Malaria Eradication Program Research Articles

From Autonomy to Partial Alignment: National Malaria Programs in the Time of Global Eradication, Brazil, 1941–1961

This article analyses the Brazilian experience in the battle against malaria from 1941, when the Serviço Nacional de Malaria (National Malaria Service) was created and a large-scale national program for malaria control begun, until the end of the Kubitscheck administration (1956-61) when Brazil joined the Global Malaria Eradication Program (MEP), led by the World Health Organization (WHO). We will discuss the relationship between the national program, aimed at controlling--and, in short order, eliminating--malaria using Brazilian strategies and methods and the international health organization's exclusively eradication-based program. Of particular importance is the role played by malariologist Mário Pinotti, who developed a special method for malaria control in the Amazon region, based on chloroquinated cooking salt, and who wielded tremendous political influence upon Brazil's public health path during the 1940s and 1950s. The article also highlights the implications of changes in Brazilian-US relations during the Kubitscheck term for Brazil's adoption of a malaria eradication program according to the WHO model.

Lessons from the past: managing insecticide resistance in malaria control and eradication programmes

The distribution of insecticide-treated bednets to help combat the burden of malaria in sub-Saharan Africa has accelerated in the past 5 years. Additionally, many countries are also considering, or have already begun, indoor residual spraying campaigns. These are positive developments, since vector control has repeatedly proven to be an effective means of reducing malaria transmission. However, the sustainability of these insecticide-based interventions relies on the continuing susceptibility of the anopheles vectors to the limited number of available insecticides. Continual monitoring for early signs of insecticide resistance and the adoption of carefully considered resistance management strategies are therefore required. Regrettably, this essential monitoring component is frequently given a low priority in the push to meet ambitious coverage targets. We outline the key requirements for establishing an insecticide resistance surveillance system and urge all those involved in malaria vector control, either directly or as facilitators, to ensure that these measures are incorporated into control programmes. Failure to act now will inevitably lead to a future breakdown in disease control and jeopardise hopes of eradicating this major public-health problem.

A new global malaria eradication strategy

A new global malaria eradication strategy

Malaria eradication back on the table

After a lapse of almost 40 years, malaria eradication is back on the global health agenda. Inspired by the Gates Malaria Forum in October 2007,1,2 key organizations are starting to debate the pros and cons of redefining eradication as an explicit goal of malaria control efforts. Attempts to eliminate malaria in southern Africa3 and Pacific Island states,4 and WHO’s Global Malaria Programme agenda and field manual for malaria elimination,5,6 foreshadow this movement towards another global attempt at eradication. When marking 60 years of WHO’s commitment to fighting malaria, we must ask what has been achieved, but also what can we learn from the past. We now know so much more about the biology of parasite-host responses, the determinants of endemicity and transmission dynamics, the social, economic and cultural implications of malaria at household, community and national levels, and the demands made upon health systems in endemic countries. We do not yet know how to synthesize and integrate this knowledge to achieve elimination in different settings. Regional malaria elimination campaigns were first conducted in the late 1940s, preparing the ground for the Global Malaria Eradication Program in 1955. This campaign succeeded in eliminating malaria from Europe, North America, the Caribbean and parts of Asia and South-Central America.7 But no major success occurred in sub-Saharan Africa, which accounts for 80% of today’s burden of malaria.8 When the aspiration of global eradication was abandoned in 1969, the main reasons for failure were technical challenges of executing the strategy especially in Africa. The post-eradication era from 1969 to 1991 focused on technical issues, and research and development for new tools, leading to advances in drug and vaccine development, vector control and insecticide-treated nets. These decades also brought a better understanding of the social, economic and cultural dimensions of malaria. There was little global support provided specifically for malaria control in the newly independent states of Africa that were struggling to establish broad-based health systems and primary health care. By 1992, the combination of a worsening malaria situation and promising technical developments led to renewed global focus on malaria control. The Roll Back Malaria initiative, launched by WHO in 1998, led to the Abuja Declaration in 2000, which defined progressive intervention coverage targets for control designed to eliminate malaria as a public health problem, while emphasizing that this could only be achieved through vastly strengthened local health systems.9 Increased resources through the Global Fund to Fight AIDS, Tuberculosis and Malaria, the World Bank’s Booster Program, the US President’s Malaria Initiative and many others has meant that this page is finally beginning to turn as intervention coverage is rising.10 It is against this background that we hear this call for elimination/eradication. The challenges remain formidable. We all know that elimination in Africa is not possible with current tools. But efforts must focus beyond simply developing better tools, to include how existing and future tools can be strategically combined for maximum synergistic effectiveness when integrated into different health and social systems prevailing in endemic areas. Aiming at elimination and eradication further implies the need for effective surveillance strategies to monitor progress (again a challenge for health systems). This in turn requires a better understanding of malaria transmission heterogeneity in a globalized world with rapidly changing dynamics in environment, climate, migration and transnational cooperation. Maintaining long-term momentum in the face of success in regional elimination while waiting to achieve final eradication will be a major challenge. Shrinking the map by starting on the malaria margins with the “easy-to-eliminate” settings will boost morale initially but may bring marginal benefits to such areas at the expense of those where the burden of malaria is highest. Any strategic plan – and here we learn again from the past – needs to be a synchronous global effort, locally adapted in all endemic areas. Although we lack sufficient knowledge, systems and tools to eradicate malaria today, we do have a window of political will and financial resources to refocus on the goal of effective control through universal coverage of appropriate interventions. The prerequisites for a successful start are: (i) a process of inclusive discourse to agree on global vision, goals and strategy; and (ii) a global plan for all endemic areas describing how, where and when we move from control towards elimination. What must distinguish the new era, especially in Africa, is a real rather than rhetorical emphasis on health systems. ■

