Vector Borne Disease Control Programme Research Articles

Evaluation of mass drug administration programme for elimination of lymphatic filariasis in Nalgonda district, Telangana, India

Background: Lymphatic filariasis is an important public health problem in India. Nalgonda district of Telangana is one of the endemic districts where Mass Drug Administration programme is undertaken every year to eliminate lymphatic filariasis. The present study was undertaken to evaluate the coverage and compliance rates of the MDA programme conducted during December 2015. Methods: The guidelines of National Vector Borne Disease Control Programme (NVBDCP) was used to select a total of 131 households from three villages and one urban ward using three stage random sampling. Each household was visited by a team and data was recorded on structured questionnaire. Data was compiled on Windows excel spreadsheet and analyzed using SPSS software version 21. Results: The study population consisted of 523 individuals from 131 households, out of which 498 (95.21%) were eligible for mass drug administration. The study revealed that coverage rate, compliance rate and effective compliance rate were 73.29%, 72.05% and 52.81% respectively. Fear of side effects (76.47%) and being unaware of the benefits (21.56%) were the main reasons for non-compliance. Side effects were reported by only 1.14% of cases. Conclusions: The study reveals that the programme managers at all levels must ensure the upgradation of coverage rates by involving more human resources, supervision and incentive linked to work-output and enhance compliance by intense information, education and communication activities.

Spatio-temporal dynamics of mosquitoes in stream pools of a biosphere reserve of Southern Western Ghats, India

The spatial and temporal dynamics of mosquitoes in stream pools were examined in a biosphere reserve of the Southern Western Ghats, India. The immature mosquitoes in stream pools were collected from stream substrates of bedrock pool, boulder cavity and sand puddle. The collected larvae and pupae were reared and identified. In total, 16 species from four genera of mosquitoes were collected. The mosquito species from Culex and Anopheles were predominantly occurred. The bedrock pool had the highest diversity and abundance of mosquitoes. The statistical analyses showed that the substrate specificity and the seasons were positively related to the distribution of mosquitoes rather than spatial pattern. This study described the spatial and temporal pattern of mosquitoes in stream pools of the Southern Western Ghats. This information would be helpful to National Vector borne disease control program for surveillance and control.

Japanese Encephalitis/Acute Encephalitis Syndrome: Prevention and Control Strategies in India

Outbreaks of acute encephalitis syndrome (AES) occur seasonally in the country and lead to substantial mortality and disability. Japanese encephalitis (JE) virus traditionally is known to be causing AES with significant mortality and disability. However, enteroviruses and other causes are being increasingly incriminated in AES outbreaks in different regions of the country. Hence newer strategies have been developed under national vector borne disease control programme (NVBDCP) to prevent and control JE/AES. Many ministries have converged with the lead of health ministry to successfully operationalize the JE/AES prevention and control strategies in the country.

Educational intervention: a useful tool for assessing knowledge of medical students regarding national vector borne disease control programme

Background: Quizzes are considered one of the most effective methods for promoting self-learning and motivating students to be more attentive during teaching activities. Understanding of a National Health Programme is necessary for medical students not only because it is a part of the medical curriculum, but also to provide the same knowledge to others for control of vector borne diseases. Objective: Present study aimed to assess the effectiveness of a quiz on knowledge of undergraduate MBBS medical students regarding National Vector Borne Disease Control Programme. Methods: All seventh semester medical undergraduates, (n=145) of Bharati Vidyapeeth Medical College, Pune participated in the quiz and completed pre and post intervention questionnaires. The data was analyzed by using McNemar‟s test. Results: Out of the ten questions, significant improvement in knowledge was found after the quiz in seven questions while for three questions though knowledge was increased it was not statistically significant. The response of students for insecticide used in insecticidal impregnated bed nets, which was zero in the pre-test increased to 6.9% in the post-test. Conclusion: Present study showed significant improvement in medical student‟s knowledge regarding the National Vector Borne Disease Control Programme as a result of a quiz based Educational intervention.

Malaria situation in India with special reference to tribal areas.

