If you think the medical fraternity or the civic authorities will help you to escape the fangs of malaria, you are absolutely right! A new model of Malaria control, which has been developed by the city’s Malaria expert Dr Shantaram Baliga and the IT genius Naren Koduvatt, has given the city a ‘project that works’ towards the control of the city’s sworn enemy- Malaria. This directed approach has now attracted international attention as it may hold the key for the control of the disease in many parts of the world.
One of the main reasons for the coastal areas of Karnataka to be on the map of high malaria zones is the increase in construction activities. The growth of Malaria has been exponential during the last 20 years, ever since the construction activities took an upward trend, resulting in an increase in stagnation of water used for curing the buildings during the construction stages. “These become incubators for the mosquito larvae. Ever since the development, numbers of Malaria cases in Mangaluru and the coastal areas have been on the rise. The huge buildings that were coming up everywhere take not less than two years to complete, and during that period, the curing water stagnated on various floors, including the toilet pits, lift columns and even the storage of water for construction, become breeding grounds. I remember when buildings were under construction in many areas in 2013, the entire locality had one or two cases of Malaria in each house. In one case, a neighbouring girls’ hostel of a college, there were cases of both Vivax and Falciparum infections,” say the medico-social workers
The Mangalore Medical Relief Society (MMRS), which had observed that malaria could one day be a big problem for the city, had initiated a Malaria Research Cell in the Mangalore City Corporation in the early 90s and had been diligently following it up. Dr. K R Shetty, one of the founding members of the MMRS says, “Right from the beginning, the MMRS had taken a proactive stance against malaria and made pioneering efforts in its control, many stalwarts of medical technology and expertise across the medical profession, including Dr. A V Shetty, Dr. P Kodandaraya, Dr. S R Ullal, and Dr. P N Ariga and Mangalureans in general, had helped in bringing in control factors for Malaria. The pioneering efforts have now borne fruits. The MMRS had also augmented and expended funding for the malaria research and control measures.”
Medical practitioners, specialising in Malaria treatment, point out that the Vivax type of Malaria is treated with Cholorquinn and Falciferum is generally treated with Chloroquinn, Pyrimethamine and Sulfa. In complicated Falciferum cases, the Chinese herbal drug called Artemesinin will also be administered in limited doses along with Chloroquinn. For Indian conditions, there is no need of any new drugs, the medical experts point out. “Which is why we have researched and developed a system that will track, target and deliver medication within 24 hours after cases of malaria infection are reported,” the brain behind the new model of Malaria control Dr Shantaram Baliga told this correspondent.
“Malaria is more a social problem. The labourers working at the construction sites stop taking medicines once their primary symptoms disappear. The usual dose is for five days, but due to economic conditions, they stop taking it midway. The sixth day and 28th day blood smear tests are also important, which the workers always resist for the fear of losing one day’s work and wages. This condition helps the parasite to dwell deep into the constitution of the individual and surface again in a fortnight or a month. If the recurrence is more often and the individual keeps on taking half the medication, there are chances that the individual will grow immune to the drugs and his system will fail to effectively control the Malaria parasites. There are chances that the individual could harbour the Malaria parasite without having any symptoms and distributes the parasites through mosquitoes freely in the society. This is where the new model comes into the picture, in 2014 a new approach was found. It is the project that has turned the eyes of the international experts on vector bound infections, even in the first world, towards us,” said the doctor.
Speaking about the control model, the doctor said, “I conceived the idea and finalized the process requirements. Subsequently, I did the overall program management including software development, conducting of the field trials, implementation, troubleshooting during implementation, interaction with all stakeholders, training of users, motivating for participation, liaisoning with concerned administrators in the government. I was also responsible for the overall mobilization of funds required for the development and implement of the solution in 2014, after which, it was implemented in 2015. In this journey, Mr Naren Koduvattat, CEO of i-Point Consulting Services, Mangaluru, is the co-creator of the solution blueprint and designed the software. He created and trained the technology team and led them through software development, quality assurance, field trials and implementation stages. He was also actively involved with program governance and also provided part of the funding, as part of his company’s corporate social responsibility, to develop the initial software. His team did the enhancements and support following the field trials implementation and was responsible for the program management at the back end.
“It could not have reached the present level of fruition without the help of Mr Manu Kumar, Environmental Engineer at the Mangaluru City Corporation. He was the administrator supervising the malaria control programme in the urban limits of the city. His contribution includes inputs and requirements for developing software, training of all the field workers, laboratory technicians from both the public and private sectors, participate in field trials followed by the introduction of the software into the prevailing malaria control programme, supervision and feedback on the working of the system. Dr Arun Kumar, District Malaria Officer, contributed requirements to develop the software according to the National Vector Borne Disease Control Program guidelines. All of us had participated in the field trials, training programme and supported its implementation in the initial stages.”