Research Themes and Advances in Malaria Research Capacity Made by the Multilateral Initiative on Malaria

The Multilateral Initiative on Malaria was created after an international conference on malaria in Africa held in Dakar, Senegal, in early 1997. The main goal of the conference was to "strengthen and sustain, through collaborative research and training, the capability of malaria endemic countries in Africa to carry out research required to develop or improve tools for malaria control." This conference marked the beginning of a new global focus on malaria research and capacity building three decades after a partially successful global malaria eradication program. In addition to promoting research on and institutional strengthening for malaria, the initiative was created to develop mechanisms and systems to facilitate timely communication of information to scientists working in Africa, enhance the capacity to conduct malaria collaborative/multi center research in Africa, and promote application of research results to address malaria control needs. This report summarizes the increased malaria research capacity and empowerment of African researchers facilitated by the Multilateral Initiative on Malaria through the Special Program for Research and Training in Tropical Disease Research at the World Health Organization.

In an effort to achieve a malaria-free region, the countries of the Arabian Peninsula have agreed to donate $US17 million to implement a malaria eradication programme in Yemen,

In an effort to achieve a malaria-free region, the countries of the Arabian Peninsula have agreed to donate $US17 million to implement a malaria eradication programme in Yemen,

Socioecological Perspectives of Malaria in India: A Review

P-522 Introduction: Malaria is a major health problem in India and every year it claims the lives of thousands of people and infects millions. Although nearly eradicated, it is significantly on the rise. According to the WHO, in 2003, there were approximately 2.8 million reported cases of malaria in India. There are several opinions regarding the resurgence of malaria and majority of them blame the operational aspect, which are often too simplistic and far from the reality. The present study has tried to establish the complex social and ecological perspective of malaria occurrence in various geographical locations in the country. Methods: Data for the malaria study was retrieved from the Central Bureau of Health Intelligence (CBHI) of India for the years 1994 to 2001. The study also analyzed socio-ecological perspectives of epidemics derived from several secondary sources. The majority of the secondary data on epidemics was collected from online searches (Pub med, google scholar) and unpublished government reports. We also linked the malaria outbreak with the dynamics of recent ecological change due to human interactions. Results: Our analysis led to the identification of states and areas of the county yielding high number of malaria cases in the past decade and to those regions in which there was an increased rate in malaria cases during the same period. State level data analysis identified Orissa, Madhya Pradesh, and Karnataka among the states with high number of malaria cases. Furthermore, we recognized that the states such as Gujarat and Chandigarh were showing a decrease in malaria cases. Falciparum malaria continues to exist in remote tribal forest areas in central and eastern part of the country where health service is very poor. The appearance of vectors in several hilly areas indicates the possible role of global warming and population mobility from endemic areas. Investment and priority in malaria eradication program was found to be linked with recent epidemics. Irrational medication and improper insecticide spray resulted in resistance of parasites and vectors respectively, hence more malaria incidence and fatality. Discussion and Conclusion: This study clearly recognizes a need for better disease and vector surveillance, rational treatment and proper vector control for effective eradication of malaria in India. There is a requirement of micro and macro level analysis on demographics, population behavior and movement, irrigation, deforestation and environment change in order to implement a need based control approach.

