Malaria in India

Malaria has been a problem in India for centuries. Details of this disease can be found even in the ancient Indian medical literature like the Atharva Veda and Charaka Samhita. In the 30’s there was no aspect of life in the country that was not affected by malaria. During the latter parts of nineteenth and early twentieth centuries, nearly one-fourth of India’s population suffered from malaria, particularly in the states like Punjab and Bengal.[1] The economic loss due to the loss of man-days due to malaria was estimated to be at Rs. 10,000 million per year in 1935.

At the time of independence in 1947, of a population of 330 million, about 75 million people were estimated to be infected with malaria every year, and the direct mortality due to the disease was estimated at 0.8 million per annum.[2,3] To combat this menace, the Govt. of India launched the National Malaria Control Programme in April 1953. The programme proved highly successful and the number of malaria cases significantly declined to about 2 million by 1958.[4] Encouraged by this, the programme was changed to a more ambitious National Malaria Eradication Programme in 1958. By 1961 the incidence dropped further to a mere 49151 cases, with no deaths.[5]

But since then the programme suffered repeated set-backs due to technical, operational and administrative reasons and the cases started rising again.[3] Early setbacks in malaria eradication coincided with DDT shortages. Later in the 1960s and 1970s malaria resurgence was the result of technical, financial and operational problems. In the late 1960s malaria cases in urban areas started to multiply, and upsurge of malaria was widespread. As a result in 1976, 6.45 million cases were recorded by the National Malaria Eradication Programme (NMEP), highest since resurgence.

The implementation of urban malaria scheme (UMS) in 1971-72 and the modified plan of operation (MPO) in 1977 improved the malaria situation for 5-6 years. Malaria cases were reduced to about 2 million. The impact was mainly on vivax malaria. Easy availability of drugs under the MPO prevented deaths due to malaria and reduced morbidity. The P. falciparum containment programme (PfCP) launched in 1977 helped reduce falciparum malaria in the areas where the containment programme was operated but its general spread could not be contained. P. falciparum showed a steady upward trend during the 1970s and thereafter. Rising trend of malaria was facilitated by developments in various sectors to improve the national economy under successive 5 year plans.

Malaria, at one time a rural disease, diversified under the pressure of developments into various ecotypes. These ecotypes have been identified as forest malaria, urban malaria, rural malaria, industrial malaria, border malaria and migration malaria; the latter cutting across boundaries of various epidemiological types. Further, malaria in the 1990s has returned with new features not witnessed during the pre-eradication days. These are the vector resistance to insecticide(s); pronounced exophilic vector behaviour; extensive vector breeding grounds created principally by the water resource development projects, urbanization and industrialization; change in parasite formula in favour of P. falciparum; resistance in P. falciparum to chloroquine and other anti-malarial drugs; and human resistance to chemical control of vectors.[6]

According to the World Malaria Report 2014, 22% (275.5m) of India’s population lived in high transmission (> 1 case per 1000 population) areas, 67%  (838.9m) lived in low transmission (0–1 cases per 1000 population) areas and 11% (137.7m) lived in malaria-free (0 cases) areas.[7] In 2013, 0.88 million cases were recorded, with 128 million tests being conducted on the suspected cases, with P. falciparum causing 53% and P. vivax causing 47% of the infections. The incidence of malaria in India accounted for 58% of cases in the South East Asia Region of WHO.[7]

According to the World Malaria Report 2017, in the year 2016, more than half of the population (698 million) was at risk of malaria. According to the Report, India accounted for 6% of all malaria cases in the world, 6% of the deaths, and 51% of the global P. vivax cases. The Report estimates the total cases in India at 1.31 million (0.94-1.83 million) and deaths at 23990 (1600-46500)[8]

Study Contradicts NVBDCP and WHO Data: A study conducted by teams from the office of the Registrar General of India, Centre for Global Health Research at St Michael’s Hospital and University of Toronto, Canada, published in The Lancet on 20 November 2010 has reported that malaria causes 205 000 malaria deaths per year in India before age 70 years (55 000 in early childhood, 30 000 at ages 5—14 years, 120 000 at ages 15—69 years) with a 1.8% cumulative probability of death from malaria before age 70 years. The report says that 90 per cent of the deaths were recorded in rural areas, of which 86 per cent occurred at home without any medical attention. It also found that Orissa reported the highest number of deaths — 50,000, followed by Chhattisgarh, Jharkhand and Assam. The study, which began in 2002, covered 6,671 areas, each with about 200 households.[9-11] However, WHO has rebutted these estimates.[12]

Yet other study on the global malaria mortality between 1980 and 2010 by Murray at al, published in The Lancet in Feb 2012, estimated the malaria mortality in India in 2010 at 46,800.[13]

