Acknowledgement
We acknowledge the kind support and encouragement provided by Dr. V.M.
Katoch, Secretary, DHR, Govt. of India & DG, ICMR for the formation of Tribal
Health Research Forum and because of his tireless effort today it has become a
flagship programme of ICMR. It is he who encouraged us to take this arduous task
of documenting the achievements of this forum in the form of this compendium. We
bestowed our sincere thanks to Dr. Katoch with the belief that under his able
guidance this forum will achieve its goals targeted for the improvement of the tribal
health in India.
Special mention may be made of Lt. Gen D. Raghunath, for his support and
valuable advises for the development of the functional ability of the forum. It is nice
to mention that inspite of his busy schedule he has gone through meticulously the
manuscript of this compendium and provided scholarly suggestions.
Thanks are due to Shri T.S. Jawahar, IAS, Senior Deputy Director General
(Admn), ICMR for his kind support and encouragement.
We take this opportunity to thank Smt. Dharitri Panda, Senior Financial
Advisor, ICMR for her inputs in various meetings of the forum. She is a constant
source of support whenever we need.
It is worth mentioning the support, suggestion and encouragement provided
by Shri Sanjiv Dutta, Former Financial Advisor of ICMR, during the formation of this
forum.
The support and encouragement provided by Dr. Rashmi Arora, Chief ECD
and head of other divisions of ICMR particularly of NCD and RHN of ICMR deserve
to be mentioned with praise. Without their support and help it would be difficult to
bind all the activities of the forum with a common thread.
Last but not the least, we acknowledge with thanks, all the Directors,
scientists and staff of the participating institutes/centres of the ICMR for their
assistance and support from time to time, but for their scholarly contributions it
would not be possible to bring out this compendium in a short time.
National Coordinator of THRF, Scientists & Staff
RMRCT, Jabalpur
INDEX
Acronyms i - iii
Précis of Tribal Health Research Forum (THRF) of ICMR 2 – 10
Research work being carried out by ICMR in Tribal Health 11 – 15
Specific achievements of ICMR institutes
Regional Medical Research Centre for Tribals, Jabalpur 16 – 22
National Institute of Immunohaematology (NIIH) 23 – 31
Regional Medical Research Centre, NE Region, Dibrugarh 32 – 37
Regional Medical Research Centre, Port Blair 38 – 40
Regional Medical Research Centre, Bhubaneshwar 41 – 43
Vector Control Research Center, Puducherry 44 – 47
National Institute of Nutrition, Hyderabad 48 – 51
National Institute of Epidemiology, Chennai 52 – 53
National Institute for Research in Tuberculosis, Chennai 54
National Institute of Malaria Research (NIMR) 55 – 56
Division of ECD, ICMR 56 – 59
Division of NCD, ICMR 59 – 61
Success Stories 62 – 68
Support to National Programme 69 – 80
New Emerging Infection 81 – 82
New Members of the forum 82
i
Acronyms
ACT Artesunate and SP combination therapy
ANC Antenatal Care
ANM Auxillary Nurse midwife
ASHA Acridated Social & Health Activist
BCP Basal Core Promoter
BLAST Basic Local Alignment Search Tool
Census Census of India
CG Chhattisgarh
CHC Community Health Centre
CRME Centre for Research in Medical Entomology, Madurai
DEC Diethylcarbamazine
DEN Dengue
DG Director General, ICMR
DHR Department of Health Research
DMRC Desert Medicine Research Centre, Jodhpur
DOT Directly Observable Therapy
DST Drug Sensitivity Testing
ECD Epidemiology of Communicable Disease, Division of ICMR, New Delhi
ELISA enzyme linked immunosorbent assay
FGD Focused Group Discussion
G6PD Glucose-6-phosphate dehydrogenase
GIS Geographical Information System
HAV Hepatitis A Virus
Hb Haemoglobin
HbAS Sickle cell heterozygous
HbE Heamoglobin E
HBI Human Blood Index
HbS Sickle cell homozygotes
HBsAG Hepatitis B Surface Antigen
HBV Hepatitis B Virus
HCV Hepatitis C Virus
HEV Hepatitis E Virus
HgDI Hunter–Gaston discrimination index
HIV Human Immuno Deficiency Virus
HQ Head Quarters
ii
IBBA Integrated biological & behavioural Studies
ICMR Indian Council of Medical Research
IEC Information Education & Communication
IGM Immunoglobulin M
IRL Intermediate Reference Laboratory
IRS Indoor Residual Spraying
ITN Insecticide Treated Net
JALMA National JALMA institute for Leprosy & Other Mycobacterial Diseases
JE Japanese Encephalitis
LLIN Long Lasting Insecticide Impregnated Nets
M/O Medical Officer
MCH Maternal & Child Health
MDA Mass Drug Administration
MDG Millennium Development Goals
MDR Multi Drug Resistance
MIRU-VNTR
analysis
Mycobacterial Interspersed Repetitive Units-Variable number tandem repeat
analysis
MP Madhya Pradesh
MPI Malaria Parasite Incidence
n RT PCR Nested Reverse transcriptase Polymerase chain reaction
NBS New Born Screening
NCD Non Communicable Disease, Division of ICMR, New Delhi
NE North East
NEERI National Environmental Engineering Research Institute, Nagpur
NIE National Institute of Epidemology, Chennai
NIIH National Institute of Immunohaematology, Mumbai
NIMR National Institute of Malaria Research, New Delhi
NIMS National Institute of Medical Statistics, New Delhi
NIN National Institute of Nutrition, Hyderabad
NIRD National Institute of Rural Development, Hyderabad
NNMB National Nutritional Monitoring Bureau, Hyderabad
NRHM National Rural Health Mission
NS1 Non Structural Protein 1
NSS Nutritional Surveillance System
NVBDCP National Vector Borne Disease Control Programme
PCR Polymerase Chain Reaction
iii
Pf Plasmodium falciparum
PHC Primary Health Centre
PVTG Particularly Vulnerable Tribal Group
Pv Plasmodium vivax
RCH Reproductive & Child Health
RDK Rapid Diagnostic Kits
RDT Rapid Diagnostic Test
RMNCH&A Reproductive , maternal, neonatal, child and adolesent health
RMRC Regional Medical Research Centre
RMRCT Regional Medical Research Centre for Tribals, Jabalpur
RMRIMS Rajendra Memorial Research Institute of Medical Sciences, Patna
RNTCP Revised National Tuberculosis Control Programme
RTI Respiratory Tract Infection
RTPCR Reverse transcriptase PCR
SP Sulphadoxine Pyrimethamine
SPR Slide positivity rate
ST Scheduled Tribes
TB Tuberculosis
THRF Tribal Health Research Forum
UNICEF United Nation Childs Emergency Fund
VCRC Vector Control Research Centre, Puducherry
VDL Viral Diagnostic Laboratory
WHO World Health Organization
1
Fig 1: Map showing Network of ICMR institutes involved in
Tribal Health Research Forum (THRF)
2
PRÉCIS OF TRIBAL HEALTH RESEARCH FORUM
OF ICMR
Adivasis, or Tribals are the aboriginal people of the nation. Their population
covers about 15% of the land area. These communities belong to different ethno-
lingual groups and living at suboptimal levels of socio-economic conditions. Their
spatial distribution is characterized by a tendency of clustering and concentration in
pockets which have suffered from isolation. According to census of India, 2001, the
Scheduled Tribes are the tribes or tribal communities or part of or groups within
these tribes and tribal communities which have been declared as such by the
President through a public notification (Ministry of Tribal Affairs, Govt. of India)1. As
per the 2001 census, tribal population was 84.3 million, constituting 8.2% of the
total population with 91.7% dwelling in rural and 8.3% in urban areas2 (Census
2001). According to Article 342 of the constitution of India, at present, there are 697
tribes. Among them, 75 are known as Particularly Vulnerable Tribal Groups
(Planning Commission 2006, Govt. of India)3. Some of the primitive tribes are
Abujmaria, Bodo, Birhore, Baiga, Kamar, Saharia and Onges etc. Three
numerically dominant tribes in India are Gond, Bhil and Santhals. Gond and Bhils
are predominantly distributed in Central and Western India, whereas Santhals are
distributed in Eastern part of the country, predominantly in Bihar, West Bengal,
Orissa and Jharkhand. Nagas, Mizos, Garo, Khasi, Chakma etc., and are found
predominantly in the North Eastern states of the country. In the North East, even
though, these tribes constitute small groups, their share in the state population is in
excess of 50 percent. Tribes located in the Andaman & Nicobar Islands are
Jarawas, Onges, Sentinelese, Andamanese with Negrito characteristic and
Shompens & the Nicobaries with an anthropological links to the Mongoloid groups
of South East Asia. Central and Northern part of the country is the home of the
tribes like Gaddies, Bhotia, Kamar, Birhore, Jaunsaris, Baiga, Khampa, Meena and
Ministry of Tribal Affairs,
1available from: http://www.tribal.nic.in/Content/IntroductionScheduledTribes.aspx,
accessed on 03 Aug, 2013
Census 2001, 2available from:
http://censusindia.gov.in/Census_And_You/scheduled_castes_and_sceduled_tribes.aspx, accessed on 03
Aug, 2013
Planning Commission 2006, 3available from:
http://planningcommission.nic.in/reports/sereport/ser/stdy_thr.pdf, accessed on 03 Aug, 2013
3
Gujjar, etc. In Southern India, some of the tribal groups are Andh, Chenchu, Dubla,
Gadabas, Kolam, Todas and Irulas (Fig 2).
Fig 2: Tribal dominated states of India
Fifty two percent of rural Tribal population was below poverty line and
54% tribals have no access to resources or infrastructure such as communication
linkages, roads, and transport (Planning Commission 2006, Govt. of India)4. A
major cause of their marginalization lies in their geographical isolation, leading to
lack of access to the main stream activities, resulting in unstable growth, poor
health and development. This disadvantaged population requiring special focus and
care. Tribal Health Research Forum constituted by the Indian Council of Medical
Research (ICMR) aims to address these issues and to provide holistic solutions to
alleviate various health related issues.
ICMR, under its Flagship Programmes, initiated a Tribal Health Research
Forum (THRF) at Regional Medical Research Center for Tribals, Jabalpur on the
International Day of the World's indigenous people - 9th August 2010 - with the
mandate to address and provide holistic solutions to alleviate all the health issues
Planning Commission 2006, 4available from: http://planningcommission.nic.in/reports/sereport/ser/stdy_thr.pdf,
accessed on 03 Aug, 2013.
4
pertaining to the indigenous people. This forum meets every 3 months to introspect
into the progress made and develop modus operandi to meet challenges of health
problems of these people.
The forum is headed by Dr. V.M. Katoch, Secretary DHR & DG, ICMR as the
Chairman and Lt. Gen. D. Raghunath holds advisory position. Dr Neeru Singh,
Director, Regional Medical Research Centre for Tribals (ICMR), Jabalpur is the
National Coordinator of the Forum.
Communicable diseases like malaria, tuberculosis, scabies, viral hepatitis,
lymphatic filariasis, diarrhoea, and non communicable diseases like hypertension,
fluorosis, cancer, nutritional deficiency disorders and genetic disorders in particular
haemoglobinopathies, etc are major health problems in these tribes. Presence of
these diseases coupled with illiteracy, poverty and malnutrition makes the situation
more complex in absence of proper health infrastructure and management. Thus
there is an urgent need to bring them into the mainstream so as to attain the targets
of Millennium Development Goals (MDG).
ICMR has a strong network of research institutes/centers/field stations in
almost all the nine states identified by the Ministry of Tribal Affair for developing a
common strategy at National Level for focused interventions and utilization of
health services including RMNCH+A (reproductive, maternal. neonatal, child health
and adolescent health) in these tribal districts/states in collaboration with Ministry of
Health & Family Welfare, Govt. of India to be named as „National Tribal Health
Strategy‟ for the country. ICMR efforts in these states have been focused on the
Health problems of the tribal population of these areas such as malaria,
malnutrition, genetic disorders, reproductive health, etc. Besides, new field stations
were also initiated in tribal dominated remote and inaccessible areas like
Rayagada, Kalahandi in Odissa and Car Nicobar and Kamorta in Andaman &
Nicobar Islands. It is also proposed to establish a new field station at Jagdalpur,
Bastar and a branch of RMRCT at Raipur, Chhattisgarh (CG) on the request of the
State Government.
To appraise the general public, government and non-governmental
organizations about need, activities and achievements of ICMR, launched a
5
website of THRF on June 4, 2012
(http://www.rmrct.org/ICMR_forum%20Tr...Health/indexTRHF.htm).
There is a necessity for initiating research capable of making a positive
impact on the health status of the tribal populations. These changes are aimed as a
total health package with shortest lead period. The outcome of research needs to
include public health indicators to assess impact of research, involvement of local
medical colleges, universities, other research organization and the state authorities
for anticipated and critical impact.
Based on these needs, THRF has established tribal units in 6 ICMR centers
in Phase I to exclusively work in tribal areas to meet their health needs (Fig. 3).
Further 5 Tribal units will be established at DMRC-Jodhpur, RMRIMS- Patna,
RMRC-Belgaum, NIE-Chennai and VCRC- Puducherry in Phase II in the next
financial year.
RMRCT, Jabalpur has previously mapped the central India for
haemoglobinopathies. Utilizing this data, and as lead center of THRF has mobilized
MP state Govt. to establish sickle cell clinics in 5 affected districts. The Health
professionals of these clinics are being trained by the RMRCT. Notably, Sickle Cell
Clinic run by this center since the year 2005 is the only facility available in the
region for diagnosis of various haemoglobinopathies. The viral diagnostic
laboratory instituted under virology network has been striving to record and
diagnose newly emerging and re-emerging viral diseases among tribal
communities.
At the behest of Secretary DHR & DG, ICMR the Coordinator of THRF, Dr.
