Comprehensive case management of malaria: Operational research informing policy

In 2013, the Odisha state Vector Borne Disease Control Programme led a five year operational research project, under programmatic conditions, in close collaboration with several partners. This Comprehensive Case Management Project covered a population of 900,000 across paired control and intervention blocks in four districts, each with different transmission intensities. Key gaps in access to malaria services were identified through household surveys and a detailed situation analysis. The interventions included ensuring adequate stocks of rapid diagnostic tests and antimalarial drugs at the village level, the capacity building of health workers and ASHAs, setting up microscopy centres at the primary health care level, and conducting mass screening and treatment in poorly accessible areas. The programme strengthened the routine health system, and improved malaria surveillance as well as the access to and quality of care. Initially, the programme led to increased case reporting due to improved detection, followed by a decline in malaria incidence. Lessons from the project were then scaled up statewide in the form of a new initiative-Durgama Anchalare Malaria Nirakaran (DAMaN).

In vitro susceptibility of Indian Plasmodium falciparum isolates to different antimalarial drugs & antibiotics

Background & objectives:

The in vitro assays for susceptibility of Plasmodium falciparum to antimalarial drugs are important tools for monitoring drug resistance. During the present study, efforts were made to establish long-term continuous in vitro culture of Indian field isolates of P. falciparum and to determine their sensitivity to standard antimalarial drugs and antibiotics.

Methods:

Four (MZR-I, -II, -III and -IV) P. falciparum isolates were obtained from four patients who showed artemisinin-based combination therapy (ACT) from Mizoram, a north-eastern State of India, and characterized for their in vitro susceptibility to chloroquine diphosphate (CQ), quinine hydrochloride dehydrate, mefloquine, piperaquine, artemether, arteether, dihydro-artemisinin (DHA), lumefantrine and atovaquone and antibiotics, azithromycin and doxycycline. These patients showed ACT treatment failure. Two-fold serial dilutions of each drug were tested and the effect was evaluated using the malaria SYBR Green I fluorescence assay. K1 (chloroquine-resistant) and 3D7 (chloroquine-sensitive) reference strains were used as controls.

Results:

Growth profile of all field isolates was identical to that of reference parasites. The IC₅₀ values of all the drugs were also similar against field isolates and reference parasite strains, except K1, exhibited high IC₅₀ value (275±12.5 nM) of CQ for which it was resistant. All field isolates exhibited higher IC₅₀ values of CQ, quinine hydrochloride dihydrate and DHA compared to reference strains. The resistance index of field isolates with respect to 3D7 ranged between 260.55 and 403.78 to CQ, 39.83 and 46.42 to quinine, and 2.98 and 4.16 to DHA, and with respect to K1 strain ranged between 6.51 and 10.08, 39.26 and 45.75, and 2.65 and 3.71. MZR-I isolate exhibited highest resistance index.

Interpretation & conclusions:

As the increase in IC₅₀ and IC₉₀ values of DHA against field isolates of P. falciparum was not significant, the tolerance to DHA-piperaquine (PPQ) combination might be because of PPQ only. Further study is required on more number of such isolates to generate data for a meaningful conclusion.

Malaria in India: challenges and opportunities

India contributes about 70% of malaria in the South East Asian Region of WHO. Although annually India reports about two million cases and 1000 deaths attributable to malaria,there is an increasing trend in the proportion of Plasmodium falciparum as the agent. There exists heterogeneity and variability in the risk of malaria transmission between and within the states of the country as many ecotypes/paradigms of malaria have been recognized. The pattern of clinical presentation of severe malaria has also changed and while multi-organ failure is more frequently observed in falciparum malaria, there are reports of vivax malaria presenting with severe manifestations. The high burden populations are ethnic tribes living in the forested pockets of the states like Orissa, Jharkhand, Madhya Pradesh, Chhattisgarh and the North Eastern states which contribute bulk of morbidity and mortality due to malaria in the country. Drug resistance,insecticide resistance,lack of knowledge of actual disease burden along with new paradigms of malaria pose a challenge for malaria control in the country. Considering the existing gaps in reported and estimated morbidity and mortality, need for estimation of true burden of malaria has been stressed. Administrative, financial,technical and operational challenges faced by the national programme have been elucidated. Approaches and priorities that may be helpful in tackling serious issues confronting malaria programme have been outlined.

