrease of 65%). The Annual Parasite
Incidence has dropped to 1.53 in 1999 from 4.4 in 1996. The slide positivity rate has
dropped to 1.26 in 1999 from 2.98 in 1996. The incidence of P. falciparum malaria
has also dropped- the Slide Falciparum Rate has dropped to 0.0843 in 1999 from 0.4177 in
1996 and the P. falciparum Percentage has dropped to 6.64% in 1999 from 18.37% in
1995. There has been significant decrease in the mortality due to malaria in the very next
year of starting the malaria control programme. The mortality dropped to 5 in 1996 from 26
in 1995 and there was only one death reported each in 1998 and 1999.
Total, P. vivax and P. falciparum cases, 1991-1999 |
|
Slide Positivity Rate – 1991-1999
(S.P.R.=Total positive x 100 / Total slides examined) |
|
P. falciparum Percentage and Total deaths 1991-1999 |
|
Discussion:
Reemergence of malaria is a great
challenge before us. It is now an accepted fact that malaria can be controlled only with
integrated efforts. The World Health Organization in its Amsterdam meet in 1992 has
endorsed a Global Strategy for Malaria Control in which the emphasis has shifted from
vector control to early diagnosis and prompt treatment1. The key to success is
to apply the right strategies in the right place at the right time and on sustained basis5.
An integrated, community centered,
ecofriendly, voluntary initiative for control of malaria was organized in Mangalore, South
India.
The epidemiological studies revealed that
the malarial epidemic in Mangalore was a result of increased construction activities that
brought imported labour force from malaria endemic areas of northern Karnataka state and
other parts of northern India. Anopheles stephensi was identified as the vector and the
breeding sites were identified as wells, puddles, overhead tanks, flower pots, paddy
fields, tender coconut shells, bottles and tyres thrown out in the open. The construction
sites provided ample scope for mosquito breeding and the parasites found it easy to spread
to the workers at these sites and thereafter to the neighbouring houses, apartments,
hostels, hotels and orphanages. The incidence was found to increase with the monsoon in
June to October every year. This pattern of malarial epidemic has been observed in other
parts of the world as well5,6,7.
The integrated malaria control strategy
was developed on the basis of the local conditions in 1995. The strategy involved
promotion of early diagnosis and prompt treatment, extensive campaign for the public as
well as medical practitioners, involvement of all sections of the society, integration of
private medical practitioners and agencies with that of the Government, minimal use of
insecticides and use of biolarvicides like the Guppy fish that are ecofriendly and
sustainable. There has been a decline in mortality from 1996 and sustained reduction in
the annual incidence of malaria since 1997. This supports the concept of the Global
Strategy for Malaria Control endorsed by the WHO in 19921,5.
 |
Guppy fish have been proved
to be useful in malaria control in studies elsewhere in India1. In a study done
at Goa, India, it was found that the incidence of malaria dropped within a year in the
village where they used only biolarvicides, but it increased in the other villages where
DDT was continued3. |
Conclusions:
Urbanization, increased constructions and imported labour force triggered the epidemic of
malaria in Mangalore since 1990-91. An integrated, community centered, ecofriendly
voluntary initiative for control of malaria was developed based on the local conditions
and implemented by involving all sections of the society since 1995. The annual incidence
of malaria and malarial mortality have showed a decline since 1996-1997.
 |
Dedicated to
Sir Ronald Ross, who not only proved the vector in Anopheles, but also could control
malaria in the town of Ismailia in 1902 by sanitation measures only, when it was ravaged
by malaria owing to construction of the Suez canal4. |
References:
-
WHO Expert Committee on Malaria (Twentieth
Report)
-
Malaria in K. Park, Park’s Textbook
of preventive and social medicine, Fifteenth Ed, Banarasidas Bhanot, 1997
-
Dynamics and control of Anopheles
stephensi Liston, 1901 transmitted malaria in Goa, India; Ashwani Kumar, V. P. Sharma and
others; Proceedings of the second symposium on vectors and vector borne diseases, March
1997, National Academy of Vector Borne Diseases, 1997, pp 176-186).
-
Ronald Ross and the Mystery of Malaria;
Elmer Bendiner, Hospital Practice, October 15th, 1994 pp 95-112).
-
World Declaration on the Control of
Malaria available at http://165.158.1.110/english/hcp/hctmal01.htm
-
Falciparum malaria and climate change in
the northwest frontier province of Pakistan Bouma MJ, Dye C, van der Kaay HJ, Medicins
Sans Frontieres-Holland, Amsterdam, The Netherlands, Am J Trop Med Hyg 1996
Aug;55(2):131-7
-
Malaria situation in the People’s
Republic of China in 1994. Advisory Committee on malaria, MOPH Chung Kuo Chi Sheng Chung
Hsueh Yu Chi Sheng Chung Ping Tsa Chih 1995;13(3):161-4
Acknowledgements:
We sincerely thank:
Dr. Rajaram Rai, Taluk Medical
Officer, Mangalore; Staff, District Health Office; Dr. Shantharam Baliga,
Associate Professor of Paediatrics, Kasturba Medical College, Mangalore; M.S. Kotian,
Assistant Professor of Statistics, Kasturba Medical College, Mangalore; Medical Officer
and Staff, Mangalore City Corporation; District Statistics Dept., Mangalore; Dr.
Ajith Adyanthaya, Clinical Professor of Cardiology, UT Medical School of Houston,
Texas; Dr. P. Thiagarajan, Associate Professor of Medicine, UT Medical School of
Houston, Texas. |