Neeru Singh has been playing a pivotal role for Tribal emancipation through her
role as a member of the steering committee on Empowerment of Scheduled Tribes
(STs) for the formulation of the Twelfth five year plan and Chairman of the Health
Component of National Consultation on Developmental Challenges of the Planning
Commission on Particularly Vulnerable Tribal Groups (PVTGs). In addition to need
based research, the Scientists of the RMRCT, Jabalpur have contributed
academically and designed course materials for Diploma in Tribal Development
6
and Management of National Institute of Rural Development (NIRD). RMRCT is the
only WHO collaborating center for Health of Indigenous Population.
Fig 3: Establishment of Tribal Health Units at 6 institutes in Phase I
To highlight the needs and priorities of the tribals, THRF under the
stewardship of Dr. G. S. Toteja, Director, DMRC and Head Division of Nutrition,
ICMR has compiled an exhaustive compendium on tribal health. This compendium
contains disease wise information on communicable & non communicable diseases
and Morbidity and Mortality status. It also provides information on RCH and MCH
including utilization of health services, etc. specifically on Particularly Vulnerable
Tribal Groups (PVTGs) and vision for 12th Plan.
The priority areas of health under THRF based on a common protocol that
are being developed and followed by scientists working at various institutes on the
same disease are as follows:
7
1. Hypertension/Diabetes
2. Haemoglobinopathies
3. Nutritional Disorders
4. Infectious disease – Tuberculosis, Malaria, Filaria & monitoring of
HIV/AIDS and hepatitis and viral infections, childhood respiratory
infections and diarrheal disorders.
This forum meets once in every three months to assess the progress made
and to develop strategies for meeting innumerable health problems and challenges
of the tribal population. The forum has made strides in involving sixteen out of thirty
three ICMR institutes/centers to widen its scope of activities on areas related to
nutritional status, haemoglobinopathies, vector and water borne diseases for
identifying potential leads that can be translated for public health benefit. Further
THRF has identified below given areas for future research:
1. Socio-cultural studies and impact development and
2. Health Systems Research in collaboration with state and local bodies
This document presents the progress made and the insights into the
activities of THRF on tribals‟ health since its inception.
Haemoglobinopathies
Haemoglobinopathies are a kind of genetic defect that results in abnormal
structure of one of the globin chains of the hemoglobin molecule.
Haemoglobinopathies are inherited single-gene disorders. Common
haemoglobinopathies include sickle-cell disease and β-thalassemia
Haemoglobinopathies are most common in ethnic populations from Africa, the
Mediterranean basin and Southeast Asia. National Institute of Immunohaematology
(NIIH) spearheads the activities on haemoglobinopathies and has carried out vast
surveys all over India. In addition, RMRCT, Jabalpur has been responsible for
mapping these disorders in Central India. Notably, Sickle Cell Clinic run by this
center since the year 2005 is only facility available in the region for diagnosis of
various haemoglobinopathies. Utilizing this data, and as lead center of THRF, it has
8
mobilized MP state Govt. to establish sickle cell clinics in 5 affected districts (Phase
I). The Health professionals of these clinics are being trained by the RMRCT.
NIIH is also involved in intensive training of different medical colleges all
over India in generating national human resource personnel capable of diagnosing
and treating various haemoglobin related disorders. NIIH leads the multi-centric
studies such as (i) Newborn Screening (NBS) for Sickle Cell Disease and providing
comprehensive care to understand the natural history of Sickle Cell Disease in
Tribal Populations in Madhya Pradesh and Gujarat (ii) Establishment of Prenatal
Diagnosis of β-Thalassemia Syndromes and Sickle Cell Disorders in Madhya
Pradesh, Assam and the Andaman and Nicobar Islands and (iii) Micro mapping of
G6PD deficiency among the tribals of India and its importance for anti-malarial
therapy under the THRF umbrella.
Studies on Nutrition: National Institute of Nutrition, Hyderabad spearheads
intensive surveys on Diet and Nutritional status of tribal population and prevalence
of hypertension among adults through its NNMB units in various states and ICMR
institutes. These health surveys have revealed about 55% population carried
moderate anaemia among primitive tribes of central India. Vitamin deficiency was
found to be present in a majority of the tribes with a prevalence rate ranging from
5.8% to 47.3%. Some of these tribes also showed the signs of avitaminosis like
Bittot‟s spot, night blindness, angular stomatitis and skin infections. The major
cause of poor nutritional deficiency among tribal groups is parasitic infections
resulting passing parasites or their ova in the stool with a high frequency. THRF
recommended establishment of „Nutrition Surveillance System‟ (NSS), under
National Nutrition Policy to identify nutritional problems early in the risk group
population. Recently, NIN has established 6 new units to widen its activities to
newer areas following the recommendations of THRF.
Vector Borne Disease
Malaria is a major killer disease among tribal populations which while
accounting for only about 8% of the total population of India, contribute 30% of total
malaria cases, 60% of total falciparum cases and 50% of malaria deaths in the
9
country. ICMR institutes under the initiative of THRF have developed evidence
based intervention model for forest malaria control. The interventions include
Indoor Residual Spraying (IRS) with a synthetic pyrethroid (alphacypermethrin),
Long Lasting Insecticide Impregnated Nets (LLINs), Rapid Diagnostic Test (RDT)
and Artemisinin based combination therapy. Malaria showed significant decline
over 3 years 2010, 11 and 12 with 36, 38 and 26% reduction respectively in these
regions. Other malariometric indices also showed significant decline. Besides this,
some new intervention measures are being tried in areas where treated bednets
(ITNS) were not found effective.
Understanding the relationships between climate change, the environment,
and vector borne disease outbreaks are becoming increasingly important. An
efficient means of integrating and analyzing diverse data sources in a spatially
registered environment have been developed to find the cause/effect relationships
that will support predictive models and preventive measures for malaria and
Filariasis (Bancroftian &, Brugian). Monoclonal antibody based ELISA for the
diagnosis of lymphatic filariasis and control strategies have also been developed.
Malaria receptivity in tribal areas of district Ranchi, Jharkhand were also studied
during 2009-12 using Remote Sensing and GIS that revealed that a distance of
500m around streams is the cut off to define primary risk for malaria. Socially
acceptable, sustainable, culture based methods for sensitizing the local population
such as school going children and unemployed youths as agents of change for
controlling malaria in tribal areas have been developed. This IEC strategy has
improved awareness levels by 23 percent in a short span of four months.
Fever Survey: Surveys on febrile illness in tribal population indicated the
prevalence of fever was higher in > 60 yrs age group. Among the affected
population Respiratory Tract Infection (RTI) constituted 62% and Malaria
constituted 22% of the total cases. In the 0-5 yrs age group RTI was the most
important cause of fever followed by Malaria.
Viral Diseases: Hepatitis B virus infection, a blood borne and sexually transmitted
infection was found to be common among some of the tribal groups and the HBsAg
carrier rate varied from 6.0% to 21.0%. Tribes of Andaman & Nicobar Islands,
Madhya Pradesh, Rajasthan and Maharashtra have shown 10 to 21% HBsAg
10
carrier status. High incidence (12.28%) among the females from Yavatmal district
of Maharashtra is a noteworthy finding that is the result of painstaking efforts of
THRF to overcome lack of data about viral diseases among tribals. The viral
diagnostic laboratory instituted under the virology network has been making intense
efforts to record and diagnose newly emerging and re-emerging viral diseases
among the tribal communities.
Parasitic infections like paragonimiasis in the north-east and infestation by
flukes are other areas of focus. As a result of successful intervention the
paragonimiasis is on decline.
Hypertension: An overview of common health problems in tribal groups revealed
the presence of a so called life style disease “Hypertension” among tea garden
workers and others. To alleviate this health ailment THRF has initiated multi-centric
studies among various ethnic groups of different geographical locations (i) Urine
Sodium estimation & relationship with hypertension in Jabalpur (ii) Diet & Life style
intervention through IEC in Hyderabad and (iii) Community based dietary salt
reduction in blood pressure in Tea garden workers in Assam. Findings indicate that
there is a need for enriching the applied research in Tribal health towards
minimizing marginalization of ethnic populations.
11
Research Work being carried out at different Institutes/Centers of
ICMR in the area Tribal Health
Studies on Malaria and infectious diseases: India accounts for 75% malaria
cases reported in South East Asia, of which Orissa, Chhattisgarh, West Bengal,
Madhya Pradesh and Jharkhand account for nearly 60% cases. These states are
also home to numerous Tribal communities wherein 30% of the national malaria
burden lies. ICMR institutes have been continually tracking the disease burden in
these states and assessed effectiveness of intense intervention measures on
malaria control programme in tribal districts. In addition to evaluation of Biomarkers
responsible for severity to P. falciparum malaria, RMRCT have also compared
utility of Rapid Diagnostic Tests (Malaria Pf / Pv kit) vs. Traditional and molecular
techniques of malaria detection. They have ensured effective intervention of the
National program and independently successfully campaigned for awareness of
malaria among primitive tribal group through novel IEC programs.
Development of effective intensive intervention measures on
malaria prevalence in tribal districts
Baigachak covering 3 CHCs Samnapur, Bajag and Karanjia in Dindori
district, Madhya Pradesh is one of the malarious district of Madhya Pradesh and is
highly forested (37%) with undulating terrain and perennial streams near villages
inhabited by one of the most primitive aboriginal tribe known as Baigas. These
tribes live in dense evergreen forest and in foothills of Maikal range. Houses in the
study area are dark and damp lacking ventilation and are located in field or forest,
and on hilltop having tiled roof and mud walls. A study to develop an evidence
based intervention model for forest malaria control was initiated. The interventions
included Indoor Residual Spraying (IRS) with a synthetic pyrethroid
(alphacypermethrin), Long Lasting Insecticide Nets (LLINs), use of Rapid
Diagnostic Test (RDT) and Artemisinin based combination therapy.
Follow-up investigation carried out in the same area since 2010 revealed
that malaria showed significant decline (P<0.0001). Over all there was 36 and 38%
reduction in the year 2011 and 12 respectively. Spleen survey carried out in
children of 2 to 9 years of age revealed 45% spleen rate in 2010 which reduced to
12
27% in 2011 and further reduced to 5% in 2012. Entomological surveillance
showed that the density of malaria vector mosquitoes was significantly low (7.0 to
12.0 per man hour) when compared to previous year (36.7%). The sporozoite rate
of An. culicifacies and An. fluviatilis was 1.2 and 0.5 respectively in 2010 which
reduced to 0.4 and 0.0 in 2012. An. culicifacies sibling species. C is most prevalent
followed by D, B and A. An. fluviatilis, sibling species T is most prevalent, however
S was found as vector. This model can be used for similar forested areas of the
country.
A study to establish a sustainable ground communication mechanism using
culture based methods for sensitizing the local human resources such as school
going children and unemployed youths as agent of change to control malaria in the
area is also being carried out. For this RMRCT hired the services of a Kolkata
based NGO i-Land Informatics Ltd (Bangla Natak Dot Com) specialized in IEC
activities for improving health using cultural tools during the various sensitization
workshops with children in the study area. The formulated IEC strategy was also
evaluated by adopting before and after with control design. The baseline survey
revealed that awareness on malaria was 53 %. Non Baigas being slightly better
aware of malaria (59%) compared to Baigas (49%). The IEC strategy adopted
improved the awareness by 23 percent in four months time. A malaria clinic was
established at Maharani Medical College, Jagdalpur to assess the true burden of
malaria for development of intervention model in disturbed areas. The case fatality
rate was 37%.
Mosquito Bionomics
Prevalence, distribution and bionomics of morphologically identical but
biologically distinct sibling species of vectors, i.e., Anopheles culicifacies and An.
fluviatilis and their role in malaria transmission was studied in three districts,
namely Balaghat, Sidhi and Shivpuri of M.P. representing different physiographical
and geo-climatic conditions. It was identified that An. culicifacies is distributed in all
the areas with predominance of sibling species C which has been incriminated.
Similar results were obtained by RMRC Bhubaneswar. The problem is further
compounded by the fact that An. culicifacies is resistant to DDT, Malathion and
synthetic pyrethroids in most malarious tribal districts. This species is also
13
responsible for extended transmission of malaria in these areas. Both T and S
species of An. fluviatilis are incriminated in post monsoon season playing a major
role in malaria transmission.
In North Eastern region An. minimus and An. baimaii (earlier known as An.
dirus) are the main vectors incriminated as vector in many places of Assam,
Arunachal Pradesh and Nagaland for malaria transmission. Role of a number of
potential/ secondary vectors (i.e. An annularis, An philippinensis/nivipes, An.
culicifacies, An varuna) in transmitting malaria in the region has been established.
The vector biology study of An. baimaii revealed it to be considerably endophagic,
about 25% unfed females rest on walls (19 to 23.5 minutes) after entering in human
dwelling and before biting. It is highly anthropophagic (mean HBI 92.3%) and
exclusively exophilic, resting during day time in forest areas mostly on tree trunks
up to the height of 4-5 feet. These are exclusively forest breeder, breeding in
small, shallow, transient, rain water filled, shady ground pools during hot-wet
season and similar stream side pools during cool-dry season.
NIMR, New Delhi carried out a study in 22 malaria endemic tribal dominated
districts of 11 states in east central, north-eastern and peninsular India to map the
distribution of the members of fluviatilis-minimus group and study their biological
characteristics for effective vector control strategies. Results revealed that An.
fluviatilis species S was prevalent and predominant in forest areas of study districts
in Odisha, Chhattisgarh and Andhra Pradesh states. An. culicifacies was found co-
existing with An. fluviatilis in study districts and comprised sibling species B and C
which were primarily zoophagic.
Hypertension: overview of common health problems in tribal groups, revealed the
presence of so called life style disease “Hypertension” among Tea garden workers
and others. To alleviate this health ailment THRF has initiated multi-centric studies
among various ethnic groups of different geographical locations (i) Urine Sodium
estimation & relationship with hypertension in Jabalpur (ii) Diet & Life style
intervention through IEC in Hyderabad and (iii) Community based dietary salt
reduction in blood pressure in Tea garden workers in Assam.
