In Gemalivalasa village in Araku Valley in Visakhapatnam, 13-year-old GA Ashwath Kumar lay on his bed shivering with fever for three days. The Class 9 student had returned from his hostel, about 70 km away in the neighbouring district of Vizianagaram, after he had fallen ill in the first week of July.
People in the Araku Valley where Kumar lives have a high risk of infection by Plasmodium falciparum, the deadly protozoan parasite that causes malaria in humans.
K Kanamma, the village Accredited Social Health Activist or ASHA worker, tried to check whether Kumar had malaria using the Rapid Blood Test kit given by the district medical authorities. But the kit did not work since it lacked the buffer solution – a chemical reagent required to conduct the test. Kanamma gave Ashwath tablets of chloroquine and paracetamol anyway. The tablets had no effect on the patient.
Chloroquine, once the main antimalarial drug used in India, is no longer considered effective against malaria caused by Plasmodium falciparum. The National Vector Borne Disease Control Programme restricted the use of chloroquine in 2008 after many cases of chloroquine-resistant malaria cases were detected in the country.
As per the revised guidelines, chloroquine should be given only to people who test positive for malaria caused by Plasmodium vivax, another protozoan parasite responsible for malaria infections in more urban settings. The drug should not be administered as presumptive treatment – where medicines are given presuming the fever has been caused by malaria even before test results confirm it.
However, in Andhra Pradesh, community health workers continue to routinely administer chloroquine to anyone with fever.
Public health experts working on malaria say that indiscriminate use of chloroquine not only creates increases drug resistance in the pathogen, but can also throw up wrong results in laboratory tests. According to Dr Yogesh Jain, founder-member of the Jan Swasthya Sahyog which runs a community hospital in Bilaspur in Chhattisgarh – another malaria endemic area – chloroquine may work partially on a patient such that the parasite load is reduced within the body but may not cure the patient of the disease. This reduces the chance of the malaria parasite being detected. The symptoms could go away temporarily, but the patient could have a relapse.
So, if Kumar had malaria caused by Plasmodium falciparum, the drug would neither help him recover nor allow doctors to confirm the disease through tests. The wide use of chloroquine thus ends up suppressing the number of reported malaria cases.
How many malaria cases and deaths?
India has recorded 2.67 lakh malaria cases this year till May, of which 1.88 lakh cases were falciparum malaria cases. Seventeen deaths have been recorded this year.
Health experts have reason to believe the numbers are gross underestimates.
A 2010 study based on verbal autopsies of 122,291 deaths in India showed that the real malaria burden in India could be as high as 2,00,000 deaths every year, as opposed to the World Health Organisation’s estimate of only 15,000 deaths in 2006.
Last year, an Al Jazeera investigation showed that data related to malaria cases in Andhra Pradesh and Odisha is either tampered with, or not recorded correctly. The report also detailed the systemic failure of reporting due of lack of manpower.
This series of reports by Scroll.in from Andhra Pradesh focuses on the other ways in which malaria numbers are suppressed. One of them is the use of chloroquine.
Till May, the state recorded 5,703 confirmed cases of malaria, of which 5,198 cases were positive for Plasmodium falciparum infections. No death has recorded by the health authorities so far.
Most cases have been reported from two districts – Visakhapatnam and East Godavari – which have hilly belts inhabited by Adivasis and are generally called the Agency areas. Both the districts are among the 200 districts in India that the National Vector Borne Disease Control Programme has designated as high-risk areas for malaria.
Till July 22, 2,735 cases have been confirmed in Visakhapatnam Agency, and 3,699 cases have been confirmed in East Godavari Agency. Both the Agencies have a combined population of about 12 lakhs people.
The risk of malaria in any area is estimated by calculating its Annual Parasite Incidence – a ratio of the number of confirmed malaria cases in a year to (multiplied by 1,000) the total population under surveillance. If Annual Parasite Incidence is more than two, the area is considered high risk. The Agency areas of Visakhapatnam and East Godavari have an Annual Parasite Incidence more than two. In some pockets of tribal villages, the ratio exceeds five.
But the actual Annual Parasite Incidence could be higher, if the actual number of malaria cases are counted.