According to the estimates of a 16-member committee set up by the National Vector Borne Disease Control Programme (NVBDCP) to assess India’s actual malaria death burden, the total annual number of cases in India may be about 9.7 million, with about 30,014 – 48,660 deaths (40,297 on an average).[14]

Another paper estimates the malaria burden in India at India at 180 million, with as many as 90 million cases of P. falciparum malaria per year.[15]

[Source]

The biggest burden of malaria in India is borne by the most backward, poor and remote parts of the country, with >90-95% cases reported from rural areas and <5-10% from urban areas; however, the low malaria incidence in urban areas may be due to almost non-existing surveillance. The state of Orissa, with a population of 36.7 million (3.5%), contributes about 25% of the total annual malaria cases, more than 40% of P. falciparum malaria cases and nearly 20–30% of deaths caused by malaria in India, followed by Meghalaya, Mizoram, Maharashtra, Rajasthan, Gujarat, Karnataka, Goa, southern Madhya Pradesh, Chhattisgarh, and Jharkhand that also report significant number of malaria cases and deaths.[3,17] The proportion of P. vivax and P. falciparum varies in different parts of India; P. falciparum accounts for 30–90% of the infections in the forested areas inhabited by ethnic tribes and <10% of malaria cases in mostly indogangetic plains and northern hilly states, northwestern India, and southern Tamil Nadu.[3]

Unbridled urbanization, drought, migration of workers, and lax control efforts are all contributing to the resurgence of malaria in India and the problem is expected to exacerbate in the years to come. With increasing global warming, it is projected that in 2050s, malaria is likely to persist in Orissa, West Bengal and southern parts of Assam, bordering north of West Bengal, but may shift from the central Indian region to the south western coastal states of Maharashtra, Karnataka and Kerala. Also the northern states, including Himachal Pradesh and Arunachal Pradesh, Nagaland, Manipur and Mizoram in the northeast may become malaria prone.[18]

Incidence of Malaria in India

Year	Total cases	P. falciparum	Deaths
1947	75 million	?	8,00,000
1961	49151	?
1962	59375	?	--
1963	87306	?
1964	112942	?
1965	99667	?	--
1966	148012	?
1967	278214
1968	274634
1969	347975
1970	694017
1971	1322398
1972	1428649
1973	1930273
1974	3167658
1975	5166142
1976	6470000	0.75 million	59
1977	4700000
1978	3600000
1979	3100000
1980	2800000
1981	2600000
1982	2182302
1983	2018605
1984	2.18 million	0.65 million	247
1985	1.86 million	0.54 million	213
1986	1.79 million	0.64 million	323
1987	1.66 million	0.62 million	188
1988	1.85 million	0.68 million	209
1989	2.05 million	0.76 million	268
1990	2.02 million	0.75 million	353
1991	2.12 million	0.92 million	421
1992	2.13 million	0.88 million	422
1993	2.21 million	0.85 million	354
1994	2.51 million	0.99 million	1122
1995	2.93 million	1.14 million	1151
1996	3.04 million	1.18 million	1010
1997	2.66 million	1.01 million	879
1998	2.22 million	1.03 million	664
1999	2.28 million	1.14 million	1048
2000	2.03 million	1.05 million	932
2001	2.09 million	1.01 million	1005
2002	1.84 million	0.90 million	973
2003	1.87 million	0.86 million	1006
2004	1.92 million	0.89 million	949
2005	1.82 million	0.81 million	963
2006	1.79 million	0.84 million	1707
2007	1.51 million	0.74 million	1311
2008	1.53 million	0.77 million	1055
2009	1.56 million	0.84 million	1144
2010	1.60 million	0.83 million	1018
2011	1.31 million	0.67 million	754
2012	1.07 million	0.53 million	519
2013	0.88 million	0.46 million	440
2014	1.10 million	0.72 million	562
2015	1.17 million	0.78 million	384
2016	1.09 million	0.71 million	331
2017	0.84 million	0.53 million	194
2018	429928	207198	96
2019	338494	156940	77
2020	186532	119088	93
2021	161753	101566	90
2022	173975	99849	68

[Sources: National Vector Borne Disease Control Programme (http://nvbdcp.gov.in/malaria-new.html; Malaria Situation); World Malaria Report 2017 (8)]