Background & objectives:In India, malaria is a major public health problem in States having predominantly tribal population. The objective of this analysis was to find out the incidence of malaria in various States/districts having varied proportions of tribal population using National Vector Borne Disease Control Programme (NVBDCP) data.Methods:States and districts were classified into three categories based on proportions of Scheduled Tribes (ST) population as <10, 10-29.9 and 30 per cent + ST population. Five year average (2008-2012) of all important malaria indicators collected by NVBDCP was taken to normalize the effect of annual fluctuations in malaria incidence.Results:State level analysis revealed that ten States/UTs with 30 per cent or more tribal population comprising only three per cent of total population, contributed 14 per cent of total malaria, 21 per cent Plasmodium falciparum and 29 per cent of deaths due to malaria. Similarly, district level analysis showed that districts with 30 per cent or more tribal population comprising about eight per cent country's population contributed to 46 per cent of total malaria cases, 70 per cent P. falciparum and 47 per cent malarial deaths in the country.Interpretation & conclusions:Our analysis showed that the neglect of the ethnic communities in tribal areas would be detrimental to the overall reduction of morbidity and mortality due to malaria. The fight against the increasing burden of malaria in tribal belt requires adoption of multiple approaches and socio-economic development of the tribal communities.

English

Introduction: Malaria is a common condition in tribal regions globally and can be a killer disease if not treated. In India it is widely prevalent specifically in rural and tribal regions and responsible for huge number of morbidity and also mortality. Aims: To know the status of malaria in hospitalized fever cases at a tertiary care centre of a tribal cum rural region of south India. Materials and Methods: Data of six months of all fever cases screened for malaria, reported to RIMS and National Vector Borne Disease Control Program (NVBDCP) and hospitalized was collected and analyzed. Result: Out of 4060 hospitalized fever cases 154 (slide positivity rate SPR 3.71) were malaria positive including 148 (96.1%) Falciparum and 6 (3.9%) vivax malaria. Among all the diagnosed malaria cases, 74 were male (1.82% from all fever cases and 2.43% among all male screened cases) while 80 were female cases (1.97% from all fever cases and 7.88% among all female screened cases) indicating relatively high number of cases in less reported female fever cases. Villages were found with poor preventive precautions. Most were farmers and didn’t know about how malaria spreads. Conclusion: With many limitations of the study it can be concluded that, malaria is not uncommon in the region. Number of falciparum malaria is also common and females are the main victims of complicated falciparum malaria. There is urgent need for more serious malaria awareness and control program for the region.

Malarial trend in Dakshina Kannada, Karnataka: An epidemiological assessment from 2004 to 2013

Background: Malaria is one of the main causes for morbidity in India and many of the tropical countries. Dakshina Kannada in Karnataka is one of the Malaria endemic districts. Various efforts to contain the transmission of this deadly disease by National Vector Borne Disease Control Program (NVBDCP) has been effective up to an extent. Methods: A retrospective report based study over a period of ten years was conducted in Dakshina Kannada district. The community based data of confirmed cases of malaria was collected and analysed. Results: Highest cases of Malaria were recorded in 2005 (16,154) . The incidence of Malaria ranged from 26% to 85% in the last ten years. The magnitude of Plasmodium falciparum %(Pf%) ranged from 6.8%-30.9%. Conclusion: Prevalence of malaria has been on a declining trend but some of the malariometric indices have been on a fluctuating trend. This is indicative of a multidisciplinary approach to curb the disease.

Malaria Control in India: Strategies, Progress and Challenges

Malaria continues to be one of India's leading public health problems. About 95% population in the country resides in malaria endemic areas consisting of high burden states the North-Eastern (NE) states, Chhatisgarh, Jharkhand, Gujrat, Rajasthan, West Bengal and Karnataka. In 2013 alone total 881730 malaria cases (463846 cases were falciparum malaria) and 440 deaths were reported. In India, malaria control comes under NVBDCP (National Vector Borne Disease Control Programme) under National Rural Health Mission. The National strategy on malaria control has undergone a paradigm shift with the introduction of new interventions for case management and vector control.

Usage pattern, physical integrity & insecticidal efficacy of long-lasting insecticidal nets in Odisha State, India.