New policy, old practices
Chloroquine was the drug of choice during India’s malaria eradication programme conducted between the 1950s and 1970s. In malaria endemic areas, the drug was given as presumptive treatment, when a fever was presumed as being caused by malaria before test results confirmed it. Chloroquine resistance was first detected in India in 1973 in Karbi-Anglong district in Assam and soon spread to other parts of India.
Since 2008, the drug has no longer been used for presumptive treatment, as per the drug policy advocated by the National Vector Borne Disease Control Programme. As per the policy, any patient with fever should first be tested for malaria using a Rapid Blood Test kit. The kit looks like a urine pregnancy test kit and can detect malaria from a drop of blood on a film of paper. The test can easily be administered and does not need a trained technician. It detects antigens of both malaria parasites Plasmodium vivax and Plasmodium falciparum.
If the test shows infection by Plasmodium falciparum, the community health worker can give an oral dose of artemisinin-based combination medicine. In case of the blood tests positive for Plasmodium vivax, the patient gets doses of chloroquine and primaquine.
States like Odisha, Karnataka and West Bengal have been following the new policy and have stopped presumptive chloroquine treatment for malaria. Some states like Chhattisgarh and Jharkhand recognise the national policy, but admit that the practice of letting ASHAs administer chloroquine continues in some areas. A Madhya Pradesh health official said that the state still uses presumptive malaria treatment with chloroquine.
Andhra Pradesh not only uses chloroquine as presumptive treatment for fever patients, the state continues to following the decades-old practice of giving chloroquine as a prophylactic drug – a preventive treatment for people who do not have malaria or any other fever but who are at risk of contracting malaria.
Since chloroquine reduces the chances of malaria being detected in tests, the Andhra Pradesh health department said that they have given instructions to all the community health workers to first take the blood sample from patients before giving them chloroquine. But this does not always happen.
Community health workers are usually Accredited Social Health Activists called ASHAs and Auxiliary Nurse Midwives called ANMs.
In Kumar’s case, the ASHA Kanamma did not have slides to take a smear of blood for testing. ASHAs in a other villages in the Visakhapatnam agency said that they administer chloroquine to fever patients without taking blood samples.
Andhra Pradesh health officials justify the continued presumptive use of chloroquine by saying that that is what fever patients want.
“Though it is not in the guidelines, there is a strong belief among patients that chloroquine works,” said Dr Uma Sundar, district health medical officer at Visakhapatnam.
Others worry about delays in starting treatment.
“We do not want patients to waste time before the diagnosis is made,” said Dr Geetha Prasadini, additional director from the state’s directorate of health.
In two villages of Araku valley, ASHA workers complained that they did not have enough Rapid Blood Test kits. Also, as opposed to the national guidelines, the Andhra Pradesh health department insists on having results from a time-consuming laboratory test to start treatment with artemisinin-combination drugs for malaria caused by falciparum malaria, unless the patient has been clinically examined by a qualified doctor.
ASHA workers are also not given artemisinin-combination therapy medicine to treat falciparum malaria at the community level, even though the national programme insists on community health workers having access to these kits .
“The logic followed [by the Andhra Pradesh health department] is that something is better than nothing,” said Jain. “That is just nonsense. We know that more than 25% of the cases are resistant to chloroquine. That will only increase if this practice continues.”
Dr Neena Valecha, director of National Institute of Malaria Research, called the presumptive and prophylactic distribution of chloroquine a completely wrong practice. “These people will not be fully cured and will keep transmitting the malaria,” she said. “They can go into severe malaria.”
Puzzled by the policy followed by Andhra Pradesh, Dr Neeraj Dhingra, additional director at the National Vector Borne Disease Control Programme, said that there could be a gap in the understanding of the state officials.
“What is the point of having chloroquine?” he asked. “How many ever days they keep giving chloroquine, it will have no impact.”
This is the second part of a series on disease outbreaks in the Adivasi hamlets of Andhra Pradesh. Read the first part here. The next story looks at other factors that contribute to the underreporting of malaria cases.
This reporting project has been made possible partly by funding from New Venture Fund for Communications.
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