EMERGING DISEASES IN INDONESIA: CONTROL AND CHALLENGES

Infectious diseases remain an important cause of morbidity and mortality in Indonesia. The reduction, elimination, and eradication of infectious diseases have been the subject of numerous meetings and public health initiatives for decades. The malaria, yaws and other communicable disease eradication programs of earlier years, although unsuccessful, contributed greatly to an understanding of the difficulties faced in trying to achieve goal of disease control. The reemergence of old infectious diseases, along with the emergence of new diseases such as SARS, Avian Influenza and the development of antimicrobial resistance, pose significant challenges to public health.

Reappearance of Anopheles minimus in Singhbum hills of East-Central India

Anopheles minimus, an important malaria vector of South East Asia, has reappeared in the Singhbum hills, East-Central India where deforestation and DDT residual spraying had reportedly eliminated it during the Malaria Eradication Programme. The species reported has been identified as sibling species A of the An. minimus complex. An. minimus is susceptible to both deltamethrin and DDT. The study shows that the environmental conditions in this region still favour the existence of the species and one of the possible reasons for its reappearance may be the scaling down of residual insecticide spraying in the area.

ARE MULTILATERAL MALARIA RESEARCH AND CONTROL PROGRAMS THE MOST SUCCESSFUL? LESSONS FROM THE PAST 100 YEARS IN AFRICA

Multilateral malaria research and control programs in Africa have regained prominence recently as bilateral assistance has diminished. The transnational nature of the threat and the need for inspired leadership, good coordination, and new discoveries to decrease the impact of the disease has led to the founding of the Multilateral Initiative on Malaria, the Roll Back Malaria Project, Global Fund for HIV, Tuberculosis and Malaria (Global Fund), the Medicines for Malaria Venture, and the Malaria Vaccine Initiative, among other groups. Historically, the most striking feature of malaria control and elimination activities was the connectedness and balance between malaria research and control especially, from 1892 to 1949. A combination of scientific originality, perseverance in research, integrated approaches, and social concern were the keys for success. The elimination of Anopheles gambiae from Upper Egypt in 1942 using integrated vector control methods is a prime example of malaria control during the first half of the 20th century where those factors were brought together. After 1949, there were three decades of great optimism. Four notable landmarks characterized this period: the Kampala Conference in 1950; the Global Malaria Eradication Program beginning in 1955; the primary health care strategies adopted by most African States after attaining their political independence in the 1960s, and accelerating in the 1980s; and creation of the Special Program in Training and Research in Tropical Diseases at the World Health Organization in 1975. The initial highly encouraging operational results, largely obtained in temperate or subtropical areas where transmission was unstable, engendered undue expectations for the success of identical antimalarial measures elsewhere. Many were convinced that the eradication was in sight, such that support for malaria research virtually ceased. Young, bright scientists were discouraged from seeking a career in a discipline that appeared to soon become superfluous. It took more than three decades to modify antimalarial strategies and to rehabilitate long-term control as an intermediate objective. In Africa, although multilateral malaria programs have grown over the past half century and proved the most successful, fragmentation of co-ordination remains and is a major challenge. The proliferation of malaria programs in the late 1990s has brought substantial additional funds and expertise. However, excessive funding competition and failure of different programs to collaborate has resulted in poor communication and duplication of activities. The capacities of the African nations to conduct high-quality research and to coordinate control efforts are in great jeopardy. There is an urgent need for a non-partisan umbrella organ to coordinate and facilitate the network of alliances and programs in malaria research and control in Africa.

La malaria en Colombia, Antioquia y las zonas de Urabá y Bajo Cauca: panorama para interpretar la falla terapéutica antimalárica. Parte 1

