National 2 (Spotlight Weekly)

Ruinous Resurgence

Decades after it was brought under control, malaria returns to threaten lives in the southern plains

By KESHAB POUDEL

Still struggling with the outbreak of fever in Chitwan a few weeks ago, health officials are now confronting a new epidemic of high temperatures in various parts of the southern Terai districts. Although preliminary studies have shown that the fever in Chitwan was not caused by malaria, the disease continues to affect life in Kanchanpur, Sindhuli and Jhapa districts.

For the last six months, Jhalari and Krishnapur villages of Kanchanpur districts, 700 km west† of Kathmandu, have been badly affected by malaria. According to the Epidemiology Disease Control Division of the Department of Health Services, 1,700 cases of malaria were reported in the two places in the last six months.

Patients : Waiting for help

Although the figure is lower than the 2,600 recorded during the same period last year, medical practitioners believe the real incidence may be much higher. Many cases go unnoticed as primary care is easily available at local pharmaceutical shops. As Kanchanpur is regarded as an endemic area for the malaria parasite, there is always the risk of an epidemic breaking out. The local people, who live in open huts, are particularly vulnerable to mosquito bites.

Malaria has also been reported in Jhapa and Sindhuli districts. Health officials have a new reason to be worried this time: the strain is resistant to traditional treatment. Health posts have found a large number of patients with chloroquine-resistant plasmodium falciparum malaria.

"There is no reason to panic, as the infection is under control," said Dr. Govinda P. Ojha, director of the Epidemiology Disease Control Division. "We have already sent medical teams and necessary medicines to Kanchanpur district."

About half a dozen people have lost their lives to malaria in those places in recent weeks. Moreover, the number of malaria-infected patients is increasing in the Terai. Although the government lacks reliable data, annually 100,000 to 150,000 people with malaria are thought to visit health posts.

"We don't have any reports of an outbreak of malaria in other districts in the Terai, although there have scattered cases," said Dr. Ojha. "Awareness is the best way of prevention and the government has launched a publicity campaign in the most affected districts."

Alarmed by the resurgence of malaria, the National Health Education, Information and Communication Center has initiated an awareness campaign presenting a short advertisement urging people to use nets to avoid mosquito bites.

Bir Hospital : Resource-crunch

But that approach may be inadequate. "In districts like Kanchanpur, the people are too poor to buy nets. Moreover, they sleep in open places and in houses without walls around. How can we spray pesticides in such places?" Dr. Ojha asks.

Despite the government's efforts to spray pesticides and step up awareness, malaria is going to be a major challenge for the health sector in the coming years. As Nepal's eastern border district of Jhapa is very close to Indian state of Assam where malaria is said to rampant, the possibility of a major epidemic in Nepal cannot be ruled out.

Mortality in Nepal is still low compared to other parts of the world. According to the World Health Organization (WHO), almost 300 million clinical cases of malaria occur worldwide each year and over one million people die. Almost 90 percent of the deaths occur in sub-Saharan Africa.

The Nepalese government initiated a malaria eradication program in the 1960s with support from donor countries. After the massive spraying of pesticides like DDT, malaria cases were drastically reduced in the Terai. But resistance also increased. According to the Ministry of Health, the number of malaria cases in 1990 was 115 in every 100,000 population. That figure drastically fell to 29 per 100,000 people in 2000.

Malaria incidence between 1992 and 1997 shows a strong declining trend, but there is no reason to believe that the disease has been eradicated. Medical experts hold the view that this indicator should be interpreted taking into account two considerations: an under-reporting of malaria cases and periodic fluctuations in the epidemiological trend of malaria.

According to the Ministry of Health, in spite of the downward trend, malaria persists as a significant public health problem in Nepal. More than 16.5 million people are exposed to the risk of infections. Several thousand cases are reported annually. The slide positivity rate was 9 percent in 1999-2000 as against 4.5 percent in 1995-1996. The proportion of Plasmodium falciparum malaria is around 6 percent of the total cases. Medicine for chloroquine-resistant Plasmodium falciparum is not available everywhere.

"We need a broad-based strategic approach to halt and reverse the incidence of malaria," said a senior official at the Ministry of Health. "Because of the threat of terrorism, many health posts have been closed down in far-western region, where malaria is rampant."

There is a low rate of slide examination, under reporting of malaria cases, inadequate diagnosis and management of severe cases, and lack of supportive supervision. Moreover, political commitment needs to be reinforced to ensure effective implementation of the anti-malaria strategy. According to a WHO report, during the first half of the 20th century, the world sustained around 2 million deaths from malaria each year, most in the Asian and Pacific tropics. Nepal, too, had high mortality in the early days.

Following the DDT-spraying program in 1960, spectacular reductions in malaria incidence and malaria-related mortality were achieved. Thanks to the support of the US Agency for International Development (USAID), the country made a major achievement. According to the book "Half-a-Century of Development, the History of US Assistance to Nepal 1951-2001" published by USAID, from more than two million cases annually in the early 1950s, malaria was reduced to an all-time low of 2,468 cases in 1968.

The control of the disease in the Terai encouraged migration to the fertile plains. Malaria control has brought immeasurable benefits to Nepal in the areas of economic efficiency and production. However, its resurgence is threatening the poor migrants from the hills.

"In subsequent decades, the economic and political costs of sustaining the intensive efforts involved in the initial campaigns, combined with emerging resistance of the parasites and their vectors to the chemicals used to attack them, led to the resurgence of malaria transmission throughout Terai," said an expert.

Emergence of Plasmodium falciparum

Multi-drug and chloroquine-resistant Plasmodium falciparum began spreading in the mid-1960s from South East Asia. Plasmodium falciparum† has been gradually extending its wings in Nepal. The threat of the resistant malaria parasite looms large in Jhapa district.

The case of Kanchanpur shows that malaria and underdevelopment are closely linked. Over 80 percent of the population infected by malaria are poor. According to medical practitioners, the disease causes widespread premature deaths and suffering and imposes financial hardships.

Malaria grows fast in situations of social and environmental crisis and weak health systems and among disadvantaged communities. Effective interventions are available but they are not reaching the people with the greatest burden of malaria because the capacity for malaria control is inadequate in endemic districts where the health system does not exist.

Although new medicines are available in the market, the rapid spread of resistance to anti-malarial drugs presents a potentially difficult situation. Chloroquine was a widely used drug before resistance posed a problem. If malaria is diagnosed and treated promptly, the infection may quickly subside. In case of unavailability of effective medicines, a patient has to face severe complications such as cerebral malaria, severe anemia or multiple organ failure. The mortality rates are between 10 and 30 percent but mortality is not only the problem. There are serious implications for health.

Among the four species of parasite that affect humans, P. Falciparum is the most dangerous. The malaria transmissions occur continuously over many areas. Epidemics of malaria also occur over large parts of the Indian peninsula and Sri Lanka.

In highly endemic areas, children and pregnant women are most vulnerable to attacks, as other adults acquire a degree of immunity through continued exposure. But in epidemic areas, most of the population is likely to be non-immune and at risk.

The greatest obstacle to controlling malaria is the loss of effectiveness of chloroquine because of resistance. "We find the effectiveness of the medicine is falling," said a medical practitioner. For the treatment of falciparum malaria, the usual successor to choloroqine is a combination of pyrimethanmine and a long acting sulfonamide.

Malaria is largely dependent on the type of mosquito, the parasite species, and the climate, which broadly determine the intensity and length of transmission. The case for a multi-pronged strategy could not have been more compelling.