Published Date: 2006-05-07 00:00:00
Subject: PRO/EDR> Malaria - India (Assam) (03)
Archive Number: 20060507.1318
MALARIA - INDIA (ASSAM) (03)
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Date: Sun 7 May 2006
From: T Jacob John <vlr_tjjohn@sancharnet.in>
Comment on malaria in Assam, India
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The situation is worse than previously reported, according to a report in
The Hindu, Bangalore edition, 5 May 2006.
The earlier ProMED-mail report (30 Apr 2006) mentioned 77 deaths in 2006
due to malaria in Lakhimpur district in Assam state. Today's [5 May 2006]
report puts the figures at 200 deaths in Lakhimpur, and a total of 500
deaths in the whole state. The earlier report mentioned discord between the
central and state government departments concerned with malaria control. A
new bone of contention between physicians and public health officials is
over the case definition of malaria (falciparum) to be counted as death due
to malaria. Many hospitals use rapid tests for diagnosing malaria in
appropriate clinical cases, but the officials want blood smear detection of
the malarial parasite. This leads to under-counting of deaths due to
malaria in the current outbreak.
The North Lakhimpur Civil Hospital has patients overflowing the available
200 beds into the corridors (on mattresses on the floor). Apparently, even
doctors' offices are being vacated to accommodate more fever patients. A
12-member medical team has been mobilized from elsewhere, and a UNICEF team
from New Delhi has already visited and has proposed remedial measures.
Ganesh Saikia, sub-divisional medical and health officer, has been quoted
as stating that this outbreak was the result of lack of active surveillance
and failure of the malaria control structure to carry out timely measures
under the national vectorborne disease control program.
There are several striking points. One, there is no accurate count of
either laboratory-diagnosed malaria or of malarial deaths. Therefore, the
given figures are rounded off to the nearest hundreds. Two, a crisis is on
hand, and the response is too slow and insufficient to prevent further
mortality. Three, diagnostic facilities are very limited locally -- in
spite of the fact that this state is well-known to be endemic for
falciparum malaria, and every year cases occur with many deaths. Four, the
required-by-the-book "malaria surveillance" (blood collection from fever
cases by house visits, once in 15 days, and smear examination under
microscope) has not been sustained. Such intensive surveillance is required
only in hyper-endemic areas, such as many places in Assam. So, the lack of
preparedness for an outbreak speaks volumes on the sincerity of the system
and staff.
The question of chloroquin resistance remains unanswered so far. This
region is known for resistant falciparum, but I have no quantitative data
on hand. The causes of death also remain unreported in the newspapers, but
falciparum malaria causes many syndromes with fatal outcome, such as
cerebral malaria, severe hemolysis, pulmonary edema, acute renal tubular
necrosis, disseminated intravascular coagulation etc.
The many recent advances in diagnosis and treatment may not have been
applied or even been possible, under what appear to be very difficult
circumstances locally. Is the government's responsibility only just to give
some care, or is there an obligation to give quality care? The term
"medical and health officer" may not be clear to readers outside India: in
most states in India, district or divisional medical officers
(seniority-based promotion) are in charge of the government health care
system and, in addition, double up as public health officers in times of
need such as an outbreak. No training in public health or epidemiology is
required for such "medical and health officers." This is the main reason
why disease surveillance does not function and also why childhood
immunization is not managed well to achieve satisfactory coverage.
The international community interested in infectious diseases must take
these deficiencies seriously and put pressure on India to rebuild the
public health system, without which any new (emerging or re-emerging)
disease may not be picked up for a long time, putting at risk wider
populations beyond state and national borders. The current policy is to
control a limited number of specific diseases, such as tuberculosis,
malaria, HIV, leprosy and childhood clusters of vaccine-preventable
diseases through "vertical" (centrally sponsored, designed, funded, and
implemented by state) schemes, and each of these will send patients away if
the diagnosis does not fit its jurisdiction. No one is looking for new
infectious diseases.
For influenza, there are 3 national laboratories to investigate human
infections and one for animal infections in a population of one billion.
When a Henipah virus outbreak occurred, it was misdiagnosed with laboratory
evidence of measles virus, only to be corrected by CDC, Atlanta that it was
not measles but Henipah, and publicly announced 4 years after the event.
The country is economically strong and can afford quality medical and
public health services, but most leaders do not know what is needed and
what is possible, and technically informed international agencies praise
them to the face and severely criticize behind the back. They are not
willing to call a spade a spade for the sake of diplomacy. Others with
financial resources try to apply their own agenda and pet schemes without
regard to appropriateness or adequacy. They seem not to know what local
spades should look like. The Assam malaria outbreak is the outcome of a
severely damaged public health system in India. And hardly anyone is
willing to shout that the emperor is naked, lest he be called unwise and
ignorant. I take the risk.
--
T Jacob John
Retired Professor of Clinical Virology
Christian Medical College
Vellore, India
<vlr_tjjohn@sancharnet.in>
[ProMED-mail thanks T Jacob John for this personal comment on the malaria
situation in Assam. It may not always be possible to obtain malaria blood
smears on every patient, especially not outpatients, but the malaria
slide-positive rate on fever cases admitted for suspected malaria will give
an indication of how much malaria contributes to the current epidemic.
Also, follow-up on day 14 or 28 may not be possible in all cases, but if
done on a selected number of cases, the rate of recrudescense will be
known, and hence, data on resistance and treatment failure can be obtained.
- Mod.EP]
See Also
Malaria - India (Assam) (02) 20060430.1254Malaria - India (Assam) 20060420.1160
2005
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Malaria, resistant - India 20050107.0047
2004
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Malaria - India (Mumbai) 20041002.2716
Malaria - India, Myanmar: RFI 20040111.0120
2003
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Malaria - India (Haryana) (02) 20031018.2620
Malaria - India (Haryana) 20031005.2504
Malaria - India (Kerala): request for information 20030605.1378
2002
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Malaria - India (Assam) 20020613.4483
2001
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Malaria - India (Assam) 20010604.1102
2000
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Malaria - India (Uttar Pradesh) 20001017.1777
1999
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Malaria, vivax, resistant - India (Mumbai) 19990316.0389
1996
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Malaria - India, 1995 (5) 19960405.0652
Malaria - India, 1995 (4) 19960403.0625
Malaria - India, 1995 (3) 19960402.0619
Malaria - India, 1995 (2) 19960402.0617
Malaria - India, 1995: RFI 19960330.0590
................ep/msp/sh
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