Background & objectives:One of the major strategies being pursued for malaria control by the National Vector Borne Disease Control Programme is the distribution of long lasting insecticidal nets (LLINs) in endemic areas since 2009. Information on durability of insecticidal efficacy and physical integrity of LLINs and community usage at different time intervals of their use is essential to plan net replacements to maintain universal coverage for an effective and sustainable malaria control strategy. Therefore, a study was undertaken to assess these parameters in two malaria endemic districts of the Odisha State.Methods:A total of 309 households were selected in 15 villages of two community health centres (CHCs) (Borigumma and Laxmipur) from Koraput district and one (Khairput) from Malkangiri district. Data on net usage were collected during March to July 2014 using semi-structured questionnaires. PermaNet 2.0 were sampled from all households, replaced with new ones, and bioassays were carried out to determine the insecticidal efficacy of LLINs after four and half, four and two years of field use following the standard procedure of World Health Organization.Results:LLIN use rate varied from 57.9 to 90.2 per cent in the study CHCs. The annual washing rate per net in Borigumma, Khairput and Laxmipur was 6.6, 3.2 and 4.8, respectively. The LLINs used two years in the field caused 100 per cent mortality and four to four and half years caused below 80 per cent mortality, except one net.Interpretation & conclusions:Nearly 20 per cent of the people were out of net coverage and hence the Programme to ensure 100 per cent coverage. The community should adequately be educated so as to increase the net use rate and avoid incorrect washing practices.

Mid-term assessment of mass drug administration of DEC for filariasis in Rewa district of Madhya Pradesh

Background: Filariasis has been a major public health problem in India that leads to both medical and social consequences. It causes irreversible chronic manifestations, such as elephantiasis, lymphoedema, and hydrocele, that are responsible for social stigma besides causing considerable economic loss and severe physical disability to the affected individuals. Objective: Mid-term assessment of mass drug administration (MDA) of diethylcarbamazine (DEC) was carried out with objectives to review the progress of activities of single-dose DEC mass administration with respect to process and outcome indicators and to recommend mid-course correction measures. Materials and Methods: This study was a cross-sectional study that was carried out in Rewa, one of the filaria endemic affected districts of Madhya Pradesh, India. It was carried out in August 2013. The study was conducted as per the standard guidelines given by National Vector Borne Disease Control Programme. In Rewa district, 120 households from three community health centers and one urban ward were randomly selected. Thereafter, randomly selected 30 households (each from three rural and one urban site) were interviewed for MDA of DEC for filariasis. Results: Coverage rate of DEC tablets was 91.02% whereas compliance rate was 84.66% in Rewa. Conclusion: The coverage in the study was 91.02%, but the compliance rate with drug ingestion was 84.66%, which ultimately led to a lower effective coverage (77.06%). The overall coverage was better in rural areas compared to urban areas, whereas compliance was little better in urban areas.

Declining efficacy of artesunate plus sulphadoxine-pyrimethamine in northeastern India.

BackgroundAnti-malarial drug resistance in Plasmodium falciparum in India has historically travelled from northeast India along the Myanmar border. The treatment policy for P. falciparum in the region was, therefore, changed from chloroquine to artesunate (AS) plus sulphadoxine-pyrimethamine (SP) in selected areas in 2005 and in 2008 it became the first-line treatment. Recognizing that resistance to the partner drug can limit the useful life of this combination therapy, routine in vivo and molecular monitoring of anti-malarial drug efficacy through sentinel sites was initiated in 2009.MethodsBetween May and October 2012, 190 subjects with acute uncomplicated falciparum malaria were enrolled in therapeutic efficacy studies in the states of Arunachal Pradesh, Tripura, and Mizoram. Clinical and parasitological assessments were conducted over 42 days of follow-up. Multivariate analysis was used to determine risk factors associated with treatment failure. Genotyping was done to distinguish re-infection from recrudescence as well as to determine the prevalence of molecular markers of antifolate resistance among isolates.ResultsA total of 169 patients completed 42 days of follow-up at three sites. The crude and PCR-corrected Kaplan-Meier survival estimates of AS + SP were 60.8% (95% CI: 48.0-71.4) and 76.6% (95% CI: 64.1-85.2) in Gomati, Tripura; 74.6% (95% CI: 62.0-83.6) and 81.7% (95% CI: 69.4-89.5) in Lunglei, Mizoram; and, 59.5% (95% CI: 42.0-73.2) and 82.3% (95% CI: 64.6-91.6) in Changlang, Arunachal Pradesh. Most patients with P. falciparum cleared parasitaemia within 24 hours of treatment, but eight, including three patients who failed treatment, remained parasitaemic on day 3. Risk factors associated with treatment failure included age < five years, fever at the time of enrolment and AS under dosing. No adverse events were reported. Presence of dhfr plus dhps quintuple mutation was observed predominantly in treatment failure samples.ConclusionAS + SP treatment failure was widespread in northeast India and exceeded the threshold for changing drug policy. Based on these results, in January 2013 the expert committee of the National Vector Borne Disease Control Programme formulated the first subnational drug policy for India and selected artemether plus lumefantrine as the new first-line treatment in the northeast. Continued monitoring of anti-malarial drug efficacy is essential for effective malaria control.

