Malaria control in a tribal area of central India using existing tools.

Malaria is difficult to control in central India because of geographical terrain, efficient vectors, and perennial transmission of Plasmodium falciparum and socio-cultural practices of ethnic tribes. The objective was to develop a model to prevent and control malaria in hard to reach areas using existing tools. Baigachak (Tribe population 31,900) situated in Dindori district was undertaken for this study. Intervention measures used are indoor residual spray (IRS), long lasting insecticide treated bed nets (LLINs), prompt diagnosis and treatment along with intensive Information, Education and Communication (IEC) involving school children as agent of change. Door to door rapid fever surveys were carried out in the study area from 2009 to 14 and finger prick blood smears were made from all fever cases and examined under microscope. Mosquitoes were assayed for the presence of sporozoites by enzyme-linked immunosorbent assay (ELISA) technique and sibling species by polymerase chain reaction (PCR). There are two highly efficient vectors i.e. Anopheles culicifacies and An. fluviatilis. In monsoon season of 2009, the man hour density for An. culicifacies was 36.2 which declined to 10.9 during monsoon season of 2010-14 (t = 6.52; p < 0.0001). Epidemiological results revealed that malaria positivity was declined from 27% in 2009-3% in 2014 (Trend chi2 = 57.21; p < 0.0001) and P. falciparum declined from 23.6 to 2.4% (Trend chi2 = 48.33; p < 0.0001). Spleen rate was declined from 47% in 2009-5% in 2014 (χ2 for trend = 6.1; p = 0.0135). Baigachak has achieved a remarkable 89% reduction in malaria. This study confirms that the control strategies undertaken in this study are useful and should be extended at multiple sites for further validation.

Therapeutic efficacy of artemether-lumefantrine for the treatment of uncomplicated Plasmodium falciparum malaria from three highly malarious states in India.

BACKGROUND: Anti-malarial drug resistance continues to be a leading threat to malaria control efforts and calls for continued monitoring of waning efficacy of artemisinin-based combination therapy (ACT). Artesunate + sulfadoxine/pyrimethamine (AS + SP) is used for the treatment of uncomplicated Plasmodium falciparum malaria in India. However, resistance against AS + SP is emerged in northeastern states. Therefore, artemether-lumefantrine (AL) is the recommended first line treatment for falciparum malaria in north eastern states. This study investigates the therapeutic efficacy and safety of AL for the treatment of uncomplicated falciparum malaria in three malaria-endemic states in India. The data generated through this study will benefit the immediate implementation of second-line ACT as and when required. METHODS: This was a one-arm prospective evaluation of clinical and parasitological responses for uncomplicated falciparum malaria using WHO protocol. Patients diagnosed with uncomplicated mono P. falciparum infection were administered six-dose regimen of AL over 3 days and subsequent follow-up was carried out up to 28 days. Molecular markers msp-1 and msp-2 were used to differentiate recrudescence and re-infection and K13 propeller gene was amplified and sequenced covering the codon 450-680. RESULTS: A total of 402 eligible patients were enrolled in the study from all four sites. Overall, adequate clinical and parasitological response (ACPR) was 98 % without PCR correction and 99 % with PCR correction. At three study sites, ACPR rates were 100 %, while at Bastar, cure rate was 92.5 % on day 28. No early treatment failure was found. The PCR-corrected endpoint finding confirmed that one late clinical failure (LCF) and two late parasitological failures (LPF) were recrudescences. The PCR corrected cure rate was 96.5 %. The mean fever clearance time was 27.2 h ± 8.2 (24-48 h) and the mean parasite clearance time was 30.1 h ± 11.0 (24-72 h). Additionally, no adverse event was recorded. Analysis of total 186 samples revealed a mutation in the k13 gene along with non-synonymous mutation at codon M579T in three (1.6 %) samples. CONCLUSION: AL is an efficacious drug for the treatment of uncomplicated falciparum malaria. However, regular monitoring of AL is required in view of malaria elimination initiatives, which will be largely dependent on therapeutic interventions, regular surveillance and targeted vector control.