Antecedentes y Problema: en 1998-2002 se investigó en Antioquia (Turbo, Zaragoza y El Bagre), la eficacia terapéutica de medicamentos y combinaciones antimaláricos. La interpretación de la respuesta terapéutica (adecuada, fallas precoz y tardía) requiere información adicional para una mejor comprensión. Objetivo: definir un marco de referencia para interpretar los resultados de las evaluaciones de respuesta terapéutica antimalárica, constituido por información sobre el comportamiento de los programas antimaláricos en Colombia y por información demográfica, epidemiológica, climatológica y socioeconómica sobre el departamento de Antioquia, las regiones de Urabá y Bajo Cauca y los municipios de Turbo y El Bagre. Metodología: se usó información oficial secundaria y en menor cantidad, información primaria. Con los datos recogidos se construyeron cuadros y gráficos, y se hicieron cálculos sobre otras variables. Resultados: se describe la malaria (paludismo) en Colombia en 1960-2002. En 2002, de los 43,707 millones de habitantes, 22,403 millones (51,17%) están expuestos (41,88% con bajo riesgo). El P. vivax es la especie predominante (66% de los casos), excepto en la región del Pacífico, donde el P. falciparum causa el 75% de los casos. Hay brotes de malaria cada 2 a 7 años; la más intensa epidemia en la historia conocida ocurrió en 1998. La mortalidad ha pasado de 25 por cien mil en 1983 a 3 por cien mil en 2000. El índice parasitario anual (IPA) ha estado alrededor de 8 por mil expuestos después de 1990, valor que es el cuádruple del existente en 1960-1970. La ineficacia del programa ha sido evidente casi desde su inicio en 1958 y la tendencia de la enfermedad siempre ha sido creciente. El fracaso de los programas gubernamentales antimalaria no tiene origen en fenómenos principalmente biológicos (resistencias del plasmodio a los medicamentos y del anofeles a los insecticidas), ni tampoco en las “condiciones de orden público”. Las principales responsables de la situación malárica en Colombia han sido fallas de origen social: a) las deficiencias financieras de origen gubernamental, b) querer aplicar insecticidas residuales en las viviendas humanas en un país donde ellas, en las zonas palúdicas, con alta frecuencia carecen de paredes y donde los anofelinos tienen hábitos extradomiciliarios, c) se supone que han influido la automedicación inadecuada y la ausencia de diagnóstico oportuno, d) el desinterés de muchos gobernantes y funcionarios y e) después de 1993, con la ley 100 de ese año, la situación ha llegado a su peor nivel. En 1959-2003, se describe la malaria en Antioquia, donde la población expuesta es menos del 20%. El paludismo ha estado siempre presente (IPA ajustado para 1959-2002: mínimo 8, máximo 140,7 y mediana 23,8 por mil expuestos) y desde comienzos del decenio de 1980 hasta ahora su frecuencia se ha incrementado, en 2000-2002 es el doble de la existente hace 30 ó 40 años. Según el IPA bruto máximo (2,66 por mil), Antioquia sería una región de riesgo medio, pero según la mediana del IPA ajustado sería de muy alto riesgo. En 1985- 1999, la razón vivax/falciparum osciló entre 1,6 y 4,7 (promedio: 2,5). La mortalidad y letalidad por malaria han disminuido en forma casi constante desde 1946; en 1985-1989 ocurrieron 154 decesos, de los cuales el 86% fueron por P. falciparum.

A framework for monitoring the malaria eradication programme in Korea.

The World Health Organisation established the Roll Back Malaria (RBM) strategy to reduce the global burden of malaria in 1998. A set of RBM indicators will not be suitable to the Republic of Korea due to the differences of the epidemiological and socio-cultural situation. Therefore, we have developed a framework and indicators for monitoring the outcomes and impact of the national malaria eradication programme that are appropriate for the situation in Korea. We reviewed the existing data in the national malaria eradication programme. We adopted general principles in developing a monitoring framework and indicators for monitoring RBM. Monitoring areas were recombined components and content that included the project plan, training health personnel, health education and public information, supply for manpower, equipment and materials, disease control, information system, supervision, community participation, intersectoral collaboration within practical guidelines for the national malaria eradication programme along with malaria control and RBM strategy of WHO. Twenty one monitoring areas were selected that identified critical areas for the national malaria eradication programme. Fifteen indicators of ten categories are proposed for use by the national malaria eradication programme in Korea.

Presidential address: The American Society of Tropical Medicine and Hygiene in the last half century: from apparent anachronism to international leader and innovator.

Presidential address: The American Society of Tropical Medicine and Hygiene in the last half century: from apparent anachronism to international leader and innovator.

RADICAL CURE OF VIVAX MALARIA : 5 OR 14 DAYS.