Prevalence of malaria and anemia among pregnant women residing in malaria-endemic forest villages in India

India has the highest burden ofmalaria in Southeast Asia, accounting for 61% of confirmed cases in the region in 2011 [1]. Furthermore, more than one-fifth (22.6%) of Plasmodium falciparum and 42% of Plasmodium vivax infections globally occur in the country [2]. The prevalence of malaria is increased among the ethnic tribal population residing in areas of India affected by long-term conflicts of low intensity [3]. Malaria in pregnancy is the most common yet preventable cause of maternal and perinatal morbidity and mortality. Additionally, anemia is a major public health problem among pregnant women in India; about 80% of maternal deaths in South Asia are related to this condition [4]. The aim of the present study was to assess the prevalence of malaria and anemia among pregnant women from ethnic tribes in Andhra Pradesh and Chhattisgarh. Datawere used that had been previously collected byMedecins Sans Frontieres India for 1222 pregnant women residing in adjoining forest villages who attended one of seven mobile prenatal-care clinics between January 1 and December 31, 2012. Rapid diagnostic tests were performed to detect malaria among pregnant women with a history of fever. To detect anemia in the pregnant women, hemoglobin levels were estimated using HemoCue (HemoCue AB, Angelholm, Sweden). For the present study, only the secondary data pertaining to the total number of pregnant women and whether results were positive or negative were obtained; other information such as type of malaria was not collected. Ethical clearance was not necessary, because data were obtained from a retrospective review of records. The overall prevalence of malaria was 20.6%, ranging from 13.3% in Tippapuram to 47.6% in Maita (Table 1). The proportion of pregnant women with anemia was 73.2% (Table 1). In spite of the National Vector Borne Disease Control Programme and the introduction of artemisinin-based combination therapy, insecticide treated bed nets, and a longlasting insecticidal net, the prevalence of malaria in the study area is alarmingly high. Similarly, although the National Nutritional Anemia Control Programme has been implemented for more than three decades, anemia continues to be a severe public health problem. Access to modern health care is poor in the region, not because of geographic isolation, but as a result of constant conflictrelated issues leading to security restrictions for health staff. Therefore, individuals seek healthcare services from traditional healers, untrained individuals, and dais (traditional birth attendants). Sustainable intervention strategies—e.g. health and nutrition education through information, education, and communication activities, and behavior change communication—need to be implemented, with a focus on women of reproductive age. In India, local health workers and the community could be mobilized to prevent and control anemia and malaria among the women of reproductive age from ethnic tribes in general and those who are pregnant in particular.

Wolbachia enhances West Nile virus (WNV) infection in the mosquito Culex tarsalis.

Novel strategies are required to control mosquitoes and the pathogens they transmit. One attractive approach involves maternally inherited endosymbiotic Wolbachia bacteria. After artificial infection with Wolbachia, many mosquitoes become refractory to infection and transmission of diverse pathogens. We evaluated the effects of Wolbachia (wAlbB strain) on infection, dissemination and transmission of West Nile virus (WNV) in the naturally uninfected mosquito Culex tarsalis, which is an important WNV vector in North America. After inoculation into adult female mosquitoes, Wolbachia reached high titers and disseminated widely to numerous tissues including the head, thoracic flight muscles, fat body and ovarian follicles. Contrary to other systems, Wolbachia did not inhibit WNV in this mosquito. Rather, WNV infection rate was significantly higher in Wolbachia-infected mosquitoes compared to controls. Quantitative PCR of selected innate immune genes indicated that REL1 (the activator of the antiviral Toll immune pathway) was down regulated in Wolbachia-infected relative to control mosquitoes. This is the first observation of Wolbachia-induced enhancement of a human pathogen in mosquitoes, suggesting that caution should be applied before releasing Wolbachia-infected insects as part of a vector-borne disease control program.

Current status of dengue and chikungunya in India.