14
Haemoglobinopathies screening in India
The hereditary disorders like haemoglobinopathies are highly prevalent
among the tribal groups which pose a major public health problem. Of these, sickle
cell anemia is very important because the sickle cell gene was found to be present
in all most all the tribal groups except the tribes of Jharkhand and Andaman and
Nicobar Islands and the prevalence rate ranges from 1% to 35%. National Institute
immunohematolgy (NIIH) spearheads the activities on haemoglobinopathies and
has carried out vast surveys all over India. A very higher frequency of sickle cell
gene was observed among the tribal groups of Tamil Nadu (16.5% to 22.0%),
Maharashtra (6.0% to 30.0%), Madhya Pradesh (11.8% to 30.5%), and
Chhattisgarh (1.0% to 20.0%) and, Gujarat (11.0% to 21.0%). The clinical
manifestations of sickle cell anemia in Indian patients were found to be mild to
moderate as compared to African populations.
NIIH also leads the multicentric studies such as (i) Newborn Screening
(NBS) for Sickle Cell Disease and providing comprehensive care to understand the
natural history of Sickle Cell Disease in Tribal Populations in Madhya Pradesh and
Gujarat, (ii) Establishment of Prenatal Diagnosis of β-Thalassemia Syndromes and
Sickle Cell Disorders in Madhya Pradesh, Assam and the Andaman and Nicobar
Islands and (iii) Micro mapping of G6PD deficiency among the tribals of India and
its importance for anti-malarial therapy. THRF, has been instrumental in developing
trained human resource personnel for diagnosis, molecular genetics, management
and control of genetic and hematological disorders like haemoglobinopathies
particularly sickle cell disease and β-thalassemia of different medical colleges and
ICMR centers working in regions where these disorders are a major health
predicament.
During the last two years, NIIH organized two workshops on “Screening,
Molecular analysis and Prenatal diagnosis of Haemoglobinopathies” as well as
“Screening and enzyme assay for G6PD deficiency” where hands on training was
given to the participants from 5 to 6 ICMR centers. Perseverance of RMRCT,
Jabalpur has resulted in establishment of Sickle Cell Diagnostic clinics in 5 districts
of MP (Badwani, Shadol, Mandla, Rewa and Mundsore) whose health
professionals and paramedical staff are trained at the centre.
15
Studies on Nutrition: Health and Nutritional status of the primitive tribes have
been intensively investigated by ICMR institutes, spear headed by NIN, Hyderabad.
NIN has carried out Diet and Nutritional status of tribal population and prevalence
of hypertension among adults though its NNMB units in various states. Recently, it
further established 6 new units under the recommendation of THRF. Parasitic
infection is an important cause of poor nutritional deficiency and most of the tribal
groups have a history of passing parasites in the stool with a high frequency.
Health surveys among primitive tribes of central India revealed about 55%
population carried moderate anemia. Vitamin deficiency was found to be present in
majority of the tribes with a prevalence rate of 5.8% to 47.3%. Some of these tribes
also showed the signs of avitaminosis like Bittot‟s spot, angular stomatitis, night
blindness and skin infections. THRF recommends establishment of „Nutrition
Surveillance System‟ (NSS), under National Nutrition Policy to identify nutrition
problems early, in the risk group population. A training module has also been
developed to help all the stakeholders towards the establishment of „Nutrition
Surveillance System‟, to identify nutrition problems early in the risk group
population and initiate appropriate action immediately so as to prevent and control
of under-nutrition and morbidities. Nutrition surveillance system is expected to
provide timely warning about the impending nutrition problems, better program
management, help in assess the extent of achievement against the goals.
Finally, the above narrative only provides the gist of efforts carried by ICMR
institutes and centres in alleviating the sufferings of the ethnic populations. The
detailed reports and methodology are available on the website of these institutes.
RMRCT, Jabalpur also publishes a bilingual, biannual periodical and 2 newsletters
dedicated to tribal health and these documents are also available in web
(http://www.rmrct.org).
16
The specific achievements of ICMR institutes in the
thematic areas of THRF
Regional Medical Research Centre for Tribals, Jabalpur
The Regional Medical Research Centre for Tribals (RMRCT) at Jabalpur
was established in 1984, with the mandate (i) to plan, conduct & coordinate
research in order to bring out specific health problems & health needs of the tribals
of the country (ii) to conduct epidemiological studies on major health problems of
tribes of the region (iii) to investigate haemoglobinopathies in tribals and other
communities and (iv) to assist and advice health authorities in planning, monitoring
and evaluating the regional health programs and in training of health professionals.
The thrust areas of research are communicable diseases and
Haemoglobinopathies. The centre is striving to estimate and alleviate the health
ailments posed by common diseases such as Malaria, Tuberculosis, Filariasis,
Fluorosis and viral infections etc. Further, the centre also studies the abnormal
hemoglobin and other genetic health problems of tribal of central India and provides
diagnostic services through its sickle cell clinic. Efforts are also made to identify the
Socio-economic, Demographic and Cultural profile of the tribal population to dissect
the complex role of these variables in their predicament of life style and living.
Nutritional disorders are a major stumbling block and play a critical role in health of
the ethnic populations. RMRCT has developed nutritional supplementation and
safe drinking water model to counteract flourosis and under nutrition.
On 9th August 2010, the International Day of the World's indigenous people,
ICMR under its Flagship Programmes, initiated a Tribal Health Research Forum
(THRF) at Regional Medical Research Center for Tribals, Jabalpur, with the
mandate address and discuss all the health related issues pertaining to these
people.
17
Inauguration of Tribal Health Research Forum, August 9, 2010
Initiatives of RMRCT, Jabalpur as lead institute of Tribal Health Research
Forum has resulted in the establishment of Sickle Cell Clinics in the State of
Madhya Pradesh (Fig. 4). RMRCT is providing technical support through training of
Clinicians and paramedical staff of MP state for screening of various
haemoglobinopathies. These clinics were launched in 5 districts (Badwani,
Mandsore, Mandla, Rewa and Shadol) on October 2, 2012. Three such trainings
have completed in May and July 2013 for Clinicians and Technicians of various
hospitals of Districts Badwani and Mandsaur.
Fig 4: Map showing five districts where sickle cell clinics established in M.P.
18
Hands-on-training on laboratory diagnosis of various haemoglobinopathies
Studies on Malaria: Dynamics of forest malaria transmission
An epidemiological and entomological study was carried out in Balaghat
district, Madhya Pradesh, India to understand the dynamics of forest malaria
transmission in a difficult and hard to reach area where indoor residual spray and
insecticide treated nets were used for vector control.
This community based cross-sectional study was undertaken from January
2010 to December 2012 in Baihar and Birsa Community Health Centres of district
Balaghat for screening malaria cases. Entomological surveillance included indoor
resting collections, pyrethrum spray catches and light trap catches. Anophelines
were assayed by ELISA for detection of Plasmodium circumsporozoite protein.
P. falciparum infection accounted for >80% of all infections. P. vivax 16.5%,
P. malariae 0.75% and remaining were mixed infections of P. falciparum, P. vivax
and P. malariae. More than, 30% infections were found in infants under 6 months of
age. Overall, an increasing trend in malaria positivity was observed from 2010 to
2012 (chi-square for trend = 663.55; P<0.0001).
19
Twenty five Anopheles culicifacies (sibling species C, D and E) were positive
for circumsporozoite protein of P. falciparum (44%) and P. vivax (56%).
Additionally, 2 An. fluviatilis, were found positive for P. falciparum and 1 for P. vivax
(sibling species S and T). An. fluviatilis sibling species T was found as vector in
forest villages for the first time in India.
These results showed that the study villages are experiencing almost
perennial malaria transmission inspite of indoor residual spray and insecticide
treated nets. Therefore, there is a need for new indoor residual insecticides which
has longer residual life or complete coverage of population with long lasting
insecticide treated nets or both indoor residual spray and long lasting bed nets for
effective vector control5(Singh et al 2013).
A study to establish a sustainable ground communication mechanism using
culture based methods for sensitizing the local human resources such as school
going children and unemployed youths as agent of change to control malaria in the
area is also being carried out in Dindori district. The formulated IEC strategy was
also evaluated by adopting before and after with control design. The baseline
survey revealed that awareness on malaria was 53 Percent with non Baigas were
slightly better aware of malaria (59%) compared to Baigas (49%). The IEC strategy
adopted improved the awareness by 23 percent within four months. Participating
students/ youths were brought to RMRCT for exposure. Some of the snapshots
showing different student‟s exposure and IEC activities are shown below:
Scientist explaining the exposure programme to visiting students from Baigachak
5 Singh N, Chand SK, Bharti PK, Singh MP, Chand G, Mishra AK, Shukla MM, Mahulia MM, Sharma RK,
(2013). Dynamics of forest malaria transmission in Balaghat district, Madhya Pradesh, India. Plos One. [Epub ahead of print]
20
Baiga youths/children were brought to RMRCT & exposed to laboratory
Dissemination of malaria information at community meeting as part of IEC strategy
Sensitizing on malaria using hand masks in the villages
Tribal communities carry haemoglobinopathic disorders like sickle
haemoglobin, α-thalassaemia type II and β-thalassaemia along with G-6-PD
deficiency in various proportions. These markers are stated to provide some
protection against P. falciparum malaria and thus have attained moderate to high
frequencies in tribal and other communities living in malaria endemic areas. A study
was undertaken in nine villages dominated by Baiga tribe in Baiga Chak area of
Dindori district, Madhya Pradesh and was followed up for malarial infection through
weekly active fever surveys. Sickle cell trait, G-6-PD deficient, β-thalassaemia trait
and raised foetal haemoglobin individuals showed significantly (p<0.05) low
malarial infection as compared to their respective controls. Maximum protection
phenomena were seen in G-6-PD deficient persons where SPR was half than the
normal population (odd‟s ratio of 0.314). The probability of having malarial infection
in individual with raised fetal hemoglobin was about one third. However, these
finding needs further confirmation as this study was conducted in highly malarious
outbreak affected areas.
21
Situation Analysis of Mass Drug Administration (MDA) in control of
Lymphatic Filariasis – was carried out to evaluate coverage & compliance rate of
MDA and impact on transmission of disease in selected areas of Madhya Pradesh.
The analysis revealed that coverage was only 44% and compliance was 20%. A
new foci in Narsinghpur6(Chand et al 2013) and Shivpuri district was found (Fig. 5).
The National program was informed and accordingly a guideline was issued to all
concerned.
Fig 5: Map of Madhya Pradesh showing Filariasis endemic districts and New Foci
Tuberculosis: Prevalence of Pulmonary Tuberculosis in primitive tribal population
of Madhya Pradesh was studied and found to be very high among Saharias
(15/1000) while in Baigas (1.4/1000) and Bharia (4.36/1000) the prevalence was
relatively low indicating the need for in-depth studies to find out if there are tribe
specific genetic risk abnormalities/factors. Studies to address awareness, health-
care seeking behavior, response to treatment, applicability of DOTS in inaccessible
tribal areas are ongoing. Efforts to institute diagnostic measures and deliver the
treatment regimens in the tribal areas are being carried out.
6 Chand G, Barde PV, Singh N, (2013). Emergence of new foci of filariasis in Madhya Pradesh, India. Trans R
Soc Trop Med Hyg. 107(7): 462-4. doi: 10.1093.
22
Fluorosis Mitigation: During the routine health surveys, RMRCT encountered
numerous cases of skeletal disorders due presence of Flouride in water (2-13
PPM) in tribal areas. These skeletal disorders were found to be reversible with
supplementation of nutrients like Calcium, iron and safe drinking water. This model
was inducted into the National Flourosis prevention program and water testing has
been made mandatory in M P state. Several workshops for capacity building of
medical officers, district administrators and public health engineers have been
organized at RMRCT to develop trained human resource personnel (Fig. 6).
Fig 6: Map showing workshops on fluorosis undertaken in different district of MP
In a study to empower tribals against HIV/AIDS in Kundam Block of Jabalpur
sixteen villages from tribal dominant Kundam block of Jabalpur district were
selected for the study. The actual knowledge of HIV among these was very less
and there exist different misconceptions about the root of transmission. Twenty
percent of individuals gave history of migration up to 6 months for work. However, it
is interesting to note that of the 2004 individuals who were tested for HIV by rapid
test (Comb aids by Span diagnostics) none was found positive for HIV.
23
National Institute of Immunohaematology (NIIH)
The Institute over the last 40 years has concentrated its activities on tribal
health research through various projects. A total of 35 tribal groups from 27 districts
of Maharashtra, Rajasthan, Gujarat, Dadra & Nagar Haveli, Madhya Pradesh,
Chhattisgarh, Orissa, Jharkhand, Tamil Nadu and Andaman and Nicobar islands
were studied (Fig 7).
Fig 7: Map of India showing the geographical locations and name of the tribes studied at NIIH
24
Anemia in particular iron deficiency anemia (IDA) was found to be one of the
commonest problems among the tribal groups and the prevalence rate varied from
5% to 57%. The highest prevalence was observed among the tribal groups of
Orissa. The high prevalence of IDA in some of the tribal groups could be partially
explained by the higher prevalence of parasitic infections in these groups. It has
been observed that by giving anti helmintic drugs regularly, their hemoglobin levels
were improved.
The hereditary disorders like haemoglobinopathies added to the further
problems because of their high prevalence in some of the tribal groups which poses
a major public health problem. Of these, sickle cell anemia is very important
because the sickle cell gene was found to be present in all most all the tribal groups
except the tribes of Jharkhand and Andaman and Nicobar Islands and the
prevalence rate varied between 1 to 30%.
Vasoocclusive crisis in the form of pain all over the body was observed
commonly as one of the major clinical manifestations and some of the patients also
required hospitalization for the painful episodes. Infections usually in the form of
high grade fever and involving the upper respiratory or urinary tract were found to
be common in these patients. Enlargement of the spleen and liver were also
observed in these patients. Visual acuity and fields of vision were found to be
normal. Iron deficiency anemia was found to be very common in sickle cell anemia
patients.
