Bangalore (Karnataka)

A field unit in Karnataka was opened following the request from the state government. Trainingworkshops were organised and the state health staff was fully trained. Bioenvironmental interven-tions have successfully controlled malaria in 400 villages in some of the hard-core and most diffi-cult areas of the state. Cost-wise it has turned out to be the cheapest and sustainable method ofmalaria control. The field unit also demonstrated the following:

� First time the application of sibling species knowledge generated by the NIMR was appliedin the control of malaria by bioenvironmental methods

� Malaria control is being extended to the control of dengue and urban malaria in Mangalore

� Work in Karnataka has triggered application of bioenvironmental malaria control inMaharashtra and now the entire state is using this technology in malaria control instead of in-secticides

� Bioenvironmental malaria control is being expanded to cover the entire state. This work isin progress in collaboration with the NGOs and the state health department

Background

Karnataka state is situated on the western edge of theDeccan Plateau having an area of 1,71,791 km2 and27 districts. It contributes to about 7 to 10% of totalmalaria cases in the country. Since late 1980s malariawas showing an increasing trend in the state. Pres-ently, Hassan, Tumkur, Chitradurga, Chickmagalur,Mandya, Raichur and Gulbarga districts are the mostproblematic. In the rural areas, An. culicifacies and An.fluviatilis are known vectors of malaria. Mangalore Cityon the western coast is also under the rage of malariafor last one decade. Besides this, Bellary town alsohas problem of malaria. An. stephensi is the mainvector in these urban areas. District Bellary is at riskof Japanese encephalitis too.

Various field units of the IDVC project located in dif-ferent parts of the country demonstrated the feasibil-ity of malaria control using integrated methods.Therefore, in 1992 a field unit was established inBangalore to transfer the technology of malaria con-trol and to demonstrate malaria control through pri-mary health care system in the state.

Activities, Progress and Achievements

Bioenvironmental control of malaria inDistrict Kolar

In District Kolar, where sericulture is the major cottageindustry, silk farmers resist to indoor residual insecti-cide spraying due to its toxic effect on the silk worms.As a result, malaria incidence in the area was high inthe early nineties. A geographical reconnaissance(GR) was done in four problematic PHCs covering222 villages. Geographical reconnaissance revealedirrigation tanks, wells and streams to be the majorbreeding habitats for An. culicifacies. As the breedingsites of An. culicifacies were well-defined (Tiwari et al.,2001), use of larvivorous fish was considered the mostsuitable method for malaria control.

The work on bioenvironmental control of malaria wasinitiated in the PHC Kamasamudram (93 villages, pop.36,627). Intervention with larvivorous fishes, Guppy(P. reticulata) in wells and streams and G. affinis intanks was found suitable. Entomological monitoringshowed significant impact on the densities of larvae

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Fig. 1: Villagewise changes in malaria incidence following release of larvivorous fishes in PHC Kamasamudram(pop. 36,848), District Kolar from 1993–2004 (1993—Baseline year, 1994—Guppy released in wells, and

1995—Gambusia released in tanks)

0Up to 2> 2 to 10> 10 to 25> 25 to 50> 50 to 100> 100

API

of all mosquitoes (p<0.001) and vector species in allthe breeding habitats (p <0.001), while no impact wasobserved on the breeding of An. fluviatilis in streams(p<0.05). There was significant impact on the densityof An. culicifacies but no impact was observed on An.fluviatilis.

Sibling species A of An. culicifacies was found inmajority in the villages having wells (~ 90%) whilesibling species B was in majority in the villages by thestreams (~90%). Of the two sibling species of An.culicifacies, species B is a non-vector. All the An.fluviatilis were found to be sibling species T, a non-vector. Impact on malaria incidence was highly signifi-cant. The annual parasite index declined from 41.8/1000 in 1993 to a low of 0.18/1000 by 2004 (Fig. 1).Survival of fish was studied and it was found thatfishes were breeding in all natural habitats.

Evaluation of larvivorous fish and treatedbednets in District Hassan

Selective vector control of malaria was carried out inPHCs Banavara and Kanakatte in Hassan district. In1995 these PHCs were showing high incidence of

malaria. In PHC Banavara (108 villages; pop. 55,619)only larvivorous fishes were used as an interventionmeasure. In PHC Kanakatte three sets of experimen-tal villages were selected: (a) area with only fish (38villages; pop. 20,546); (b) area with only cyfluthrin-treated bednets (7 villages; pop. 3448); and (c) areawith both fish and treated bednets (7 villages; pop.4651).

Tanks and wells were the main contributors of vectormosquito, An. culicifacies. In 1996, Guppy or Gambu-sia were released in all the breeding habitats. Gam-busia could not survive due to drying up of tanks in thesubsequent years. However, Gambusia released in1999 got established in all the areas.

