Dr. Dharmakanta Kumbhakar
Even after a century of the discovery of malaria transmission through mosquitoes in India by Sir Ronald Ross in 1897, malaria continues to be one of Assam’s leading public health problems. Till date, we are unable to control malaria in the State. Assam, which has only 2.6% of the country’s population, contributes more than 5% of the total malaria cases in the country, and over 20% of the total malaria deaths occurring in the country annually.
Malaria constitutes nearly 30 to 40% of outdoor cases and 3.60 to 7% of all hospital admissions in Assam during the peak transmission period (May to September) corresponding to the rainy months. Though both Plasmodium Falciparum and P. Vivax are found in abundance in the state, the P. Falciparum is the predominant parasite which accounts for more than 60% of malaria cases.
As per a report, the total number of malaria cases, P.falciparum cases and deaths in Assam were as follows: 2013 (19542, 14969, 7), 2014 (14540, 11210, 11) and 2015 (15557, 11675, 4). Malaria is responsible for high morbidity and mortality in the state. In Assam, malaria is one of the most important causes of direct or indirect infant, child, maternal and adult mortality. Malaria constitutes one of the most important causes of economic misfortune, engendering poverty which lower the physical and intellectual standards of the people and hamper prosperity and economic progress in every possible way.
Malaria is endemic in Assam. Districts like Karbi Anglong, Nagaon, Dima Hasao, Hailakandi, Kokrajhar, Goalpara, Darrang, Sonitpur, Odalguri and Baksa have been identified as more vulnerable though no district of the State is malaria free. Amongst these districts, the hill districts of Karbi Anglong and Dima Hasao, which are having more than one inter-State border and a higher concentration of tribal aborigines (more than 50%), are most vulnerable.
Malaria is now establishing its foothold in the bordering districts, which were previously free of the disease, such as Lakhimpur, Jorhat and Tinsukia owing to deforestation and population migration/ new settlements in the Reserve Forest areas.
It is surprising how malaria has remained endemic in the State despite intervention strategies for malaria control being in force ever since the establishment of the National Malaria Control Programme in 1953. Malaria control in Assam faces many challenges. Here, malaria transmission is perennial and persistent with the seasonal peak during April-September corresponding to the months of rainfall. The region is highly receptive to malaria transmission due to excessive and prolonged rainfall. Tropical rain-forests rich in wildlife, including reserve forests and sanctuaries, interspersed with valleys, hills and settlements make the region highly receptive for perennial malaria transmission.
As many as 130 species of mosquitoes, including 37 Anophelines and 93 Culicines belonging to 12 genera, have been recorded in the region.
There are many administrative and socio-economic problems hampering successful malaria control in Assam. Healthcare facilities in the State tend to be located in urban areas; consequently, treatment access is poorly addressed by the health systems in the periphery where it is needed most. There are many vacancies at all levels of health care and there is a shortage of essential medicines in the State. During floods, the situation becomes worse as vast areas are inundated with water and become inaccessible settlements, cut off from the rest of the world. Incidentally, this mostly occurs the rainy season which happens to be the peak transmission season for malaria.
In Assam, the tribal population and tea garden population are important risk groups for malaria infection. They suffer from neglect and high levels of poverty; about 30-40% population of Assam lives below the poverty line which is a big cause behind the perennial transmission. They often sleep in open places without using mosquito nets. They rely on traditional methods of treatment and healers instead of modern medicines. Close contact and free movement of people in bordering areas make these pockets more vulnerable to malaria.
Drug resistance, insecticide resistance, lack of knowledge of the actual disease along with newer paradigms pose a challenge for malaria control in the State. Health planners and administrators need estimates of the true burden of malaria in the State for allocation of much needed resources for interventions.
Accelerated economic and infrastructural development is urgently needed to control the malaria. In the face of rapid population increase, there is a need for increased allocation of resources for control interventions. The Union Ministry of Health and Family Welfare should provide extra financial support for the anti-malarial drive in Assam. The State Government must give extra efforts to intensify rapid diagnostic tests, distribute artemisinin-based combination therapy, distribute long lasting insecticidal nets and indoor residual spraying. Healthcare facilities along with essential medicines for malaria treatment must be increased in the periphery where it is needed most.
There is a need for identification of high-risk areas, vector incrimination and seasonal infectivity of malaria so that future outbreaks can be avoided by targeted interventions. Surveillance for probable detection of malaria infections, monitoring of vector activity and initiation of vector control measures should be ensured so as to prevent disease transmission in the high risk areas. Until malaria vaccines become available, we have to rely on old, traditional interventions with emphasis on reducing man–mosquito contact.
Information, Education and Communication (IEC) should become a continuous activity in order to help strengthen the process of early case detection and prompt treatment (EDPT). The authorities should launch a publicity campaign through different media so as to keep the people well-informed about the dos and don'ts of malaria control.