Beta-thalassemia was present in 1% to 5% of individuals in different tribal
groups. A higher prevalence of beta-thalassemia trait was observed among some
of the tribal groups of Orissa (2.4% to 4.8%), Gujarat (3.1% to 4.5%), Maharashtra
(1.6% to 3.2%) and Tamil Nadu (0.9% to 2.3%). Delta beta-thalassemia/HPFH trait
cases were also identified in some of the tribal groups from Maharashtra, Gujarat,
Tamil Nadu and Orissa with a prevalence of 0.6% to 4.1%. Sporadic cases of Hb D
trait were also found among the tribals of Gujarat, Orissa and Tamil Nadu. It is
interesting to note that a higher prevalence of HbE trait was observed among the
Great Andamanase which is the smallest tribal community from Andaman and
Nicobar Islands. Another striking observation was a high prevalence of beta
thalassemia trait among the Nicobarese (7.8%) and the presence of a very rare
25
mutation, codon 47(+A) in this group. A higher prevalence (56% to 98%) of one or
the other form of alpha-thalassemia was also found among some of the tribal
groups of Maharashtra and Gujarat. This kind of alpha-thalassemia is due to either
one or two gene deletions. The clinical importance of this is the interaction of alpha-
thalassemia with other haemoglobinopathies like hemoglobin S or beta-
thalassemia. It has been observed that the clinical course of sickle cell anemia
cases were milder whenever it was associated with alpha-thalassemia and
splenomegaly was more common among these patients.
Prenatal diagnosis for sickle cell anemia, sickle-beta thalassemia and beta
thalassemia major has been offered by us to several tribal couples from
Maharashtra and Gujarat and a few from Madhya Pradesh and Rajasthan. We
have helped to establish two centres for prenatal diagnosis at Valsad and Nagpur
to cater to tribal populations in South Gujarat and Maharashtra. The feasibility of
undertaking newborn screening for sickle cell disorders and enrolling babies with
sickle cell disease and sickle-beta thalassemia for comprehensive care has been
demonstrated by us in these two areas.
G6PD deficiency was also found in all the tribal groups and the prevalence
rate varied from 1.5 % to 16.0%. A higher prevalence of G6PD deficiency was
observed in some of the tribal groups of Chhattisgarh, Orissa, Maharashtra, Guajrat
and Tamil Nadu. G6PD Orissa (131 CG) was found to be the main mutational
event causing G6PD deficiency among majority of the tribal groups studied while
G6PD Namoru (208 TC) was exclusively found among the tribes of Nilgiri district,
Tamil Nadu.
To get an overview of other common health problems in these tribal groups,
an elaborate history was taken and detailed clinical examination was done in all
age groups and both sexes. Pallor and malaria were found to be very common
among all the tribal groups except tribals of Tamil Nadu. Parasitic infection is an
important cause of poor nutritional deficiency and most of the tribal groups had a
history of passing parasites in the stool with a high frequency. Diarrhoeal disorders
were also found to be very common in all the tribal groups. Vitamin deficiency was
found to be present in majority of the tribes with a prevalence rate of 5.8% to
47.3%. Some of these tribes also showed the signs of avitaminosis like Bittot‟s
26
spot, angular stomatitis, night blindness and skin infections. Tuberculosis has also
been encountered in some of the tribal groups. A large number of tribals had
unhealthy teeth, which may be due to improper cleaning and brushing of the teeth.
New initiatives by NIIH under the Tribal Health Research Forum
(THRF)
NIIH is spear heading following three multi-centric projects:
1. Newborn Screening (NBS) for Sickle Cell Disease and providing
comprehensive care to understand the natural history of Sickle Cell
Disease in Tribal Populations in Madhya Pradesh and Gujarat.
The project has been approved for funding and awaiting release of
funds. RMRCT, Jabalpur and NIIH, Mumbai along with Valsad Raktadan
Kendra are the 3 institutes involved in the study (Fig. 8). NIIH had already
undertaken a pilot study with Valsad Raktadan Kendra. In addition the center
initiated screening of few newborns for sickle cell disease from both the
centers.
2. Micro mapping of G6PD deficiency among the tribals of India and its
importance for antimalarial therapy
This project includes seven ICMR centers from different regions
where G6PD deficiency is common among the different tribal groups. Project
is approved and funding for this project is awaited (Fig. 9).
3. Establishment of Prenatal Diagnosis of βThalassemia Syndromes and
Sickle Cell Disorders in Madhya Pradesh and Assam
This project originally included establishment of prenatal
diagnosis facilities at three centers and the concept proposal was submitted
to ICMR and accepted. The full proposal has now been prepared and
submitted to ICMR for funding under the THRF.
27
Fig 8: Multi centric studies for new born screening and prenatal diagnosis
28
Fig 9: Multi centric studies on G6PD mapping
29
Workshop on “Molecular and Prenatal Diagnosis of
Haemoglobinopathies” Under Tribal Health Research Forum Held
from 11th – 14th October, 2011
Hands–on-Training
30
Quarterly Meeting of Tribal Health Research Forum at the Institute
on 6th December, 2011
31
Workshop on “Newborn Screening for Haemoglobinopathies and
Micromapping of G6PD deficiency” under the Tribal Health
Research Forum held on 19th and 20th March, 2013
Hands–on-Training
32
Regional Medical Research Centre, NE Region, Dibrugarh
North east Region of India comprising of 8 states e.g Arunachal Pradesh,
Assam, Meghalaya, Mizoram, Manipur, Nagaland, Tripura and Sikkim has a
population of 4.55 Crore. The region accounts for about 30% of total tribal
population of the country. However, the distribution of the tribal population is
skewed in the north-eastern states. While 90% of population in Arunachal Pradesh,
Meghalaya, Mizoram, and Nagaland is tribal, the remaining northeast states have
about 20 to 30 percent of the tribal population. It is pertinent to mention here that a
big chunk (~50 lakh) of population working in tea garden area of Assam are the
tribal people from Central and Eastern India who are yet to be designated as ST in
north-east India.
Regional Medical Research Centre, NE, Dibrugarh cater to the biomedical
research needs of all 8 states of Northeast India. Indigenous tribal population
spread over the region are having unique health problems. Brief outline of
achievements and areas of research among the tribal population in north-east India
by RMRC for NE are as listed below.
Achievements of RMRC Dibrugarh from 2010
Non-communicable Diseases
1. Disease burden and epidemiology
a. Cancer: The centre in collaboration with the National Cancer Registry
programme has established population based cancer registries in all
the 8 states to find the actual burden of disease. This has brought to
light the very high incidence of stomach cancer in Mizoram, lung
cancer among both sexes in Mizoram and Manipur. Studies of the
centre showed highest incidence of nasopharyngeal cancer in
Nagaland and very high cancer of oral cavity in Meghalaya. Various
dietary habits viz use of smoked meat and shoot, tobacco and alkali
have been implicated as factors contributing to high incidence.
b. Hypertension & Cardio vascular Diseases: Epidemiological studies
showed very high prevalence of hypertension among tea garden
33
tribes of Assam. Studies showed high dietary salt as one of the
determinant. Studies on genetic factors also indicated salt sensitivity
among them.
c. Diabetes: Study on burden of type-2 diabetes among the tribals has
been initiated as a part of bigger study. Already Mizoram and
Arunachal has been covered which showed lower prevalence than
non tribals.
d. Haemoglobinopathies: Prevalence studies showed high prevalence
(20-60%) of Hb E among plain tribals belonging to Mongoloid ethnic
stock of Assam and Hb S among the immigrant tea tribes. About 3-
5% tribal population is having E β-thalassaemia.
2. Translation potential and initiatives:
a. The research finding has been used to translate the benefit to the
community through initiation of a salt intervention project among
them.
b. A multi-centric study under Jai Vigyan Mission mode project for
community control of thalaseamia and heamoglobinopathy was done
in Assam and subsequently capacity building in local gynecologists
for chorion villus sampling has been initiated.
c. Lead from cancer epidemiology and disease burden has opened new
research area and potential intervention niche.
Communicable Diseases
1. Mosquito borne parasitic Diseases
a. Malaria epidemiology: Different studies on Malaria epidemiology,
transmission dynamics, anti-malarial drug resistance and malaria vector
biology and vector control are carried out in both plain and hilly tribes of
Assam, Meghalaya, Mizoram, Nagaland, Manipur and Tripura. Mapping of
parasite species showed predominance of Plasmodium falciparum malaria
(~80%) in hills, foothills and forest areas of NE India, chiefly maintained by
Anopheles baimaii and An. minimus complex mosquitoes. Health seeking
behavior of the community is a big determinant for maintenance of malaria
endemicity in the region.
34
Malaria vectors and their bionomics: Besides incrimination of An.
minimus and An. baimaii (earlier known as An. dirus sp D) the role of a
number of potential/secondary vectors (i.e. An annularis, An
philippinensis/nivipes, An maculatus ) in transmitting malaria in tribal
dominated area has been established. The vector biology study of An.
baimaii revealed it to be considerably endophagic, About 25% unfed females
take rest on walls (averaging 19 to 23.5 minutes) after entering in human
dwelling and before biting. It is highly anthropophagic (mean HBI 92.3%) and
exclusively exophilic, resting during day time in forest areas mostly on tree
trunks up to the height of 4-5 feet. These are exclusively forest breeder,
breeding in small, shallow, transient, rain water filled, shady ground pools
during hot-wet season and similar stream side pools during cool-dry season.
Sibling species mapping of An. dirus complex mosquitoes revealed the
presence of predominantly, rather exclusively, species D (An. baimaii) in the
region.
Socio-behavioral study: The exophillic behavior of An. baimaii, poor
acceptance of Indoor Residual Spray has made vector control difficult in
tribal areas of Northeast. Acceptability of mosquito nets is very high among
tribal households of ethnic communities studied in 26 villages of 5 PHCs in 4
districts of Arunachal Pradesh and Nagaland states. Insecticide impregnated
nets were introduced in these area.
Anti-malarial drug resistance: Centre has the distinction of reporting for
the first time concurrent resistance of Pf to chloroquine, sulphadoxine +
pyrimethamine and low dosage of quinine for the first time in NE Region
among the tribals inhabiting in Jairampur area of Arunachal Pradesh.
Translation and Programme implication of research: The Centre
developed a module to control malaria in forest based security camps and
was successfully tested in tribal dominated areas for malaria control.
Multi drug resistance in malaria and ACT trial result by RMRC
prompted introduction of alternate drug strategy of NVBDCP in Northeast
India.
35
b. Filariasis: Bancroftian filariasis is concentrated among the tea tribes (2-11%
microfilaraemia). Single dose DEC treatment showed good compliance and
reduction of microfilaraemia below 1%.
2. Mosquito borne viral diseases
a) Japanese encephalitis burden: Working on disease burden among tribal
population of northeast India, expanding JE activity has been reported from
5 states (Assam, Arunachal Pradesh, Manipur, Nagaland and Meghalaya) of
NE region. Assam is the worst JE affected state among all the states.
However, JE is more prevalent among pig raring tribal population.
b) Diagnosis and forecast: RMRC acted as apex laboratory for JE diagnosis
in north-east India. This centre also developed early warning system for JE
using remote sensing, GIS & epidemiological tools in Dibrugarh district of
Assam which can predict (i) onset time of JE occurrence (ii) intensity of JE
cases (iii) JE prone villages which further help in advance planning of control
and prevention of JE in respective areas.
c. Translation of Research in control and prevention: Centre documented
that JE can be controlled by protecting both humans and pigs with
insecticide treated nets (ITNs). This module can reduce infection rates up to
72%. The Centre also documented age shift (Children to adult) in Assam.
This prompted Government to introduce adult vaccination experimentally.
Dengue
Chickengunya in Meghalaya and Assam
JE in Northeast states
36
Socio-behavioral studies among tribals
o HIV: Study on sexual behavior and contraceptive use among HIV
positive peoples revealed that 65.4% married participants were sero-
concordant and 17.3% discordant in the Mizoram state. Among the
married participants, after detection of HIV, the peno-vaginal sexual
activity decreased from 52.4 to 29.8%, the oral sexual activity
decreased from 14.3 to 10.7% and the non-penetrative sexual activity
increased from 29.8 to 36.9%. Among the unmarried participants, the
peno-vaginal sexual activity decreased from 50.0 to 11.1%, the oral
sexual activity decreased from 16.7 to 8.3% and the non-penetrative
sexual activity increased from 16.7 to 25.0%. Usage of
contraceptives, mainly condoms, increased after HIV detection
among married (62% from 41%) as well as unmarried participants
(39% from 17%).
o Mapped injecting drug users in 5 states of Northeast region
including three tribal states viz Nagaland, Mizoram and Meghalaya.
o IBBA: Integrated biological and behavioural studies in Nagaland and
Manipur were done to assess the programme implementation and the
benefit for HIV control.
3. Other Parasitic Diseases
Paragonimiasis in Northeast India
37
Paragonimiasis: Paragonimiasis was first documented in Arunachal
Pradesh, Mizoram, Nagaland and among the tribals of Tripura. Disease
burden, transmission cycle and pathogenesis have been worked out.
Disease prevalence among the chest symptomatic in Arunachal Pradesh
was found to be as high as 40%. The cumulative prevalence of
Paragonimiasis in these states was found 1.9%. Besides carrying out
research on several aspects of paragonimiasis an easy diagnostic test kit
was developed to help the local doctors. Diagnostic services were offered
with the new test and treatment was offered through local health authority.
Translation of research: A module including IEC, diagnostic support and
treatment drastically reduced prevalence of paragonimiasis in Arunachal
Pradesh.
4. Bacterial Diseases
Tuberculosis: Studies conducted among tea tribes and people of Sikkim
showed high prevalence of pulmonary tuberculosis. Studies were aimed to
find out risk factors through case-control design, their awareness, causes of
default, failure and relapse. Spoligotyping showed predominance of Beijing
clad in Sikkim. Discriminatory power of 43 spacer spoligotyping analysis is
carried out so far. Discriminatory power of 15 MIRU- VNTR analysis
performed in 45 nos of type patterns (27 unique+18 clusters) revealed 107
(78.7) clustered isolates with 27 no. of maximum isolates per cluster with
HGDI 0.93.
38
Regional Medical Research Centre (ICMR), Port Blair
Marginalized communities of Andaman and Nicobar Islands
In Andaman and Nicobar Islands there are two distinct racial groups of
primitive tribes‟ viz., Negretoes in the Andamans (Great Andamanese, Onges,
Jarawas and Sentinelese) and Mongoloid in the Nicobar (Nicobarese and
Shompens).