Dengue, a Flavivirus and chikungunya, an Alphavirus, transmitted by Aedes mosquitoes, are a cause of great concern to public health in India. Every year, thousands of individuals are affected and contribute to the burden of health care. Dengue outbreaks have continued since the 1950s but severity of disease has increased in the last two decades. Chikungunya outbreaks started in the 1960s and dwindled to sporadic cases until a resurgence in 2006. Based on the data of National Vector Borne Disease Control Programme (NVBDCP), the number of cases reported in 2013 was about 74 454 for dengue with 167 deaths and 18 639 for chikungunya. The number of cases reported is increasing, probably because of the availability of IgM detection kits produced and distributed by National Institute of Virology through NVBDCP and better reporting. In the absence of well-structured epidemiological studies, this review attempts to summarize reports on dengue and chikungunya outbreaks from various regions of India. For dengue, young adults are the major group affected; the severity of disease in India is still lower than that reported elsewhere in South-East Asia; and paediatric cases of dengue haemorrhagic fever have a high mortality. For chikungunya, all age groups are affected but severe manifestations are more often seen in children. Persisting arthralgia, neurological syndromes and non-neurological manifestations are recorded. Changes in the genotype and mutations in the genome have been detected for both dengue and chikungunya viruses. The review ends with a short summary of the most recent vector-control studies.

Economic burden of malaria in India: The need for effective spending.

About 95%of India's population resides in malaria-endemic areas and, according to government sources, 80%of malaria reported in the country is confined to populations residing in tribal, hilly, difficult and inaccessible areas. Using a nationally representative sample, this study has estimated the economic burden of malaria in India by applying the cost-of-illness approach, using the information on cost of treatment, days lost and earnings foregone, from the National Sample Survey data. A sensitivity analysis was carried out, by presenting two alternative scenarios of deaths. The results indicate that the total economic burden from malaria in India could be around US$ 1940 million. The major burden comes from lost earnings (75%), while 24%comes from treatment costs. Since mortality is low, this is not a major source of economic burden of malaria. An analysis of the trend and patterns in public expenditure by the National Vector Borne Disease Control Programme shows a declining focus of the central government on vector-borne diseases.Also, allocation of financial resources among states does not reflect the burden of malaria, the major vector-borne disease in the country.

Clinico-epidemiological profile of patients with febrile illness attending malaria clinic at medical college hospital of Surat, Gujarat, India

Background: Febrile illnesses are pre-eminent contributors to morbidity and mortality. As one of the common cause, malaria is a potentially life threatening parasitic disease. Passive surveillance of malaria is carried out by primary health centers, malaria clinics, community health centers and other secondary and tertiary level health institutions that patients visit for treatment. Early diagnosis and complete treatment is one of the key strategies of national vector borne disease control programme. Aims & Objective: A study was undertaken to study the clinico-epidemiological and laboratory profile of the fever cases. Materials and Methods: It is a descriptive, cross-sectional hospital based study conducted at malaria clinic at medical college hospital of Surat, Gujarat, India. Results: The most common symptom as reported by the patients was fever with rigor (32.37%). Proportion of body ache, cough, headache and fever constituted 17.40%, 13.95%, 11.81% and 11.35% symptoms as reported by the study population. Analysis of the result of PS for MP reveals that large number of the patients (84.0%) did not show malaria parasite in their blood smear. Out of positive slides, 84 % were Plasmodium vivax whereas less than 16 % P. falciparum. Conclusion: Malaria clinic functioning at New civil hospital, Surat can act as one of the important surveillance center for malaria in Surat city as well as in South Gujarat. Relationship of different symptoms with peripheral blood smears positive for malaria is not found.

When do vertical programmes strengthen health systems? A comparative assessment of disease-specific interventions in India

Disease-specific programmes have had a long history in India and their presence has increased over time. This study has two objectives: first, it reports on the interaction between local health systems and key disease-specific programmes in India—National AIDS Control Program (NACP) (HIV/AIDS), Revised National Tuberculosis Control Program (RNTCP) (TB) and National Vector Borne Disease Control Program (NVBDCP) (Malaria), and second, it examines which factors create an enabling environment for disease-specific programmes to strengthen health systems. A total of 103 in-depth interviews were conducted in six states in 2009 and 2010. Key informants included managers of disease control programmes and health systems, central and state health ministry and staff from peripheral health facilities. Analytical themes were derived from the World Health Organization (WHO) building block and the Systems Rapid Assessment framework. Disease-specific programmes contribute to strengthening some components of the health system by sharing human and material resources, increasing demand for health services by improving public perceptions of service quality, encouraging civil society involvement in service delivery and sharing diseasespecific information with local health system managers. These synergies were observed more frequently in the RNTCP and NVBDCP compared with the NACP. Disease-specific programmes in India are widely regarded as having made a substantial contribution in disease control. They can have both positive and negative effects on health systems. Certain conditions are necessary for them to have a positive influence on health systems—the programme needs to have an explicit policy to strengthen local health systems, and should also be embedded within the health system administration.