Dear Editor, Plasmodium vivax malaria accounts for 60-65% of total malaria cases in India. Vivax infections cause significant morbidity since in addition to the primary infection, dormant liver stages (hypnozoites) may re-emerge long after completion of full course of chloroquine treatment (25mg/kg) to cause relapses. The relapse patterns of P vivax are broadly divided into the tropical or Chesson strain type characterized by an early primary attack followed by a short latent period, the appearance of frequent relapses and the St. Elizabeth strain of the temperature type by an early primary attack and a long latent period of 6-14 months followed by relapses [1]. Primaquine is the drug used for radical cure of vivax malaria. The National Malaria Eradication Programme of India recommends primaquine in a dose of 15 mg/day for 5 days to all vivax malaria patients, which is also followed in the Armed Forces. WHO while advocating the treatment of malaria including prevention of relapses has categorized population based on their immune status with respect to malaria-immune, semi-immune and non-immune. While they advocate a 5 day primaquine regimen for the first two categories, they recommend a 14 day schedule for the non immune population. For some reasons, we in India have considered ourselves as either immune or semi-immune. Practically speaking, there can be no immune population. Further, immunity in malaria is so diverse on account of strain variation within the same species that a migratory or floating population like the Armed Forces can never be considered immune or semi-immune. It has an appropriate label as non-immune since we may be semi-immune to a strain at one place but moving on to another place may not be semi-immune or immune to the strain prevalent there. Most western authorities have also advocated a 14 day primaquine regimen [2]. However. for logistic and financial reasons. 5 day primaquine regimen has been preferred in India. Various relapse patterns have been reported from different parts of India. Adak et al reported in 1998. three relapse patterns from Northern India-tropical. temperate and intermediate [3]. A recently concluded study from Mumbai has reported a relapse pattern of predominantly tropical type. in which most of the relapses occurred in first 6 months of completion of chloroquine therapy [1]. A comparison of no primaquine. 5 day primaquine and 14 day primaquine has shown that the relapse rate is zero with 14 day regimen, 19.4% with the 5 day regimen and 11.4% with no primaquine regimen [4]. Another study has shown that rhe relapse rate with 5 day primaquine regimen is 13% [5], while it was 12.67% on no primaquine regimen as recently reported from Mumbai [1]. All patients who relapsed in this study showed complete response to the 14 day primaquine regimen. Another aspect that has often been deliberated is, whether the relapses that occur in vivax cases are true relapses or a fresh infection. Scientifically, only polymerase chain reaction test can determine this, which can be undertaken only in special circumstances or for research purpose and not as a routine. The protagon ists of ‘fresh vivax infection’ subscribe to the view on account of endemicity and transmission potential of malaria existing locally. This argument can well be countered in view of the above-mentioned studies wherein the rate of relapse (should we say suffering once again) was zero with 14 day primaquine regimen. Given the 13-19.4% relapse rate with 5 day primaquine regimen. the tropical type of relapse and complete response to the 14 day primaquine regimen. the utility of the 5 day regimen needs to be considered again. We have also seen cases of vivax malaria that have relapsed after 5 day primaquine regimen (personal communication. data not available). Based on the available data. we need to revise our existing national policy as well as that in the Armed Forces on radical cure of vivax malaria. Adopting the 14 day primaquine regimen will increase the duration of hospital admission from vivax malaria. but will ultimately decrease the expenditure incurred per patient of vivax malaria. We hope through this communication, to generate opinion from the experts in the field of malariology and also encourage debate on this issue at a larger forum.

Studies on the Anopheles mosquitoes in the Ryukyu Archipelago, Japan

Seven species of Anopheles, An. bengalensis, An. l. japonicus, An. saperoi, An. sinensis, An. lesteri, An. minimus and An. tessellates, are known to occur in the Ryukyu Archipelago. This review covers and explains the distribution and biology of these species. Historical review on synonymizing An. ohamai with An. saperoi, An. saperoi as a new laboratory vector for Plasmodium y. nigeriense, and the study on its biology for maintenance of laboratory colonization are presented. Furthermore, the susceptibility status of An. sinensis, An. saperoi and An. minimus to several insecticides, mosquito control as a component of malaria eradication program, and the distribution of An. minimus just after malaria eradication and its recent status in the Yaeyama Is. are discussed.