The Regional Medical Research Centre, Port Blair carried out studies on the
health problems of the tribes.
Infectious Diseases
Tuberculosis: Tuberculosis is one of the important public health problems. Annual
risk of TB infection based on observed prevalence of infection among the children
below 15 years of age without BCG scar was 2.4%, whereas the prevalence of
smear positive cases among the population aged 15 years and above was 7.28 per
1000. The Directly Observed Treatment Strategy (DOTS) under the Revised
National TB control Programme (RNTCP) was implemented in 2005. The Centre is
undertaking efforts in collaboration with the DHS for its elimination
The Centre has established TB laboratory to extend support to the
RNTCP.
The centre has been designated as the Intermediate Reference
Laboratory (IRL) and accredited for performing drug sensitivity testing
(DST) by the Central Tuberculosis Division, New Delhi.
As a part of the diagnostic services to the ongoing TB control
programme, the Centre carries out drug sensitivity testing for detection of
multi-drug resistance (MDR).
In all a total of 83 sputum samples (2011- 2013) suspected for MDR TB
was received at the center‟s IRL facility.
39
Out of the 15 MDR suspected diagnostic samples received from the TB
control programme in tribal areas, 2 (13.3%) were found to be multi drug
resistant.
The patients enrolled for the treatment of MDR TB, are being regularly
followed up through sputum microscopy and culture.
Hepatitis B infection
Hepatitis B infection was identified as a significant public problem among the
Nicobarese.
The Centre initiated a pilot project of mass vaccination using
indigenously manufactured hepatitis B surface antigen subunit vaccine
(Shanvac-B) for the control of Hepatitis B among the Nicobarese tribe in
Car Nicobar Island.
Subsequently, another study was initiated to control peri-natal (mother–
child) transmission by administering immunoglobulin along with hepatitis
B vaccine soon after birth.
Follow up studies were undertaken to assess the impact of the
immunization programme, Seroprotection rate reached a peak of 96.7%
one month after the administration of the third dose of the vaccine, but
declined to 89% by the end of the second year and further to 85.5% by
the end of three years. Thereafter, there was no significant decrease in
the seroprotection rate till the end of seven years, though the geometric
mean titre of anti-HBsAg antibodies were steadily declining.
While mutation in the pre-core (PC) region and basal core promoter
(BCP) regions was found in only one vaccinated person, such mutations
were observed in about 19.5% of the non-vaccinated persons.
40
Lymphatic Filariasis
The Nancowry group of Islands is the only place in India where diurnally
sub-periodic form of filariasis is prevalent.
The Centre conducted a cross sectional microfilaria survey to assess the
current situation of diurnally sub periodic form of filariasis in the remotely
located Nancowry group of islands in Nicobar district, in the context of
the on-going elimination programme and the results were compared with
that of pre-MDA survey results.
Significant reduction in microfilaraemia prevalence was observed. The
overall microfilaraemia prevalence was 3.28%, ranging from 2.9% to
5.3% in different islands. Follow up of cohorts showed evidences of
persistence of infection and acquisition of new infections after six rounds
of MDA.
Assessment of the ongoing LF elimination programme, indicate >90%
drug coverage and compliance.
Persistence of infection >1% in four of the five islands is a challenge to
the elimination of this lone foci of infection in India. Administration of
DEC fortified salt could be used as a potential alternative for elimination
of this form of filariasis.
Currently, the Centrehas evolved a plan/strategy for its elimination with
the Directorate of Health Services, A & N administration under the aegis
of National Vector Borne Diseases Control Programme (NVBDCP) and
the activity has been initiated.
41
Regional Medical Research Centre, Bhubaneswar
Achievements on Tribal Health Research & Activities
1. Syndromic approach for fever diagnosis
A population based survey covering 5800 population to assess the
prevalence of morbidities associated with febrile illness was undertaken with
syndromic diagnosis approach based on the common presenting symptoms and
laboratory confirmation. Seasonal variation of the magnitude of febrile illness, its
etiology along with health seeking behavior and accessibility and utilization of
health system was assessed in three sub-centres under one block of thickly dense
tribal populated district Rayagada. A door to door questionnaire survey was
undertaken that includes detail census of the family, history of fever in family,
recording of symptoms and treatment sought in chronological order. Clinical
examination along with the biological sample collection like blood, throat swab and
urine was done at central clinic organized in the central place of the village.
2. Morbidity pattern
The prevalence of total morbidities was found to be 20.1% in rainy and 4.9%
in winter. Out of these morbidities, febrile illness associated morbidities were 35.2%
in rainy and 22.2% in winter. Major cause of fever in rainy seasons was viral fever
contributing 34% mostly URTI. URTI was found more in rainy (31.2%) than in
winter (25%). Among the fever cases, respiratory tract infection (RTI) constituted
62% and Malaria 22 % of the total cases. Among throat swab tested for respiratory
tract infections, bacterial pathogens were isolated in 75% of cases that includes S
pneumoniae, Haemophylus influenza b, and Staphylococcus aureus. Viral infection
was accompanied with the above bacterial pathogens in 20% of cases. The viruses
were mostly Corona and Para influenza. Malaria prevalence was found more
during monsoon 15.2% than during winter i.e. 9.3%. Of the total malaria cases
reported, more than 74% were Pf. The gastrointestinal infection or diarrheal
disease found to be 10.6% during rainy season in comparison to 3.1% in winter.
Protocol has been developed to assess the syndromic approach of fever in
community. Some short comings are observed at health system/ providers
operating at grass root level such as:
42
ANMs are inadequately trained on recognizing danger signs for referral
(ARI)
ANM is not able to visit daily (4-5 visits/ month)
ASHAs have low education level (<5th class majority) gives poor quality
services & inadequate coverage
Supervisor was only involved in HMIS that includes disease reporting and
monitor activities of lower staff poorly
Non availability of supplies like medicines and test kits
Inadequate & ineffective training of ASHA and they do not have direct
contact with PHC M/O.
Based on above findings innovative strategies have been developed.
3. Screening of sickle cell disease in Kalahandi district
Sickle cell disease is a major health problem in the state of Odisha. As per
the State Health Department 2008-2012 report, Odisha has 5.35 lakh of population
affected by the Sickle Cell disease, of which nearly 94% per cent live in 13 western
Odisha districts including Kalahandi. During March 2013 to May 2013, a total of 635
newborns were screened for SCD using Hb variant HPLC analysis of cord blood
samples. Out of which 17.5% were found to be positive with 103 heterozygous
(HbAS) and 8 homozygous (HbSS) cases. A strategy is being developed involving
ASHA for informing family of the patient and asking them to report to RMRC field
unit at Kalahandi District hospital for subsequent follow-up of the patients.
4. Improved regimen for control of anaemia in adolescent tribal girls
Anaemia is a significant public health problem and iron deficiency is the
major contributory factor. This has significant effect among tribal population as per
RMRC Data shown earlier with Dongria and Kondha population of Rayagada and
other districts. A 5-arm regimen strategy implemented to assess the effectiveness
of weekly supplementation of iron-folic acid in combination with vitamin B12,
deworming and nutrition education to control anaemia among tribal adolescent girls
(12-18y) in tribal dominant Gajapati district of Orissa. A total 1025 adolescent girls
included in the baseline, and 859 girls were followed after clusters randomization.
A three-level monitoring system (reported by adolescent girl herself, Anganwadi
Worker and investigators) put in to the system for compliance and coverage using
community health workers for sustainability. All the five arms showed considerable
improvements in haemoglobin level after one year. The combinational regimens of
arm-1 with 5 (iron, folic acid, vitamin B12, albendazole and nutrition education) was
43
found to be superior to current regimen. The findings have been communicated to
the state health department.
5. Prevention of diarrheal disease outbreak in three tribal districts of
Odisha
Diarrhoeal disease surveillance was conducted in the tribal blocks of 3
districts (Rayagada, Koraput & Gajapati) having severe diarrheal disorders as
epidemics in the recent past. In all seasons surveillance was done for bacterial
pathogens from diarrhoeal cases attending PHC/hospitals and to identify V. cholera
from suspected water sources as V. cholerae was the cause of severe diarrheal
disease morbidity & mortality. The surveillance will act as an early warning system
to identify the potential source for spread of the organism and take adequate
preventive measures through decontamination of water, awareness & case
management. This was successful in preventing outbreaks in the area by
continuous laboratory surveillance and immediate reporting to the district health
authority. This is being undertaken in active collaboration with the PHCs, district
health authority, NRHM and district administration. The technology of this early
warning system is in the process of transfer to the district health system through
field unit.
6. Prevalence of Drug resistance among sputum positive tuberculosis
patients in Rayagada district, Orissa
The prevalence of drug resistance among 537 sputum positive tuberculosis
patients in Rayagada district, Odisha was studied, of which 345 sputum samples
subjected for drug susceptibility testing with four first line drugs. The result showed
mono resistance to isoniazid in 8 cases, streptomycin in 5 cases and 3 showed
resistance to isoniazid and rifampicin. The drug sensitivity testing is in progress.
The centre provided support to State Government for culture and drug
sensitivity testing of MDR TB follow up sputum samples from seven tribal districts
of Odisha. So far 13 sputum samples from two districts were received and results
of 6 samples were communicated to the concerned district TB officer. Growth of
mycobacteria was observed in one sputum sample. The 1st follow up of the patient
still showing resistance to streptomycin, isoniazid, rifampicin and ethambutol,
ofloxacin and kanamycin (XDR).
44
Vector Control Research Center, Puducherry
The VCRC established a Field Station at Jeypore, Koraput District, Odisha state
in collaboration with the RMRC, Bhubaneswar in 1986 with an objective of investigating
the reasons for the persistence of malaria transmission and development of effective
control strategies. Koraput district continued to remain highly malarious from the early
parts of 20th century. Morbidity and mortality have been high and the district contributes
to considerable proportion of P. falciparum malaria in the country. There are 52 tribes in
these areas, including the primitive tribe, Bondas. The studies undertaken by VCRC
mainly focused on entomological, parasitological and socio-economic aspects of
malaria transmission among tribes that would be useful for effective implementation of
malaria control programme.
Achievements of VCRC, Puducherry
Studies on vector prevalence and bionomics in relation to transmission of
malaria and its containment.
Malaria treatment seeking behaviour of the people and their acceptability to the
intervention measures in the tribal districts of Odisha state.
Tolerability, Efficacy and Operational Feasibility of Artesunate Combination
Therapy (ACT) as 1st line anti-malarial drug for falciparum malaria control.
Studies were undertaken in the 10 southern districts of Odhisa State,
predominantly inhabited by the tribal population, in the light of the recent introduction of
malaria control tools such as long lasting insecticidal nets and ACT. The survey carried
out in 128 villages from the three major ecotypes viz., hill-top, foot-hill and plain,
selected from these districts following grid sampling method revealed presence of 18
anopheline species including An. fluviatilis and An. culicifacies, the recognized malaria
vectors. Of the total number of An. fluviatilis and An. culicifacies collected, day-time
indoor resting hand catches yielded about 85% and 99%, respectively indicating their
endophilic behaviour. Human blood index of An. fluviatilis was 0.62 and An. culicifacies
was only 0.03, indicating a higher preference of An. fluviatilis to feed on human.
45
An. fluviatilis was found susceptible to DDT, malathion and deltamethrin in all the
southern districts. An. culicifacies was resistant to DDT and malathion in all the districts,
except Gajapati and Kalahandi where its resistance to malathion needs further
confirmation. Against deltamethrin, this species was found susceptible in five districts
while in the remaining districts it showed tolerance.
P. falciparum was the predominant species constituting about 87%. Overall,
malaria parasite incidence per 1000 population (MPI) in the southern districts was 10.7.
Hill-top and foot-hill villages recorded a significantly higher MPI than plain villages.
Among the 10 districts, the MPI was higher in seven districts (8.4-42.0) having more
number of hill-top and foot-hill villages. In the remaining three districts viz., Nowrangpur,
Bolangir and Nuapada, the MPI was relatively lower (1.2-6.8) as higher proportion of
villages in these districts are of plain ecotype. Therefore, distribution of villages of hill-
top and foot-hill ecotypes determines the malaria endemicity of the district. Studies
have also shown that sensitivity of RDKs used in the districts was about 63% and
specificity was 99%. About 70% of ASHAs (n=124) had RDK in their stock, but only
31% had ACT with them at the time of interview.
Efficacy and tolerability of ACT is being studies among the Kondha tribes in
Laxmipur CHC of Koraput district. A total of 59 P. falciparum cases were followed up
after administration of ACT and there was no severe adverse events indicating that
ACT is well tolerated by the tribes. Structured interview of 106 Accredited Social Health
Activists (ASHAs) showed that all were able to use RDK and provide treatment to Pf
cases.
Prognosis of severe falciparum malaria in Koraput, Odisha, India: A
hospital based study
The clinical conditions leading to mortality in severe and complicated malaria
conditions admitted in a tertiary care hospital, Koraput were assessed. Hyperpyrexia,
cerebral malaria, malarial anemia and algid malaria are the major severe manifestations
of Pf malaria. Malaria associated conditions were respiratory infection hepatitis, urinary
tract infection, and sickle cell disease. The overall case fatality rate (CFR) was 4.3
(57/1320) and in children it was 12.3 (36/292). Renal failure was the major cause of
death in severe cases of malaria among adults. In children, cerebral malaria and
anaemia (Hb.<7 gm/dL) were the main causes of death.
46
Entomological and epidemiological investigations on Leishmaniasis
among Kani forest Tribes.
An investigation was carried out in a newly identified focus of Cutaneous
leishmaniasis among Kani tribes in Kerala state to assess the disease problem and
transmission dynamics for implementing appropriate interventions. Of the total
population of 1,444 in 28 tribal settlements, 768 persons were screened during a cross
sectional survey. In total, 27 clinical cases were recorded and of them, 16 were
confirmed to be Cutaneous leishmaniasis and the remaining 11 need further
confirmation. A total of 4,756 sand flies comprising 15 species were collected and
Phlebotomus argentipes, the recognized vector species of Visceral leishmaniasis,
constituted about 15%.
