G.P. CHATTERJEE MEMORIAL AWARD LECTURE 2003-2004 Malaria Control in India by Dr. V.P. Sharma 91st Session of the The Indian Science Congress Session Chandigarh 4th 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 90% disease burden in Africa, South of Sahara

Estimated Burden of Disease in Disability Adjusted Life Years (DALYs) (WHO Report 2001) Total DALYs Region % World 40,213,000 - Africa 35,748,000 88.89 The Americas 111,000 2.76 1,945,000 4.83 Eastern Mediterranean Europe 21,000 0.052 Western Pacific 5,16,000 1.28 South East Asia 1,874,000 4.66 India 1,311,800 (70% of SEAR DALYs)

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

HUMAN MALARIA PARASITES Plasmodium vivax Plasmodium falciparum Plasmodium malariae Plasmodium ovale

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

Total Deaths in Severe Malaria Cases 61/431 (14.15%) 236/996 (23.69%) 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%)

MALARIA TREATMENT COST OF AN ADULT IN INDIA Drugs Cost (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

MALARIA INCIDENCE AND DRUG CONSUMPTION IN INDIA 6.5 m +s CQ 61 mt CQ 400 mt 2m +s 140 mt SP

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.

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.

Role of Vectors in Malaria Transmission in India 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 +++ An. dirus 3 Coastal Vector An. sundaicus 0.4 0.001 Broad categorization based on 1996 NAMP data. + Low ++ Medium +++ High

Status of Insecticide Resistance Status of Insecticide Resistance in An. culicifacies Status of Insecticide Resistance in An. culicifacies

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

An. culicifacies Sibling Species Biological Variations Among members of An. culicifacies Sibling Species Complex 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 - Peak Biting Time Vector Potential Vector Non-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 HCH Resistance to Malathion Slow (9-10 yrs.) Medium (6-7 yrs) Fast (4-5 yrs.) - -

MAJOR MALARIA ECOTYPES FOUND IN INDIA RURAL MALARIA URBAN MALARIA FOREST MALARIA IRRIGATION MALARIA PROJECT MALARIA MIGRATION MALARIA BORDER MALARIA

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 100 65 120 80 50 160 110 20 220 155 10 Over 300 215 5 falciparum rate vivax Reproduction rate

Resistance in vectors and parasites Global warming FACTORS THAT WILL INCREASE MALARIA Irrigation Urbanization Industrialization Migration Natural disasters Resistance in vectors and parasites Global warming Malaria control costs Political instability/war

“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 infinite variety of situations.” - L.W. Hackett (1937)

PERSISTENT ORGANIC POLLUTANTS 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

TIMES OF INDIA 24 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”

IRRIGATION IN INDIA Million Hectares

An.culicifacies Breeding Sites on the Margins of Bargi Dam, M.P.

Malaria Outbreak in Bargi Dam area in Narayanganj PHC, M.P. Dam impounded Dam Dam completed

SSP Command area in Gujarat

Stagnant Water in Canals of the Sardar Sarovar Project