Economic Burden: Sinton estimated a loss of Rupees 42 crores at 1935, based only on the financial loss in the community in terms of lost wages. In 1994, Shiv Lal and others estimated that, if there were no control activities and malaria was allowed to transmit from the 1947 level, there would have been an expenditure of Rupees 76,600 million (US$1,670 million) for medication, medical advise, hospitalization, and absenteeism. If the estimates of the Malaria Research Center, Delhi were taken into account for calculation of economic loss, the cost would have been Rupees 68,600 million (US$1,508 million) versus expenditures of Rupees 3,467.9 million (US$76.2 million) for control. Thus, the net savings due to malaria control was estimated at Rupees 65,132.1 million (US$1,431 million). These authoradvicerred that every Rupee invested in malaria control has produced a direct return of Rupees 19.70. The estimated man-days saved were 1,328.75 million per year.[3]

Realising the difficulties in controlling/eradicating malaria, the National Malaria Eradication Programme has been now renamed as National Anti Malaria Programme. (See National Vector Borne Disease Control Programme Website)

Further Reading:

1. Richard Tren. Malaria and Climate Change. Working Papers Series: Julian Simon Centre For Policy Research. October 2002. Full Text at http://www.libertyindia.org/pdfs/malaria_climatechange2002.pdf
2. Shiv Lal, Sonal GS, Phukan PK. Status of Malaria in India. Journal of Indian Academy of Clinical Medicine. 2000;5(1):19-23. Full Text at http://medind.nic.in/jac/t00/i1/jact00i1p19.pdf
3. Ashwani Kumar, Neena Valecha, Tanu Jain, Aditya P. Dash. Burden of Malaria in India: Retrospective and Prospective View. Am J Trop Med Hyg. 2007;77(6_Suppl):69-78. Full Text at http://www.ajtmh.org/cgi/reprint/77/6_Suppl/69
4. PB Health. National Vector Borne Disease Control Progrmme. Available at http://pbhealth.gov.in/pdf/malaria.pdf
5. Dash AP, Valecha N, Anvikar AR, Umar A. Malaria in India: Challenges and opportunities. J. Biosci. 2008;33:583–592. Available at http://www.ias.ac.in/jbiosci/nov2008/583.pdf
6. Sharma VP. Re-emergence of malaria in India. Indian J Med Res 1996 Jan 103 26-45
7. WHO. World Malaria Report 2014. WHO, Geneva. 2014. Available at http://apps.who.int/iris/bitstream/10665/144852/2/9789241564830_eng.pdf
8. WHO. World Malaria Report, 2017. WHO. Available at http://www.who.int/malaria/publications/world-malaria-report-2017/en/
9. Dhingra N et al. Adult and child malaria mortality in India: a nationally representative mortality survey. The Lancet. 20 November 2010;376(9754):1768-1774. doi:10.1016/S0140-6736(10)60831-8. Full Text at http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)60831-8/fulltext#
10. Hay SI, Gething PW, Snow RW. India’s invisible malaria burden. The Lancet. 20 November 2010;376(9754):1716-1717. doi:10.1016/S0140-6736(10)61084-7. Available at http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)61084-7/fulltext
11. Indian Express. 2 lakh in India die of malaria annually: Lancet. Available at
    http://www.indianexpress.com/news/2-lakh-in-India-die-of-malaria-annually–Lancet/700930
12. WHO Stands By Its Malaria Death Estimates. Available at http://blogs.wsj.com/indiarealtime/2010/10/21/who-questions-lancet-on-india-malaria-death-numbers/
13. Murray CJL et al. Global malaria mortality between 1980 and 2010: a systematic analysis. The Lancet. 2012;379(9814):413-431. doi:10.1016/S0140-6736(12)60034-8. Available at http://www.lancet.com/journals/lancet/article/PIIS0140-6736(12)60034-8/fulltext
14. Kounteya Sinha. India to raise malaria toll figure 40-fold. Times News Network. Feb 4, 2012. Available at http://articles.timesofindia.indiatimes.com/2012-02-04/india/31024354_1_malaria-deaths-malaria-like-high-fever-malaria-infection
15. Brooks MI, Singh N, Hamer DH. Control measures for malaria in pregnancy in India. Indian Journal of Medical Research. Sep 2008. Available at http://findarticles.com/p/articles/mi_qa3867/is_3_128/ai_n32060546
16. Malaria Country Profile India (1995-2007). Available at http://www.whoindia.org/LinkFiles/Malaria_Country_Profile-Malaria.pdf
17. A Profile of National Institute of Malaria Research. Estimation of True Malaria Burden in India. pp 91-99. Available at http://www.mrcindia.org/MRC_profile/profile2/Estimation of true malaria burden in India.pdf
18. Bhattacharya S, Sharma C, Dhiman RC, Mitra AP. Climate change and malaria in India. Current Science. 10 Feb 2006;90(3):369-375. Full text at http://www.ias.ac.in/currsci/feb102006/369.pdf

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