Strength of community local health authority, medical colleges and
NGOs participation in VCRC activities work in tribal areas.
All the projects in the tribal areas of Odisha state are carried out in collaboration
with the state and district health departments. The state, district and/or CHC level
programme officers are involved as the co-investigators of the project. The results of
the projects are reviewed jointly and the outcomes are considered for planning and
implementation of interventions.
The project on Cutaneous leishmaniasis among 'Kani' forest tribes in Kerala
State is carried out with collaboration of the Govt. Medical College, Trivandrum and
Directorate of Health Services and Directorate of Animal Husbandry, Govt. of Kerala
who are involved as the co-investigators of the project.
47
Training of ASHAs by VCRC on malaria control in Laxmipur CHC, Koraput disrict
Health camps conducted jointly by VCRC and CHC, Laxmipur in a tribal village
A case of cutaneous leishmaniasis among Kani tribe, Kerala
48
National Institute of Nutrition, Hyderabad
National Institute of Nutrition (NIN) was founded by Sir Robert McCarrison in
the year 1918 as „Beri-Beri‟ Enquiry Unit in a single room laboratory at the Pasteur
Institute, Coonoor, Tamil Nadu. Within a short span of seven years, this unit
blossomed into a "Deficiency Disease Enquiry" and later in 1928, emerged as full-
fledged "Nutrition Research Laboratories" (NRL) with Dr. McCarrison as its first
Director. It was shifted to Hyderabad in 1958. It was renamed as National Institute
of Nutrition (NIN) in 1969. It is the oldest institute of ICMR and its objectives of
research are:
To identify various dietary and nutrition problems prevalent among
different segments of the population in the country.
Monitor diet and nutrition situation of the country.
Evolve effective methods of management and prevention of nutritional
problems.
Conduct operational research connected with planning and
implementation of national nutrition programmes.
Dovetail nutrition research with other health programmes of the
government of India
Development of Human resource in the field of nutrition.
Disseminate nutrition information and to advise governments and
other organizations on issues relating to nutrition.
Activities & Achievements in Tribal Health Research
Established 6 NNMB new units in the ICMR Institutes, where NNMB units
are nonexistent. The States are Assam, A & N Islands, Bihar, New Delhi,
Rajasthan, and Puducherry and subsequently. All the six new NNMB units are
functioning apart from earlier 10 NNMB units (Fig 10).
49
Fig 10: National Nutrition Monitoring Bureau units
50
Fig 11: Task force studies on Hypertension
Hypertension project launched as multi centric study: Epidemiological studies
on common health problems in tribal groups, revealed the presence of life style
disease “Hypertension” among Tea garden workers and others. To alleviate this
health ailment THRF has initiated multi-centric studies among various ethnic
51
groups of different geographical locations (i) Urine Sodium estimation & relationship
with hypertension in Jabalpur (ii) Diet & Life style intervention through IEC in
Hyderabad and (iii) Community based dietary salt reduction in blood pressure in
Tea garden workers in Assam (Fig. 11).
Nutritional status of the migrant tribal population in Hyderabad city: A total of
275 adults (138 men, 137 women) were covered for study. The subjects were
mostly engaged in construction work, housekeepers, vegetable vendors, and
domestic helpers. In general migrant tribal people subsist on inadequate diets both
quantitatively and qualitatively. High concentrations of glycosylated haemoglobin
levels (uncontrolled diabetes) were observed. The prevalence of overweight and
obesity was significantly higher when compared to non-tribals.
Diet and Nutritional profile of Chenchu – A primitive tribe of Andhra Pradesh:
Chenchus mainly inhabited in nallamala forest region spread in the districts of
Mahaboobnagar,Guntur, Kurnool, Prakasam and Nalgonda. A total of 416
households from 42 Chenchu gudems were covered for survey. About 83% of HHs
covered belongs to nuclear families. Forty per cent of fathers and 26% of mothers
of index children were literate. The major occupation of father (93%) and mother
(85%) of index child was labour. The average per capita income of the HHs per
month was Rs1333/-.Barring cereals, the intake of all the foodstuffs were lower
compared to RDI. The extent of deficit was relatively higher with respect to
micronutrients such as vitamin A, iron, riboflavin and free folic acid. The prevalence
of underweight, stunting and wasting was 44%, 55%, 13% respectively and the
magnitude of under-nutrition was lower when compared to their tribal counter parts
of the State (51%, 52%, and 19% respectively). The prevalence of CED was 41%
among adult men and 42% among women. Seventy one per cent of pregnant
women registered for ANC before 16 weeks of gestation. About 62% were
institutional deliveries. About 16% of the new born had low birth weight. Among
adults, Cirrhosis of liver, poisoning of alcohol, pulmonary tuberculosis form the
major causes of deaths.
52
National Institute of Epidemiology, Chennai
Achievements in Tribal Health Research
Health Problems reported in exploratory focus group discussions
with three tribes living in Western Ghats, Tamil Nadu
Tribes in Tamil Nadu constitute 1% of the total population. A study was
undertaken to assess the health needs of all the tribal populations living in the
Western Ghats of Tamil Nadu and as a prelude we conducted an exploratory Focus
Group Discussions (FGD) among Kaniyan, Muthuvans and Paliyars Tribes in six
purposively selected locations with the objective to develop and standardize the
questionnaire for the quantitative survey. The information collected during the
FGDs are presented below:
We conducted the FGDs in the six purposively selected locations in Western
Ghats of Tirunelveli and Theni districts in Tamil Nadu in March 2012 (table 1).The
qualitative approach i.e. FGD was chosen since this method is suitable for
identifying group norms, cultural values and develop tools for conducting a
quantitative study. The main themes of FGD were on social beliefs, illness,
treatment practices, utilization of health services, and other general problems like
age at marriage, food habits, and education. A semi-structured theme guideline
was used to ensure that the content of the discussions focused on issues that were
central to research objectives. The FGDs were video recorded. The focus groups
were held in their respective hamlets. Oral consent were obtained from the
participants, since the population was afraid of providing written consent.
We consolidated the findings of the FGDs conducted in the tribal populations
in Table 1.
53
Table 1: Health Problems reported during exploratory focus group discussions by three tribes of Western Ghats.
Name
of tribe
Hamlet (No. of
tenements) Health facility
Public health services
used Habits Problems expressed Study team‟s observations
Kanyan
Injikulzhi (10 huts) PHC- trecking down by 8 km
-Immunization -Reproductive and child health (RCH)
services
-Only home deliveries preferred
-Use of native medicine is common. -Traditional healers(witch)
-Fear of side effects of modern medicine.
-Hypertension
-Kids fall ill if travelled down to planes -Witch Haunting
-Need a medical facility at the foot hill.
-Difficult place to reach. 18 km deep
by unlaid road and then about 3km trekking. -Taking health services to them will be
demanding.
Periya Mylar
(15huts)
PHC/Sub-centre by trekking down 4Km and then
crossing the back-waters of Karayar dam.
-Antenatal care (ANC) -Immunization
-Family planning
-Native medicine
-Minor ailments and cuts.
-Snake bite -Stroke -Pain in the joints of lower
limbs -Sever drinking water problem
-FGD could be conducted with
relatively younger age group (20-25years). -One of the women knew the exact
protocol of immunization. -A young woman affected by Polio was seen.
-Severe drinking water problem.
Servalar (10 huts)
PHC mobile clinic.
Clinic of Tamil Nadu Electricity
Board.
-ANC -Deliveries -Common ailments
-This population is oriented to Modern medicine.
-Gastrointestinal disorders
-Pain in the joints of lower limbs -Hypertension
-Many of the men population died of
fall or from stomach ailment. -One woman with goiter was seen. -This group was not able to forecast
their health needs.
Muth
uvan
Muthuvankudi (12 single room cement structure)
Kurngani PHC- 14 km down steep rocky path
-ANC -Immunization
-Prefer Home delivery -Chewing betel nut
-Hypertension
-Chest pain -Headache -Demand own land for
cultivation
-Females were very shy to talk to outsiders.
-Habit of chewing of tobacco prevails. -A primary school with one class room was available.
-Concrete houses were provided by the Government
Kundalakudi (80 families)
Sub centre
building is located within the hamlet. Medical facilities
are provided by tea industries.
-All services of sub-centers & that of clinics of tea industries
are used by this population
-Oriented to modern medicine.
-Psychological problems. -Infertility.
-Want functional sub-centre
-This hamlet is relatively developed. -Young Women are lodged in a common room of this hamlet during
partum (menstrual & post partum) and not allowed to stay with the family.
Palia
n
Paliankudi
(50 families)
Mobile van from
Kuddalore PHC
-Antenatal care
-Minor ailments
-These tribes live along
with the mainstream of the society.
-Not able to visualize their
health needs.
-Entire village Population is looking malnourished -Poor hygiene
-Marriage within the hamlet -Younger age at marriage -Agricultural activities are common
54
National Institute for Research on Tuberculosis, Chennai
A common protocol was developed by NIRT, Chennai for the proposed /multicentric
study Task Force study on assessing burden of TB (and co-infections) among the tribal
population. The title of the proposal is "Developing an innovative Tribal Health System
Model to estimate the burden of TB, co infections and improve the effectiveness of
RNTCP in India- A multicentre study". The primary objective of this study is to develop a
tribal health system model with feasible interventions to improve case finding and
compliance for TB treatment through a community based approach.
This study will be a multicentre study involving ICMR Institutes and Medical
Colleges in different regions covering 5 zones (East, West, North, South and North East).
An overview of the proposal was presented at the Tribal forum meeting in
Puducherry on 15th April 2013 for approval of the concept proposal. On obtaining
approval, this proposal was discussed and modified based on the comments of the
Chairman, Tribal Health PRC, ECD. Lt Gen D. Raghunath and senior expert Dr D.S
Agarwal .
The revised approved protocol was sent to all the principal investigators shortlisted
by ICMR and they were asked to follow the model proposal and submit their detailed
proposals in the ICMR format to ICMR with the budget. Fourteen proposals have been
received by the ICMR in the prescribed format.
The proposals were discussed through a conference call on July 25th,2013 with the
PRC (Tribal Forum), ICMR . The detailed discussion included the criteria for selection of
the districts for the study, budget, representation of all zones and the importance of
interventions that are to be incorporated for the study that need to be highlighted by the
institutes. The final list of proposals that will be selected, will be based on the tribal
districts represented, budget and the infra structure to carry out the study.
A workshop will be organised for all the Principal Investigators to be involved in this
multicentre study coordinated by NIRT/ICMR at NIRT, Chennai during September.2013.
55
National Institute of Malaria Research (NIMR), Delhi
National Institute of Malaria Research (NIMR) was established in 1977 as 'Malaria
Research Centre', and renamed as 'National Institute of Malaria Research' in November
2005. The primary task of the Institute is to find short term as well as long term solutions to
the problems of malaria through basic, applied and operational field research. The Institute
also plays a key role in man power resource development through trainings/workshops
and transfer of technology. The major areas of research carried out over the years are on
mosquito fauna surveys, development of genetic and molecular markers for important
malaria vectors and parasites, cytotaxonomic studies identifying major vectors as species
complexes and laboratory and field studies to examine the biological variations among
sibling species, development of molecular identification techniques for sibling species,
monitoring of insecticide resistance through space and time, preparation of action plans,
etc. have yielded valuable information. Field evaluation of new insecticides, biolarvicides,
insecticide-impregnated bed nets, drugs and parasite diagnostic kits have provided new
armament to malaria control. Many of these have found place in national malaria control
programme. NIMR has a network of well developed laboratories at Delhi carrying out
research on all aspects of malaria along with 10 field laboratories in malarious areas,
which serve as testing ground for new technologies and help in the transfer of
technologies.
Activities of NIMR under THRF
Studies on Plasmodium falciparum drug resistance in endemic regions
of India
Studies on Long Lasting Insecticide Net (LLIN) and other three LLINs: LLINS
produced higher impact in curtailing transmission than plain net and in IRS villages. The
LLINS were distributed cluster wise in some districts of Jharkhand state
Mapping malaria receptivity in tribal areas of district Ranchi, Jharkhand was studied
during 2009-12 using Remote Sensing and GIS: The study suggested a distance of
56
500m around streams as cut off to define primary risk area under major threat of malaria.
Risk factors identified were - streams, river bed pools, seepage water from reservoir,
abandoned pits after brick kilning and stone quarry, rocky terrain based pools of water
where breeding was found, migratory population settlement from endemic areas around
stone quarries, limited use of ITNs, ignorance about malaria and breeding sites and
inadequate surveillance in some of the PHCs.
Filariasis survey in different district of Jharkhand state: The micro filariae rate varies
from 2.6-11.7%. Culex quinquefaciatus was incriminated as the vector for transmission of
filariasis. The microfilaria was identified as W. bancrofti. The present survey highlights the
problem of filariasis in Jharkhand state.
Division of ECD, ICMR
Achievements in Tribal Health Research
The Division of ECD has pioneered tribal health research among the scientific
community of the country since 2003-2004 in the form of ad-hoc extramural studies and
task force projects. The Division also acts as the administrative body for ICMR centers like
the Regional Medical Research Centre for Tribals at Jabalpur, Regional Medical Research
Centers at Bhubaneswar and Port Blair, which function with a special mandate to carry out
research on health problems of tribal population in close collaboration with state
government health agencies. The Division also closely collaborates with the Regional
Medical Research Center, Dibrugarh for research among the north-east tribal population.
One of the most significant tribal health research initiatives by ECD has been the
multi-centric cross sectional study to understand the epidemiology of viral hepatitis in ten
primitive tribes of Orissa, Madhya Pradesh/ Chhattisgarh (MP/CG) and Jharkhand. It was
found that infection due to HAV and HEV was rampant. The analysis of risk factors
revealed that body piercing and history of injection were significantly associated with
HBV/HCV infection. All the HBV positive samples were of genotype D, similar to other
57
parts of the country. This led to training of scientists of RMRCT, Jabalpur and RMRC,
Bhubaneswar in ELISA and molecular techniques at NIV, Pune.