Bednets were impregnated with cyfluthrin @ 30 mg/m2. With the introduction of fish and bednets as per thestrategy planned in three sets of experimental villagesand in Banvara PHC (where only fishes were used),larval and adult densities were found significantlylower in the experimental villages than in the controlones. The best impact was observed in the area whereboth treated bednets and fish were used (Fig. 2). Thestudy showed that fish alone or in combination with

84 IDVC PROJECT PROFILE

Fig. 2: Villagewise changes in malaria in PHCs Banavara and Kanakatte, District Hassan, (Pop. 85,672)in 1995 to 2004 (1995—Baseline year, 1996—Guppy released in wells, and 1999—Guppy released intanks). The increase in malaria incidence in 2000 and 2002 was due to rise in malaria cases in the

neighbouring PHCs where synthetic pyrethroids were sprayed during 1996–98. In these areas,malaria is under control after release of fish in 2002

treated bednets reduced the malaria incidence toextremely low levels making indigenous transmissionnearly impossible (Fig. 3 a–c).

Mosquito control in Bangalore City

Mosquito nuisance is a big problem in Bangalore City.A mosquito control programme was carried out withthe help of Bangalore Mahanagara Palike. In the ini-tial phase, training on different aspects of mosquitocontrol was given to the health personnel engaged inmosquito control programme. Study has shown that

wells, small drains, cess pools, unused tyres, dis-carded materials are the major breeding habitats ofmosquitoes. Geographical reconnaissance of mos-quito breeding habitats in Lingarajpuram (Ward No.87), monitoring of mosquitogenic situations and theircontrol was carried out. Cx. quinquefasciatus, An.stephensi and Ae. aegypti were the main mosquitospecies recorded. Overall, composition of mosquitoeswas as follows: Culex–82%, Anopheles–7% andAedes–11%. The Aedes population was found muchhigher than in a study in 1986. A mechanism for con-ducting geographical reconnaissance has been devel-

Dr. K. Thimmappa, Hon’ble Minister of Health & Family Welfare, Govt. of Karnataka inaugurating the fish release programme

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Fig. 3c: Overall impact of use of fish on malaria in five talukas

Fig. 3b: Impact of use of fish on malaria in Banavara and Kanakatte PHCs

Fig. 3a: Impact of use of fish on malaria in PHC Kamasamudram, District Kolar

86 IDVC PROJECT PROFILE

oped. An action plan has been made to control mos-quitoes using Guppies, which will reduce the use ofinsecticides.

Operational feasibility of use oflarvivorous fish for the control of malaria

This project was carried out under WHO-SEARO RollBack Malaria initiative. The work was carried out infour talukas, namely Arsikere of Hassan district, Kadur

of Chickmagalur district, C.N. Halli of Tumkur districtand Hosadurga of Chitradurga district. Later on Tipturtaluka was included since the local authorities cameforward. In this taluka local Taluka Zilla Parishad pro-vided financial assistance. The study area involved atotal of 44 PHCs involving 1766 villages covering over1.2 million population. The whole project was carriedout with the active participation of local health depart-ment. Entomological and parasitological surveysindicated that malaria vectors and malaria were deci-

Fig. 4: A model of intersectoral coordination for release of larvivorous fish in Karnataka

Continuous monitoring (twice in a year) and re-introductionof fish is important for effective and sustained control ofmosquito-borne diseases.

5 scientists from MRC and 12Health Inspectors from StateHealth Department

Joint Director,M&F, Bangalore

Deputy Commissioner

DHO

DMO DSO

Taluka Health Officer

PHC Medical Officer

MPWs

To produce larvivorousfish—Guppy for use in wellsand Gambusia in tanks(these two fish speciesshould NEVER beintroduced in the samewater body).Grass carp fish eliminatesaquatic weeds in irrigationtanks where malaria vectorbreeds extensively. Hencethese fishes are suggested tobe released @ 20% of carps.

For fish release work, a team attaluka level consisting of:Senior Health Inspector: 1Group-D staff: 2 (One eachfrom the taluka and respectivePHC) Driver with a Jeep

At District Level

Chief Executive Officer(Zilla Panchayat)

At Taluka Level Dy. Director(Fisheries)

Taluka Executive Officer Taluka Asstt. Director(Fisheries)

To collaborate work forreleasing of fish alongwith Gram Panchayats

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Table 1: Outbreaks of malaria investigated in Karnataka

Area Year BSE Pv Pf Mixed Total cases SPR Pf %

Hosur Bande 1998 560 93 455 12 560 100.0 83.4

Raichur 1999 341 12 225 6 243 71.2 95.1

Tumkur 2002 431 17 256 0 273 63.3 93.8

mated. The Panchayat Raj Institution were directlyinvolved in promotion of larvivorous fish and the ZillaPanchayat is sustaining this activity (Fig. 4).

