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