Studies on The Genotoxicity of An Organophosphorous Pesticide Baytex-1000

Baytex-1000 is an organophorous pesticide. It is widely used both as a larvicide and insecticide in the Na- tional Malaria Eradication Programme in India. Malaria con- trol workers are occupationally exposed to Baytex. Genotoxicity of this pesticide was studied by assaying Mitotic Index (MI), Chromosome Aberrations (CA), Sister Chromatid Exchanges (SCE) and Satellite Associations (SA), in short term lympho- cyte cultures. Peripheral blood samples were obtained from 60 malaria control workers and equal number of matched controls. MI increased upto exposure period of 5 years and declined there- after. CA in controls comprised acentric fragment, chromatid gaps and breaks only, whereas in exposed samples, dicentrics, rings, chromosomal gaps, breaks and translocations; chroma- tid gaps, breaks and isochromatid exchanges were recorded. The frequencies of CA and SCE were significantly increased by smoking and alcohol consumption (P<0.5) and depicted posi- tive correlation with period of exposure. D-G-type SA outnum- bered 2D-2G types. The mean frequencies of various param- eters in controls and workers exposed to Baytex respectively were: MI (4.29 & 6.43), CA (0.933 & 4.200), SCE (4.32 & 7.28) and SA (5.11 & 16.5). The differences were statistically significant (P < 0.05). Time and dose-yield effects of Baytex on micronuclei induction in mouse test system were also signifi- cant (p-0.05). All the cytogenetic end points investigated con- clusively show that Baytex-1000 is a highly genotoxic pesti- cide. The mechanism of its action has been described.

Studies on The Genotoxicity of An Organophosphorous Pesticide Baytex-1000

Baytex-1000 is an organophorous pesticide. It is widely used both as a larvicide and insecticide in the Na- tional Malaria Eradication Programme in India. Malaria con- trol workers are occupationally exposed to Baytex. Genotoxicity of this pesticide was studied by assaying Mitotic Index (MI), Chromosome Aberrations (CA), Sister Chromatid Exchanges (SCE) and Satellite Associations (SA), in short term lympho- cyte cultures. Peripheral blood samples were obtained from 60 malaria control workers and equal number of matched controls. MI increased upto exposure period of 5 years and declined there- after. CA in controls comprised acentric fragment, chromatid gaps and breaks only, whereas in exposed samples, dicentrics, rings, chromosomal gaps, breaks and translocations; chroma- tid gaps, breaks and isochromatid exchanges were recorded. The frequencies of CA and SCE were significantly increased by smoking and alcohol consumption (P<0.5) and depicted posi- tive correlation with period of exposure. D-G-type SA outnum- bered 2D-2G types. The mean frequencies of various param- eters in controls and workers exposed to Baytex respectively were: MI (4.29 & 6.43), CA (0.933 & 4.200), SCE (4.32 & 7.28) and SA (5.11 & 16.5). The differences were statistically significant (P < 0.05). Time and dose-yield effects of Baytex on micronuclei induction in mouse test system were also signifi- cant (p-0.05). All the cytogenetic end points investigated con- clusively show that Baytex-1000 is a highly genotoxic pesti- cide. The mechanism of its action has been described.

Changing roles of grass-root level health workers in Kerala, India

Multipurpose health workers (MPWs) are envisioned as key personnel in the delivery of primary health care. We evaluated their role and participation in implementing different national health programmes in Kerala, INDIA: Cross-sectional, community-based survey. We selected three out of the 14 districts in KERALA: Three-hundred and twenty-six MPWs (95 male and 231 female) from 44 randomly selected primary health centres from the three districts were questioned using a structured pre-tested questionnaire that sought information regarding the provision of health services by the MPWs to eligible beneficiaries in the community. We randomly selected 90 subcentres (30 from each district) and 750 households using a cluster sampling technique, and conducted household surveys to compare the actual delivery of services at the doorstep with that reported by the MPWS: Work sampling of MPWs was also performed to examine the fieldwork time spent by them on implementing individual national health programmes. These data were supplemented with focus group discussions and personal interviews of MPWs and household members. MPWs consistently 'over-reported' their performance when self-reported information was compared with that obtained from household surveys. Male MPWs concentrated on the National Malaria Eradication Programme and health education while female workers focused on the family welfare and immunization programmes. Key national health programmes (such as for tuberculosis and acute respiratory infection) were neglected by all MPWS: MPWs were aware of health problems of the elderly, but were not adequately trained nor officially expected to deliver any services in these fields. Grass-root level workers apportion more time to select national health programmes to the detriment of other health programmes, thereby negating their multipurpose role. Our study emphasizes the need for interventions to derive 'multipurpose benefits' from the MPWS:

Private practitioners and their role in the resurgence of malaria in Mumbai (Bombay) and Navi Mumbai (New Bombay), India: serving the affected or aiding an epidemic?