First indigenous transmission of Japanese Encephalitis in urban areas of National Capital Territory of Delhi, India

Until 2010, no Japanese encephalitis (JE) had been reported from Delhi. Upon report of four confirmed cases of JE in September 2011, detailed investigations were carried out to determine whether the cases were imported or indigenous. Entomological surveys were carried out and all mosquito pools were tested for the detection of JE virus by ELISA method using specific monoclonal antibody. Human blood samples from contacts of the patients were tested by IgM-captured ELISA method. Pig's blood samples were also tested for the detection of JE virus. Culex tritaeniorhynchus, Culex vishnui and Culex pseudovishnui mosquitoes were found. In contrast to rural areas, their breeding habitats were different in the city. 19 pools were tested. JE virus was detected in two pools of Cx.tritaeniorhynchus females reared from field-collected larvae, indicating vertical transmission. One pool of Cx.vishnui was also positive. This is the first report for the detection of JE virus in mosquitoes from Delhi. JE IgM antibodies in five contacts/residents indicate recent infection. JE virus was also detected in pigs. Present analysis shows that of four reported JE cases, three were confirmed indigenous, indicating that the virus is multiplying in the city. Mapping of infected JE vector mosquitoes in the cities is required for preventive measures to contain further spread of the disease.

Fight against dengue in India: progresses and challenges

At the end of the last century, India has faced resurgence of many infectious diseases, of which dengue is one of the most important in terms of morbidity and mortality. The National Vector Borne Disease Control Program data show that dengue is established in India and is becoming endemic to many areas (dengue cases have increased steadily from ∼450 to ∼50,000 from 2000 to 2012). Despite extensive efforts being made in developing the effective dengue control measures, the number of dengue cases, their severity, and geographical boundaries are expanding alarmingly and posing dengue as one of the deadly disease. Recently, the increasing burden of dengue in the country has attracted the scientific as well as Indian Government's administrative attention; however, a lot remain to be achieved for managing the disease under threshold level. Like other vector-borne diseases, better management of the dengue needs balanced approach involving various aspects like disease prevention, cure/treatment, and the vector control, simultaneously. We have briefly discussed here the situation of dengue in India and have tried to highlight the worrying facets of dengue control and its implementation in Indian perspective. The review on various aspects of dengue control has revealed an urgent need for permanent surveillance programs, coupled with improvised disease diagnostics, effective anti-dengue treatment measures, and controlling the disease transmission by following an effective implementation of vector control programs.

High Prevalence of Asymptomatic Malaria in a Tribal Population in Eastern India

Asymptomatic infection by Plasmodium falciparum is an important obstacle to eliminating malaria. Asymptomatic carriers do not seek treatment for infection, and therefore they become a reservoir for the parasite. For this reason, these carriers pose a real public health risk. The systematic identification and treatment of asymptomatic infections should reduce the parasite reservoir. A large reduction in this pool will lower the chance of transmission of the disease. In this study, we screened a tribal population of 1,040 individuals in the Purulia district of West Bengal by using a dual-antigen rapid diagnostic kit (RDK), microscopy, and species-specific PCR. All positive individuals were treated with artemisinin-based combination therapy (ACT) (artesunate plus sulfadoxine-pyrimethamine) and followed for 42 days. Polymorphisms in candidate genes were screened by DNA sequencing. A significant proportion (8.4%) of the study population was infected with P. falciparum but showed no clinical manifestations. The PCR method was more sensitive in detecting infection than the RDK or microscopy. The efficacy of the ACT was 97%. In the pfcrt gene, the mutation K76T (the mutated amino acid is indicated by bold type) was found in 100% of the cases. In the pfmdr1 gene, the mutations N86Y and Y184F were noted in 55.5% and 11% of the cases, respectively. Six different haplotypes were identified in the pfdhfr-pfdhps genes. Most importantly, the quintuple mutant A(16)I(51)R(59)N(108)I(164)-S(436)G(437)E(540)A(581)A(613) was found in 10% of the isolates, which is potentially important for the development of sulfadoxine-pyrimethamine resistance. A significant proportion of the study population harboring P. falciparum does not seek treatment and therefore serves as a reservoir for the parasite, maintaining the natural cycle. If the National Vector Borne Disease Control Programme (NVBDCP) of India is to eliminate malaria, then this hidden parasite burden needs to be addressed properly. Similar study in other parts of the country could help to determine the magnitude of the problem.