Development of a strategy for integratedcontrol of vectors of malaria, JE anddengue

District Mandya of Karnataka was selected for thisstudy from 2002–04. All types of ecotypes for mosqui-toes are present in this district. Malaria, Japaneseencephalitis and dengue are the vector-borne dis-eases. A total of 769 villages were surveyed in seventalukas of Mandya district. It was found that of the total

28,584 breeding habitats surveyed, 6361 were founddry and in 3,928 (13.7%) habitats different mosquitoeswere breeding. Principal malaria vector, An. culicifa-cies was breeding mainly in tanks, irrigation wells andseepage water, while JE vector, Cx. tritaeniorhynchuswas breeding in tanks, seepage water and streams. Itis important to note that dengue vector, Ae. aegyptiwas exclusively breeding in cement tanks in all the vil-lages surveyed. Aedes indices for containers, house,and breteau were 22.8, 18.8 and 20.2 respectively.Use of larvivorous fish would be the most appropriateintervention measure. Prevention of breeding of Aedesin cement water storing tanks and proper IEC activi-ties will help in control of dengue in this area.

Table 2: Average larval densities and percent reduction using Bti @ 0.2 g/m2

(a) Bangalore Urban area

Period Anopheles Culex Aedes % reduction

Expt. Control Expt. Control Expt. Control Anopheles Culex Aedes

Day 0 1.44 1 5.5 0.79 1.1 2.4Day 1 0.33 1 0 0.98 0 2.0 65 100 100Day 2 0 0 0 0.71 0 18.3 100 100 100Day 3 0 0 0 0.44 0 11.8 100 100 100Day 7 0.6 1 0.1 0.38 0 78.8 59.4 96.2 100Day 10 1.2 0 0.1 0.96 6.5 20.9 –32.7 98.5 32.1

(b) PHC Harohalli, Bangalore (Rural) district

Period 0.05 Control % Reduc- 0.2 g/m2 Control % 1 g/m2 Control %g/m2 tion Reduction Reduction

Ano- Ano- Ano- Ano- Culex Ano- Culex Ano- Culex Ano- Culex Ano- Culex Ano- Culex

pheles pheles pheles pheles pheles pheles pheles pheles pheles

Day 0 1.43 0.6 2.1 1.63 1 5.6 – – 16.07 8.33 4.6 0.7 – –Day 1 0.03 1.0 98.7 0 1.37 0.8 5.4 100 12.8 0 0.67 5.2 0.6 100 90.6

Day 2 0 0.2 100 0 0.2 0.8 2.2 100 68.8 0 0.13 3.0 0.1 100 89

Day 3 0 0.4 100 0 0.07 1 5.0 100 95.2 0 0 2.8 0.3 100 100Day 7 3.2 0.6 0 0.43 0 2.8 2.2 92.7 100 7.4 0.1 1.2 0.2 0 95.8

Day 10 3.1 0.8 0 0.8 0.03 2.6 4.2 85.3 97.5 12.6 0.2 3 0.2 0 91.6

Day 14 – – – 0.87 0.06 5 4.6 91.7 95.5 – – – – – –

Day 17 – – – 8.85 0.2 1.8 9.6 0 92.8 – – – – – –

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Table 4: Susceptibility of An. culicifacies to

insecticides used in the programme

District DDT Malathion Deltamethrin(4%) (5%) (0.05%)

Hassan 40 97.2 100Tumkur 48 95 100Mandya 54 86 100Bangalore Urban 30 93 100Raichur 20 87 94

Investigation of malaria outbreaks

In view of malaria outbreaks in Districts Bangalore(Urban and Rural), Tumkur, Udupi, Kolar, Chickma-galur and Raichur, investigations were done in someof the areas (Table 1). In all these areas, investiga-tions revealed that An. culicifacies is the main vectorresponsible for the transmission. In Bangalore Urbandistrict An. culicifacies was incriminated. Inadequatesurveillance and residual insecticide spraying notbeing carried out in time were the probable reasonsfor the outbreaks. These observations were reportedto the concerned authorities.

Multicentric evaluation of VectoBac WDG(B. thuringiensis israelensis)

This formulation was found to be very effective againstmosquito larvae at the dose of 0.2 g/m2 (Table 2).

Evaluation of the impact of DDT indoorresidual spraying being used in malariacontrol programme

This project initiated by ICMR was carried out in PHCPandavapura, District Mandya. DDT had very limitedeffect in reducing the density of malaria vector, An.culicifacies (Table 3 a and b). In an other study An.culicifacies was found resistant to DDT but suscep-tible to malathion and deltamethrin (Table 4).