The Division had initiated a “Call for proposals” in 2010 and successfully funded 13
research projects in tribal health, in areas of Malaria, Filariasis, Visceral leishmaniasis, TB,
HIV, Hepatitis & Diarrheal diseases. This activity is being continued during the 12th plan
period as all projects are currently ongoing. ECD has pro-actively promoted clinical, social,
behavioral and operational research to improve diagnosis and treatment interventions in
Tuberculosis, stratification for malaria control in tribal dominated high malarious zones,
burden of communicable diseases in different tribes and vaccine preven
Correlation of incidence of communicable diseases with morbidity and mortality rates,
studies on prevalence pattern of filariasis and intervention studies, epidemiology and
infections like
paragonimiasis in the north-east, infestation by flukes is prevalent in some areas are the
other areas of focus.
The Division has again issued a “Call for Concept Proposals under the Tribal Sub-
Plan” in August, 2012 through the new “Online Submission of Extramural Research
Projects” facility available at the ICMR website. The Division had also been proactive in
requesting ICMR Institutes to participate in this “Call for Proposals” in collaboration with
local Medical Colleges. The “Call for Proposals” document had clearly emphasized that
investigators must plan their project proposals involving the local tribal community in
developing suitable health promotional interventions after identification of health system/
programmatic gaps. The recommendations as well as the successfully implemented
interventions should be specific, feasible and cost-effective so as to improve the ongoing
health services and national health programmes. Proposals developed in collaboration
with local NVBDCP and State health authorities would be prioritized. Involvement of local
medical colleges, universities and established research organizations was desired.
Following the recommendations of the Expert Group meeting in May, 2012, six priority
areas were identified for ad-hoc / Task Force studies:
58
A total of 76 concept proposals were received till October, 2012 and they were
successfully screened to approve 46 concepts by December, 2012. As per decision of the
experts, the Division has asked PIs to submit ad-hoc projects (full proposals) for all
approved concept proposals in areas of Childhood Infectious Diseases; Tuberculosis;
STDs, HIV & co-infections with HIV; Genetic Aspects; and the Miscellaneous section,
following guidelines of the online submission system by 15th May, 2013, the latest (30
approved concepts).
However, for TB burden estimation, it was decided to initiate project in a multi-
centric mode with standard protocols. Accordingly, The Division had requested NIRT,
Chennai to develop a standard protocol of the TB disease burden study.
NIRT, Chennai has already developed a protocol titled “Developing an innovative
Tribal Health System Model to estimate the burden of TB, co-infections and improve the
effectiveness of RNTCP in India- a multicentre study”; and the same have been reviewed
by experts and approved. In all 14 full proposals were received. Additionally, as per advice
of DG, ICMR, ICMR Institutes/ Centers working in those areas from where tribal
populations have not been covered shall be included in this study; and these ICMR
Institutes/ Centers shall involve the local medical college researchers.
ICMR (Division of ECD) has established 3 Field Units - (Fig. 12)
ICMR Field Unit at Raygada, Odisha, under RMRC, Bhubaneswar – in collaboration with
the Odisha State Government
ICMR Field Unit at Kalahandi, Odisha, under RMRC, Bhubaneswar – in collaboration with
the Odisha State Government
ICMR Field Unit at Car Nicobar, Andaman & Nicobar Islands, under RMRC, Port Blair – in
collaboration with the Andaman & Nicobar Administration
59
Fig 12: ICMR (Division of ECD) has established 3 Field Units
Division of NCD, ICMR
The Division of Non-communicable Diseases, ICMR Headquarters, New Delhi is a
founding member of THRF. Information on NCDs and their risk factors status among tribal
populations available through published literature and reports was shared with the Forum.
In 2012, the Division of NCD constituted an Expert Group to brain storm NCD
related research to be supported in tribal populations. The epidemic of NCDs and their risk
factors has been noted to affect all populations of the country including marginalized
60
populations. even are getting affected. Studying the tribal population enables and provides
us with an opportunity to capture ongoing epidemiological transition as well as understand
the behavioral determinants of the NCD risk factors for a suitable intervention. The
Scientific Advisory Group of the Division of NCD approved the initiation of a task force on
research on NCDs in the tribal population and suggested the areas of NCD risk factor
assessment, ascertainment of causes of death with special reference to NCDs and health
system assessment for tackling NCDs. This effort includes ongoing or repeat
studies/surveys/reports/publications, partnerships with local medical colleges, universities,
other research organizations and state authorities. It has been decided that ICMR
institutes would provide leadership and facilitation services for research activities with
partners, all multi-centric studies would follow a common protocol, standard definitions,
tools and criteria‟s as laid down by the national and State level ethical and regulatory
bodies. The study sites and area are identified to cover major tribal populations of the
States with dense tribal habitation. The expert group recommendations are as follows:
The proposal on Ascertainment of causes of death (prepared by RMRC, Dibrugarh)
and Health system preparedness (prepared by NIE, Chennai) should be combined
for maximizing resources and operational feasibility. Director, NIE Chennai to be
the Coordinator for the Health system proposal and Director, RMRC Dibrugarh to
be the Coordinator for Assessment of causes of death study. These studies are to
be initially undertaken in 5 States with high tribal population (Orissa, North Eastern
States, Madhya Pradesh, Chhattisgarh and Andaman & Nicobar Islands).
As per directive, the Division of NCD received the combined proposal of NIE
Chennai and RMRC Dibrugarh titled “Health systems preparedness for interventions for
diabetes, hypertension, chronic respiratory diseases and cardiovascular disease and
deaths due to non-communicable diseases among the tribal population in India” (Fig. 13).
61
Fig 13: NCD study areas
The proposal was approved for funding in the Task Force meeting held on 6 March
2013. Further, RMRC Bhubaneswar has been identified to develop the proposal on NCD
risk factor and related morbidity survey in tribal. As part of the ICMRs regular extramural
research program, the Division of NCD funds projects related to NCDs in tribal
populations.
62
Success Stories
Malaria control in Dindori, Madhya Pradesh
Dindori (22N 40° latitude and 81E 48° longitude) is one of the malarious district of
Madhya Pradesh which is highly forested (37%) with undulating terrain and perennial
streams near villages inhabited by one of the most primitive aboriginal tribe known as
Baigas who lives in dense evergreen forest and in foothills of Maikal range.
Dindori district contributes 12% of malaria cases in the state, although its
population is only about 1% of the state's population. Both Plasmodium falciparum and P.
vivax are common and prevalent in all age groups. Baigachak area of district Dindori
Madhya Pradesh covering 3 CHCs Samnapur, Bajag and Karanjia. Bajag PHC was the
most malarious PHC in the district as it contributes about 40% of malaria in the Dindori.
From this PHC a high level of chloroquine (CQ) resistance was recorded against P.
falciparum by RMRCT. On the basis of convincing evidence that CQ was failing, the drug
was replaced by National Vector borne Disease Control Programme (NVBDCP) by
Sulphadoxine Pyrimethamine (SP) first in 2008 and to an ACT (artesunate and SP
combination) in 2009.
Systematic studies were undertaken in this area since 2009 as in this area both
drug policy and insecticide for indoor residual spray was changed as per RMRCT
recommendations.
Investigations made by RMRCT, Jabalpur in villages of Baiga chak area in the year
2009 revealed very high malaria with SPR of 27% and Pf% 87% with spleen rate of
47.0%. Review of malaria intervention measures revealed that though the area is under
synthetic pyrethroid (SP) spray, but the coverage was not good and ACT was available
inadequately failing which most of the cases are still treated with chloroquine. The matter
was brought in the knowledge of concerned state authorities who immediately took prompt
remedial action to contain the spread of disease. Long Lasting Insecticide Treated Bed
nets were introduced in this area for the first time.
63
Results: Follow-up investigation carried out in the same area since 2009 revealed that
malaria is showing significant declining trend (P<0.0001). Over all there was 36, 38 and
26% reduction in the year 2010, 11 and 12 respectively (Fig. 14 & 15). The results of the
spleen survey carried out in children of 2 to 9 years of age revealed 45% spleen rate in
2010 which reduced to 27% in 2011 and further reduced to 5% in 2012. Entomological
surveillance showed that the density of malaria vector mosquitoes was significantly low
(7.0 to 12.0 per man hour) as compared to that in the year 2009 (36.7). The sporozoite
rate of An. culicifacies and An. fluviatilis was 1.2 and 0.5 respectively in 2009 which
reduced to 0.4 and 0.0 in 2012. An. culicifacies sibling species. C is most prevalent
followed by D, B and A. An. fluviatilis, sibling species T is most prevalent, however S was
found as vector.
Recommendations: Strengthening of surveillance for fever cases and treatment of fever
cases with ACT for Pf and chloroquine for Pv promptly and adequate coverage of
population by long lasting nets and IRS would control malaria as done in this study.
Fig 14: Declining trend of malaria prevalence in Dindori since 2009
0
5
10
15
20
25
30
2009 2010 2011 2012
SPR SFR
Year
Pre
vale
nce
(%
)
OR=1
OR=1
OR=0.56
OR=0.50
OR=0.32
OR=0.31 OR=0.23
OR=0.23
Chi Square for Trend (p<0.0001)
64
Fig 15: Declining trend of spleen rate in Dindori since 2010
65
Fluorosis mitigation
Following identification of fluorosis in Mandla an intervention model was developed
by RMRCT, Jabalpur. The intervention consists of two components; a) water intervention
and b) Nutritional intervention
a) Water Intervention: The main aim of water intervention was provision of safe
drinking water so that the fluoride entry is stopped.
b) Nutritional intervention: Nutrition intervention consists of supplementation of
Calcium, Vitamin C and Iron.
Evaluation of Impact of Intervention
In the year 2010 on the recommendation of the scientific advisory committee
another intervention study (Similar to earlier intervention) was carried out in a larger
sample size (10 villages) to evaluate the effect of intervention in Seoni district of Madhya
Pradesh which again an endemic district for fluorosis.
After two years of intervention there was more than 60 % reduction in the
nonskeletal fluorosis and 35% reduction in the prevalence of skeletal fluorosis cases
(Table 2).
A Lady with skeletal fluorosis before and after intervention
66
Table 2: Impact of intervention on different forms of fluorosis in Seoni
Pre intervention Post Intervention
% +/- P value No.
Examined
No. positive
(%)
No.
Examined
No. positive
(%)
Dental
fluorosis 5437 1032 (18.9) 4670 823 (17.6) -16.9 >0.05
Genuvalgum 5437 509 (9.3) 4670 307 (6.5) -30.1 <0.001
Skeletal
Fluorosis 5437 184 (3.4) 4670 105 (2.2) -35.3 <0.01
Non skeletal
fluorosis 5437 909 (16.7) 4670 294 (6.3) -62.3 <0.0001
Other
Symptoms 5437 596 (11) 4670 110(2.3) -79.1 <0.0001
Impact of Intervention on Policy at National Level
Govt. of Madhya Pradesh changed its existing water testing policy according to our
recommendations and made fluoride testing as mandatory in every bore well before
installation of hand pumps. Later fluorosis intervention was incorporated in the wise water
management programme of Govt. of Madhya Pradesh and implemented in the whole
state.
Other states of India like West Bengal, Karnataka, Andhra Pradesh, Tamil Nadu are
in the process of implementing the model. Personnel from these states have already been
trained by Regional Medical Research Centre for Tribals (RMRCT) and National
Environmental Engineering Research Institute (NEERI) with financial help from UNICEF.
67
Scabies control in Bharias of Patalkot valley of Chhindwara district of
Madhya Pradesh
A health survey undertaken by the centre in 2009 revealed that scabies was a
major health problem in the area where about 21% populations of all age groups were
infected. Based on above findings we attempted to find out the effect of intervention
programme for the management of scabies in all villages of Patlkot Valley of Chhindwara
district with the aim to control scabies infection through regular intervention by GB lotion
and Ivermectin tablet and create awareness about personal hygiene among Ashram
school going children. In depth interview revealed that scabies has formed a vicious cycle
which can be explained in the following figure:
About 3177 individuals of different age groups surveyed from 577 households from
all the villages. Trained field workers visited daily to their allotted villages, ashram schools
and supply GB lotion and Ivermectin tablet to the affected individuals. All the workers
maintained a record of the affected individual whom GB lotion was given and explained
the method of its proper application. Two field supervisors along also visited every week
68
for quality control, verification of the records and supervision of overall field work.
Supervisors were cross checked by a medical officer every 15 days. At the beginning of
the intervention 15.3% population was affected by scabies infection, which reduced to only
0.5% after intervention (Fig.16).
Fig 16: Percent distribution of Scabies before & post intervention in Patalkot Valley (after 1 year follow up)
15.3
0.5
0
2
4
6
8
10
12
14
16
18
Before intervention After Intervention
Per
cen
tage
69
Support to National Programme
1. Establishment of Malaria Clinic in Jagdalpur
RMRCT has established a malaria clinic at Jagdalpur Medical College Hospital in
September 2010 to study the prevalence of cerebral malaria and severe malaria. As a part
of study during September 2010 to June 2013, about 34,525 malaria suspected cases
were examined. The SPR was 6%, proportion of Pf was 85%, 187 cases of cerebral
malaria and 60 cases of severe malaria were diagnosed. The study revealed that case
fatality rate was 37% among cerebral and other severe cases of malaria. All four parasite
species i.e. P.vivax, P.falciparum, P.malariae, and P.ovale are present in area. Because of
prompt and accurate diagnosis and timely treatment most of cerebral malaria and severe
malaria patients recovered.