Dr. C R Kamath, also a former top functionary of the MMRS, recalled, “None other than the President of India, V V Giri in, 1972, appreciated the concept of a community-driven Medical Relief Society such as MMRS. In fact, it was V V Giri who inaugurated the MMRS. Right from the start, the society channelized funding based on public contributions for various medical relief activities and malaria was on the top of the agenda. Further, in the last 10 years, they approached the corporate sector for funding of malaria research and anti-malaria drives, which was readily available. Dr. Baliga had spearheaded the new generation measures, which has brought in a new and directed approach in dealing with the disease.”
What makes the new model so important?
Malaria has been endemic in Mangaluru since the past 20 years. Several control measures were implemented to battle the disease with varying results. The city had an Annual Parasitic incidence of more than 2 in 2002 which had gradually increased to 18 by the year 2014. This was in spite of all the control programmes implemented by the district malaria control department and public health department of the city corporation and active participation of the medical community and society in general. The Malaria cell was created for surveillance and data processing as a public-private partnership program in July 2003. Inconsistency in implementing anti-malarial programmes, lack of accountability in the field, poor harvesting of surveillance data for effective strategies had resulted in increased incidences of malaria.- Dr Shantaram Baliga.
The problems identified for the ineffective implementation of control measures were
1) Disconnect between stakeholders involved, namely the health care providers, field workers and administrators.
2) Lack of timely transfer of information and data for action, resulting in delayed or no appropriate case management.
3) Non-availability of data for administrative decisions and financing as a consequence of manually recording.
4) Frequent change of administrators and health officials.
The surveillance data on malaria incidences became ineffective due to the late compilation of numbers at the end of each month and a lack of geographical risk stratification. There was very little data on vector dynamics especially at the construction sites which were the major breeding sites for the parasite.
Monitoring of malaria control measures was limited to monthly incidences sub-categorized by age, sex, type of malaria. The migrant population was not tracked and entomological surveillance was carried out at random. “When Naren and I conferred, we found out that there was a gap in the follow-up system. Much time had lapsed between the reporting and beginning of the treatment. This gap had to be filled up with immediate intervention, targeted delivery of medicine and follow up. All these three elements had to be incorporated into a cohesive and workable model which had to be driven by a product of technology, Naren came up with the software which interfaced with the medical model that I had created. The software was loaded onto the tabs carried by the field workers, every time when any of the blood tests reported incidence of infection the nearest available field staff got an alert on their tabs, they rushed to the infected person and arranged for treatment. This is a unique combination of medicine, technology and human resource approach,” Dr Baliga said.
The authorities at the Malaria control cell in the Mangaluru City Corporation, agree that the new system has brought the Malaria incidences by 40 percent in 2017-18, reporting has increased by 80 percent and, during the last three years, the Malarial infections has shown a consistently downward trend. The networking, effective communication, timely and quick reporting followed by action has broken the transmission cycle.
“Our field staff have found the model very user-friendly, I have been briefed by my health officials that the new model has helped the Malaria cell to expedite the control of the spread of the infection, while at the primary level another set of field workers are engaged in the spread of awareness against malaria, the model created by Dr Baliga and Mr Naren Koduvattat has helped, the cell in particular and the health department of the Corporation in general, a great deal in bringing down the incidences of Malaria,” Mayor of Mangaluru K Bhaskar told this correspondent.
The malaria control model has received”Projects That Work” Award at Towards Unity For Health conference at Limerick, Ireland.
*The project has put many previous processes used by the health departments of the district and the city corporation in control of Malaria into in suspended animation. Passive surveillance has improved as a result of the ease of reporting. Private health sector participation has improved and is getting monitored periodically. Annual blood examination rate (ABER) increased from 17.1 percent in the 1st year to 24.7 percent in the 2nd yr and 32.7 percent in the 3rd year of the project.
*Thirty six percent (36%) of the cases were reported within 24 hours, 30% between 25 and 48 hours, and 13% between 49 and 72 hours. Reporting of 79% of the cases within 72 hours reflects the changing behaviour of personnel in diagnosis and treatment
*Surveillance and information Education (IEC) was carried out in 1,95,009 houses during the 2nd year and in 1,76,398 houses during the 3rd year. This surveillance was “Incidence Centric” soon after the reporting of cases.
*Reported vector breeding sources were 11,337, out of which in 10,822 anti-larval measures were taken (95.5% compliance). The second year recorded 10,545 breeding sites and vector control in 9,910 sites (93.9% compliance)
*The malaria control operations got almost entirely digitized. Field workers were provided with tablets so as to record all their visits and activities using the app. Hospitals and clinics were asked to report incidences through the online channel. The city corporation executives were motivated to use only the data from the system for their reviews and presentations.
* Two rounds of field trials and review by ICMR Karnataka Malaria unit scientists were done, followed by the post field trials. The solution was formally implemented within the Mangaluru City Corporation limits.