Annual risk of tuberculosis infection among tribal population of central India

OBJECTIVE

To estimate the annual risk of tuberculosis infection (ARTI) among tribal children of Madhya Pradesh, central India.

METHODS

Community-based, cross-sectional tuberculin survey among children aged 1-9 years in the tribal population of Madhya Pradesh. Multistage stratified cluster sampling was used to select a representative random sample of villages predominated by tribal population from selected districts. A total of 4802 children were tuberculin-tested with 1TU of PPD RT 23 and the reaction sizes read after 72 h.

RESULTS

A total of 3062 (64%) children had no BCG scar. The frequency distribution of children by reaction sizes indicated a fair mode at 18 mm in the right hand side of the distribution. By mirror-image technique, the prevalence of infection among children with no recognizable BCG scar was estimated as 6.8% (95% CI: 4.8-8.9%). The ARTI was computed as 1.3% (0.9-1.7%). The corresponding figures for children irrespective of scar status were 7.1% (95% CI: 5.5-8.8%) and 1.3% (1.0-1.7%) respectively.

CONCLUSIONS

The risk of tuberculosis infection in tribal population of Madhya Pradesh, central India is not different from other areas of the country. There is, however, a need to further intensify tuberculosis control measures on a sustained and long-term basis.

Tuberculous infection in Saharia, a primitive tribal community of Central India

A cross-sectional tuberculin survey was carried out to estimate the prevalence of tuberculous infection and the annual risk of tuberculosis infection (ARTI) among children of Saharia, a primitive ethnic group in Madhya Pradesh, Central India. A total of 1341 children aged 1-9 years were subjected to tuberculin testing with 1 TU of PPD RT 23 and the reaction sizes were read after 72 h. The proportion of BCG scar-positive children was 34.6%. The frequency distribution of children by reaction sizes indicated a clear-cut anti-mode at 11 mm and a mode at 18 mm at the right-hand side of the distribution. The prevalence of infection among children irrespective of BCG scar was estimated as 20.4% (95% CI 18.2-22.5%) and the ARTI was 3.9% (95% CI 3.5-4.3%). The corresponding figures were 21.1% (95% CI 18.3-23.8%) and 3.9% (95% CI 3.4-4.5%) among BCG scar-negative children and 19.0% (95% CI 15.4-22.5%) and 4.0% (95% CI 3.2-4.8%) among BCG scar-positive children. The findings of the present study show a high prevalence of tuberculous infection and high ARTI in this primitive ethnic group. There is an urgent need to further intensify tuberculosis control measures on a sustained and long-term basis in this area.

Cercarial dermatitis in central India: an emerging health problem among tribal communities

Although cercarial dermatitis is an emerging disease world-wide, cases of such dermatitis may often go undiagnosed, especially in communities that are affected by various skin infections. Between August 2001 and July 2002, 1336 individuals from tribal villages in central India were examined for dermatitis. Skin scrapings were collected and examined for Sarcoptes scabiei and each subject's response to antiscabies treatment was recorded. Freshwater snails were collected from the local ponds used for bathing, and examined for cercariae. The recorded prevalence of dermatitis ranged between 2.1% and 12.5% during the study year, peaking at the end of winter (February-March) and during the rainy season (August-October). Snail positivity for cercariae peaked in the rainy season. The prevalence and the severity of dermatitis were both higher in children than in adults. As most recorded cases of dermatitis were associated with a rash that developed soon after bathing in the local pond, all the skin scrapings were negative for itch mites, and the response to antiscabies treatment was poor, most if not all of the dermatitis observed was probably cercarial. Cercarial dermatitis therefore appears to be a significant health problem among the tribal populations of central India.

Gastroenteritis due to Vibrio cholerae El-Tor Ogawa in Dhule

For V. Cholerae isolation, stool sample is better than rectal swab. Direct oxidase test on stool is easy and reliable. V. cholerae El-Tor Ogawa is predominant type in Dhule area. New phage type T27 was reported. Tetracyclin resistance needs further studies.