Table 3. Malaria cases in Maharani Hospital, Jagdalpur (CG)
Months BSE* Positive** PF PV PF+PV SPR
Cerebral
Malaria
(Pf)
Severe
Malaria
(other)
Mortality
Sept. Dec. 10 3727 308 255 53 0 8.3 33 17 13
Jan.-Dec. 11 13074 1039 915 124 0 7.9 86 18 42
Jan.-Dec.12 12016 576 463 113 0 4.8 49 15 27
Jan.-June 13 5708 149 128 18 3 2.6 19 10 9
Total 34525 2072 1761 308 3 6.0 187 60 91
Note: *BSE – Blood Slide Examined; **Positive – Positive for malaria; Pf – P. falciparum;
Pv – P. vivax; PF + PV – Mixed infection
70
RMRCT’s Malaria Clinic at Jagdalpur Medical College
71
2. Outbreak investigations
The Regional Medical Research Centre for Tribals is designated as Apex Referral
Laboratory of National Vector Borne Disease Control Programme with the mandate of
serological and molecular diagnosis of Dengue and Chikungunya outbreaks/ cases in
Madhya Pradesh and Chhattisgarh. Following outbreaks of dengue were investigated in
resent past:
Koria (Charcha colliery) outbreak
Based on media reports in Aug 2012, RMRCT team investigated suspected
outbreak of dengue in Churcha Colliery, Chhattisgarh (CG).The patients reporting to OPD
of South East Colliery Limited (SECL) hospital, Churcha and health camp organized by
district health authorities suspected of dengue were examined. Most of the patients had
complaints of fever (90.6%) followed by headache (84%), joint pain (81%). Few patients
had petechae (15.6%) on chest and forearm. Two deaths were attributed to dengue. The
platelet count of 26 dengue suspected patients were available, of these 22 had platelets
less than 1000 X103.
Entomological surveys were conducted in the area. Breeding of Aedes mosquito
was detected. The House Index was 52.4 Container index was 26.7 where as Breteau
Index was 100.4.
A total of 142 serum/plasma samples were collected during this investigation.
These samples were transported to the Laboratory. All 142 samples were tested by
NVBDCP recommended NIV‟s Dengue IgM MAC ELISA. Thirty nine samples showed
presence of anti dengue IgM abs. The samples collected in acute phase of illness were
tested by RT-PCR were found positive for dengue virus RNA. In all 53 samples of 142
collected were positive for dengue. Further PCR products were subjected to nPCR for
determination of serotype, and the results revealed that the causative agent was dengue
virus 1. The sequencing of PCR products and BLAST analysis confirmed the results.
72
Narsinghpur (Manesur & Imaliya Villages) outbreak
In the months of September to November 2012, samples from Narsingpur district
were found positive for dengue.
The team visited villages Manesur, Imalia, Kalyanpur and Harrai of blocks Kareli
and Salichouka of Narsinghpur. Two visits were made in the villages and vigorous house
to house search was done by our team. A total of 105 blood samples were collected.
Samples were brought to the virology laboratory, in cold chain and were tested by RDT kit,
PCR and ELISA. Out of 105 tested 62 (59%) were found positive for dengue. As per our
results it was confirmed that the outbreak was of dengue virus in the affected area.
Detection of dengue virus serotype-1 further confirmed the aetiology of this outbreak.
Dengue outbreak in Bakori Tribal Village, Mandla
Most recently in the month of June 2013 information was received from state health
authorities about an outbreak and few deaths in the village Bakori, district Mandla. A team
from RMRCT was proactively moved to the village and vigorous house to house search
was done.
Total 5 visits were conducted in the village and out of 573 tested 258 (45%) were
found positive for dengue. The results confirmed that the outbreak was of dengue virus in
the affected area. Detection of dengue virus serotype-2 further confirmed the aetiology of
this outbreak.
The outbreak was unique as this was the first outbreak of dengue reported from the
tribal and very backward district Mandla and there were 10 deaths attributed to dengue
with few dengue hemorrhagic fever and dengue shock syndrome cases were seen and
treated in tertiary health facility.
73
Patients examination during dengue
outbreak
Bakori Village in Mandla
Sero-typing of dengue virus of the samples collected from Ahiwara (Durg),
Chhattisgarh outbreak
Outbreak of dengue in Ahiwara (Durg), Chhattisgarh. in April-May 2013 was
investigated by Microbiology department of Raipur Medical Collage which is grade one
laboratory under ICMRs VDL network. Forty one serum samples (39 positive 2 negative)
collected during this outbreak were referred to Virology laboratory of RMRCT for
confirmation of results and identification of serotype.
The IgM ELISA results of the tests conducted at RMRCT confirmed that the
outbreak was of dengue virus. Five percent, ELISA negative samples were detected
positive by NIVs dengue IgM detection kit. RNA could be extracted from 30% samples and
those were subjected to nested PCR. Dengue virus serotype 1 was detected in nine
samples, which was further confirmed by sequencing.
The samples of sporadic cases were also referred to this laboratory for diagnosis
from 15 districts of Madhya Pradesh (Fig 17). The studies conducted on these samples
showed that all four serotypes of dengue are circulating in this part of the country.
74
Fig 17: Map of Madhya Pradesh and Chhattisgarh showing dengue effected districts
Samples referred Outbreak area
3. Emergence of new foci of filariasis
In M.P. 11 districts are known endemic for filariasis and in these districts mass drug
administration (MDA) are being carried out to eliminate the disease by 2015 from India
(Fig 18).
Recently RMRCT found two more newer foci of Filariasis in M.P. One is village
Chichali in Narsinghpur where microfilaria (Mf) rate in population and infection & infectivity
75
rate in wild caught vector population were 9.5, 7.4 and 1.4% respectively7(Chand et al
2013). Another site is village Khod in Shivpuri district where the corresponding indices
were 5.2, 5.3 and 1.3 % respectively in 2013. The fact was communicated to the national
and state vector borne disease control program and appropriate action was initiated by
them to contain the transmission.
Further impact of MDA in district Panna was assessed after 7th round. Survey
revealed that Mf rate in surveyed population was 8.9% and infection and infectivity rate in
wild caught vector population was 8.3 & 2.5 % after 7th round of MDA. These indices are
very high indicating active transmission. In a most recent survey in the month of July 57
mosquitoes were dissected of which 21(36%) were carrying infection. This information
was brought to the knowledge of National Vector Borne Disease Control program to take
appropriate action.
Fig 18: Map showing filarial endemic districts in M.P. Yellow- old districts, Red- New districts
7 Chand G, Barde PV, Singh N, (2013). Emergence of new foci of filariasis in Madhya Pradesh, India. Trans R Soc
Trop Med Hyg. 107(7): 462-4. doi: 10.1093.
76
4. Intervention Programme for the Management of Scabies and Macro
and Micro Nutrient Deficiency of Bharia Tribe of Patalkot Valley of
Madhya Pradesh
RMRCT Jabalpur carried out a survey in the month of March 2009, at the request of
Government of Madhya Pradesh in 12 villages of Patalkot valley of Chhindwara district.
About 570 individuals of different age group were examined during the survey. It revealed
that scabies was the most common morbidity affecting 21% individuals. Prevalence of
anemia among male was about 89% while among women it was about 96%. About 53% of
the pre-school children were malnourished.
After intervention with GB lotion and Ivermectin tablet and health education for
personal hygine, the prevalence of Scabies reduced from 15% to 0.5%.
GB lotion was found to be more effective in curing scabies as compared to
Ivermectin tablet.
After supplementation of Iron Folic Acid tablets Anemia reduced from 89% to
67%.Moderate Anemia reduced from 65% to 37% and number of normal increased
from 6.1 % to 33%.
Malnutrition among under five children though slightly reduced, the changes was
not statistically significant.
The general morbidity also reduced significantly after intervention.
Recommendations:
Active surveillance for scabies specially in the Ashram schools for early case
detection should be initiated.
Bed space (at least 50 ft2/person) should be increased in the Ashram schools.
Iron supplementation should be initiated even among males.
Periodic deworming should be done in Ashram school children.
ICDS activities (Anganwadi) should be expanded.
77
5. Health and Nutritional Profile of Tribals of Madhya Pradesh
Place of the study: Balaghat, Mandla, Dindori, Anuppur, Datia, Sheopur and Gwalior
Districts, Madhya Pradesh (Fig 19).
Study on health and morbidity profile of the tribals in various districts of Madhya
Pradesh was carried out to help the govt. in planning the health strategies. At the request
of Govt. of MP, Tribal welfare department studies on health and Nutritional status was
carried in Balaghat, Mandla, Dindori, Anuppur, Datia, Sheopur and Gwalior districts.
The information included collection of data on demographic and socio-economic
particulars of the house-holds nutritional anthropometry, clinical examination for general
morbidity and nutritional deficiency disorders. The detail reports were communicated to
the tribal welfare department Govt of Madhya Pradesh. Based on the findings certain
recommendations were also given.
Fig 19 : Map of Madhya Pradesh showing study districts
78
Conclusion
Malaria fever and ARI was the major morbidity in Baigas in all three districts.
Anemia prevalence was about 90%.
High malnutrition was observed in preschool children as compare to other tribe of
Madhya Pradesh and rural area of the state.
High growth retardation was observed in adolescent (<- 2SD) 40 to 50 % in all three
district.
Vitamin „A‟ deficiency in the form of conjunctival xerosis and Bitot‟s spot was seen in
children.
The overall intestinal parasitic infestations in school children were above 50% which
might be one of the causes of growth retardation.
There is poor utilization of Govt. Health Programs by the tribe.
There is also inadequate staff in all the three districts.
Recommendations
1. Considering high prevalence of fever National Malaria control program needs to be
strength need in all three districts.
2. Considering the high prevalence of anemia National Nutrition Anemia Prophylaxis
program should be strength need.
3. Vitamin A supplementation should be undertaken to all the children up to 12 year
age.
4. Deworming is essential up to the age of 14 years.
5. Pipe water supply is essential in this areas nearly 50% population is drinking unsafe
water.
6. Sanitation program also needs to be strange the need.
7. Considering the very difficult terrain vacant post of health worker should be filled up
immediately.
8. There is poor utilization of Govt health program in this area due to lack of
knowledge for this purpose periodic health education camps should be organized to
enhance the awareness.
79
As part of the support to the programme activities
dignitaries visited to RMRCT
Shri Ajay Vishnoi, Minister for Animal Husbandry and
Minority Welfare, Govt. of M.P.
Shri Mahendra Hardia, Minister for Health & Family
Welfare, Govt. of M.P.
Shri Gulsan Bhamra, Collector, Jabalpur interacting with the RMRCT Scientists and State Medical Officers at
RMRCT during Review meeting on Suine flu on 18th
August 2010
80
Distribution of LLIN by Shri Gulsan Bhamra, Collector, Jabalpur and Dr. Neeru Singh Director RMRCT,
Jabalpur at Kundam Block, M.P.
Shri Deepak Khandekar, IAS, Commissioner, Jabalpur Division visited RMRCT and its laboratories during
training of the MP State health professional on Sickle Cell Disease on 16th
July 2013
Lt Gen D. Raghunath, SAC Chairman of the RMRCT interacting with the participants during training of the MP
State health professional on Sickle Cell Disease on 19th
July 2013
81
New Emerging Infection
1. First report of detection and molecular confirmation of Plasmodium
ovale
A malaria clinic of RMRCT is established in a tertiary health care facility (Maharani
Hospital and associated medical college Jagdalpur) of South Bastar from 2010. Out of 256
cases of confirmed malaria, P. ovale was detected in 3 cases (1.2%) by species specific
nested PCR and sequencing. Of these 3 cases, one had cerebral malaria and another had
severe malaria anaemia. In both of these cases P. ovale was mixed with P. falciparum.
While in third case the infection was mixed with both P. falciparum and P. vivax.
Phylogenetic analysis revealed that these isolates showed closed homology with West
African genotypes. All 3 patients were from remote inaccessible forest villages and never
moved out of their residence. Because of prompt diagnosis and treatment all 3 patients
recovered8(Singh et al 2013). This finding also has implications in malaria control and
elimination as P. ovale causes relapses.
2. P. malariae
During an epidemiological study on malaria in forest villages of district Balaghat, out
of 22 microscopy suspected P. malariae cases, nested PCR confirmed the identity of P.
malariae in 19 cases. Among these 14 were mono P. malariae infections, 3 were mixed
infection of P. malariae with P. falciparum and two were mixed infection of P. malariae with
P. vivax. These studies highlight the need of molecular diagnosis of malaria species for
appropriate treatment and control9 (Bharti et al 2013).
8 Singh R, Jain V, Singh PP, Bharti PK, Thomas T, Basak S and Singh N, (2013). First report of detection and
molecular confirmation of Plasmodium ovale from severe malaria cases in Central India. Trop Med Int Healht. [Epub ahead of print]
9 Bharti PK, Chand SK, Singh MP, Mishra S, Shukla MM, Singh R, Singh N, (2013). Emergence of a new focus of
Plasmodium malariae in forest villages of district Balaghat, Central India: implications for the diagnosis of malaria and its control. Trop Med Int Health. 18(1):12-7. doi: 10.1111/tmi.12005.
82
3. Changing Trends of Dengue in Madhya Pradesh
Recently on request of government of Madhya Pradesh, a team from RMRCT
visited a tribal village Bakori (population about 1500), of District Mandla where more than
100 people were suffering with symptoms such as fever, body ache and vomiting.
Based on the clinical symptoms samples were tested for Dengue IgM, NS1 protein
and RT PCR, Chikungunya IgM, Hepatitis A IgM and Hepatitis E IgM. Out of 519 samples
tested so far, 236 were found positive for Dengue and 3 for Hepatitis E. The nested PCR
and sequencing confirmed the outbreak was due to dengue virus serotype 2. The virus
was also detected from vector mosquito Aedes aegypti collected from the village.
Over all positivity for dengue was 45%. Of 236 positive cases, 61 (26%) were
admitted to tertiary care hospital at Jabalpur. Hemorrhagic fever cases were noted during
this outbreak for the first time from this area. In all nine confirmed and two suspected
deaths were attributed to dengue.
New Members of the forum
Rajendra Memorial Research Institute of Medical Sciences, Patna
Regional Medical Research Center, Belgaum
Desert Medicine Research Center, Jodhpur
National Institute of Medical Statistics, New Delhi
National Institute of Epidemiology, Chennai
Centre for Research in Medical Entomology, Madurai
Division of Reproductive Health, New Delhi
National Institute of Research in Tuberculosis, Chennai
National JALMA Institute for Leprosy & Other Mycobacterial Diseases, Agra