The increased emphasis on privatization of the health care sector in many developing countries by international financial institutions and national governments expects an expanding role for private health care practitioners in the management of major communicable diseases such as tuberculosis, malaria, acute respiratory infections (ARIs) and sexually transmitted diseases (STDs). Largely unexamined in the Indian context, however, is the socio-cultural context, the micro-level political environment in which private practitioners carry out their activities, and the quality of care they provide to their patients. Examining these aspects is significant given the impressive growth of the country’s private health sector during the past decade. This paper reports the results of an ethnographic study carried out in Mumbai (Bombay) and Navi Mumbai (New Bombay), India on private general practitioners (GPs) and their role in the management of malaria at a time when these two neighboring cities were in the midst of the worst malaria epidemic in over 60 years. Described are the characteristics of a sample of 48 private practitioners from the two cities, and their clinics. This is followed by a discussion of the data gathered through untructured interviews with practitioners and patients, and complemented by observational data on doctor-patient encounters gathered at 16 clinics over a 9-month period. The findings of the study suggest that many practitioners in Mumbai and Navi Mumbai were poorly qualified and did not play a supportive role in the two cities’ public health departments to bring the epidemic under control. The majority of the practitioners adopted diagnostic and treatment practices that were not consistent with the guidelines laid down by WHO and India’s National Malaria Eradication Programme. Very few practitioners, especially those practicing in low-income areas, relied on a peripheral blood-smear test to make a diagnosis. Practitioners whose clientele was mostly the poor commonly resorted to giving one-day treatment to febrile patients that included injectable antimalarials and broad spectrum antibiotics. Such practitioners justified their mode of diagnosis and treatment by asserting that they were only responding to the demands placed on them by their patients who could not afford a blood-smear test or a full prescription. The paper argues that practitioners who acquiesced to patient demands were at once exacerbating the health problems of their patients and jeopardizing the prospects for the epidemic to be brought under control. Driven primarily by the need to retain the patronage of patients and maintain one’s popularity in a highly competitive health arena, many providers practiced medicine that was unethical and dangerous. The paper concludes by discussing the ramifications of this study for malaria control in Mumbai and Navi Mumbai, and highlights a few salient health policy issues concerning the growth of the private health sector in India and its regulation.

Randomized controlled trials of 5- and 14-days primaquine therapy against relapses of vivax malaria in an Afghan refugee settlement in Pakistan

Primaquine is the only drag available that can eliminate hypnoxoites from the liver and prevent relapses of vivax malaria. The World Health Organization recommends a course of 14–21 days depending on region and strain. The National Malaria Control and Eradication Programmes of Pakistan and India have adhered to a 5-day course as their standard as it is deemed more practical to implement and because facility for detecting glucose 6-phosphate dehydrogenase (G6PD) deficiency is seldom available at the periphery. Evidence for the efficacy of the 5-day regimen is controversial or lacking. Two, year-long, randomized controlled trials were undertaken in an Afghan refugee camp in north-western Pakistan using a process of passive case detection and treatment at the camp's clinic: the first trial compared treatment with chloroquine alone versus chloroquine plus 5-days primaquine, the second trial compared chloroquine alone versus chloroquine plus 14-days primaquine. Chloroquine is not hypnozoitocidal and was administered to eliminate the erythrocytic stages and to alleviate clinical symptoms. The daily primaquine dose was 0·25 mg/kg bodyweight and the total chloroquine dose was 25 mg/kg over 3 days. During the first trial 52% ( 129 250 ) of the non-primaquine group recorded a 2nd clinical-parasitaemic episode and 23% recorded a 3rd, whereas 51% ( 128 250 ) of the 5-days primaquine group reported a 2nd episode and 21% recorded a 3rd. During the second trial 49% ( 49 100 ) of the non-primaquine group recorded a 2nd episode and 25% recorded a 3rd, whereas only 32% ( 32 100 ) of the 14-days primaquine group recorded a 2nd and only 2% recorded a 3rd. The 5-days primaquine regimen has no value as an anti-relapse therapy and should be abandoned. In extended tests in vivo in which vivax cases ( n = 3) were treated with chloroquine 25 mg/kg and 14-days primaquine, there was no parasite recrudescence within 28 days and hence no evidence of resistance to chloroquine.