Therapeutic efficacy of chloroquineagainst P. falciparum

Studies carried out following WHO in vivo tests inKarnataka revealed that P. falciparum has developedresistance to chloroquine and sulphadoxine-py-rimethamine (Table 5). In a multicentric study of the15 south Indian isolates four had the African/South-

east Asian chloroquine resistant haplotype (CVIET),while the rest 11 had the SVMNT haplotype (Vathsalaet al., 2004).

Stratification of Karnataka, based on An.culicifacies and An. fluviatilis siblingspecies prevalence

It has been observed that sibling species A and B ofAn. culicifacies are prevalent in south Karnataka, whilespecies A, B and C are prevalent in north Karnataka.

Table 5: Results of therapeutic efficacy of chloroquine against P. falciparum

Place Drug tested Total cases Sensitivity Early resistance Late resistance

PHC Banavara, Distt. Hassan Chloroquine 78 26 (33.3 ) 19 (24.4) 33 (42.3)PHC Gabbur, Distt. Raichur Chloroquine 31* 4 (12.9) 27 (87.1) 0PHC Hosur Bande, Distt. Bangalore (U) Chloroquine 49 29 (59.2) 12 (24.5) 8 (16.2)PHC Masarkal, Distt. Raichur Sulphadoxine- 28* 6 (21.4) 22 (78.6) 0

pyrimethaminePHC Narsapura, Distt. Kolar Chloroquine 9* 0 9 (100) 0

*Follow-up up to Day 7; Figures in parentheses indicate percentage.

Table 3a: Susceptibility of An. culicifacies to

DDT (4%) during pre- and post-spraying in

Mandya district

Period No. exposed No. killed Corrected %mortality

Pre-spray 130 (7) 26 20.0Post-spray 112 (7) 30 26.7

Table 3b: Cone bioassay on DDT sprayed walls

using An. culicifacies

No. exposed No. killed Corrected %(replicates) mortality

196 (11) 40 20.40

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Fig. 5: Stratification of Karnataka, based on An. culicifacies sibling species prevalence

All the An. fluviatilis population belonged to species T.Hence, this species has no role in malaria transmis-sion in Karnataka (Fig. 5).

Malaria control in Mangalore City

Malaria is posing a great problem in Mangalore, acoastal city of the western ghats. Malaria control was

initiated by a Malaria Action Committee involving vari-ous departments including local NGOs. MRC collabo-rated with two NGOs—Mangalore Parisara SaktaUkuta and Subodha. An. stephensi is the main vec-tor which mainly breeds in wells, OHTs, curing wa-ters, fountains and cement tanks. Guppies wereeffective in this area for control of mosquitoes (Fig. 6).As suggested by MRC, a separate ‘Malaria Control

Fig. 6: Impact of Guppy fishes on the density of An. stephensi in Mangalore City

90 IDVC PROJECT PROFILE

Fig. 7b: Performing Kalajatha programme in Tumkur district

Cell’ has been established under the local city corpo-ration. Work is underway to further solve the recentproblems being faced due to construction relatedactivities. The recent rise in malaria cases is due toinclusion of cases reported by the local laboratories.

Health education through Kalajatha formalaria control

A feasibility study was carried out for better participa-tion of the community in the malaria controlprogramme. Ten government and non-governmentorganisations participated in this programme in Dis-trict Tumkur (Fig. 7 a and b). The community actively

Table 6: Malaria cases reported at malaria clinic

Year BSE P. vivax P. falciparum Mix Total SPR

1993 18 5 0 0 5 27.8

1994 18 3 1 0 4 22.2

1995 18 5 4 0 9 50.0

1996 46 5 8 0 13 28.3

1997 229 24 32 0 56 24.5

1998 105 1 35 0 36 34.3

1999 163 4 78 0 82 50.3

2000 132 1 7 0 8 6.1

2001 86 1 8 0 9 10.5

2002 87 19 15 0 34 39.1

2003 544 11 206 1 218 40.1

2004 440 8 94 2 104 23.6

2005 883 104 362 0 466 40.9

�Fig. 7a: Inauguration of Kalajatha programme by theHon’ble District Minister

cooperated in releasing larvivorous fish which re-sulted drastic reduction of malaria (Ghosh et al.,2005).

Malaria clinic

Malaria clinic functioning at the field unit continued toprovide diagnostic and treatment services to thecommunity. It also served as a sentinel site formonitoring malaria situation in Bangalore City over theyears (Table 6). Since 2002, there is an increasingtrend of malaria and an outbreak was also witnessedin rural areas of Bangalore.