The problem of rising deaths due to Malaria in Mumbai, India

Malaria is a global problem, with around half the world’s population (3.3 billion) at risk from the disease. This leads to about 250 million malaria cases and 1 million deaths every year. The majority of deaths are children under the age of 5. Around 500 children die every hour, 3000-10000 per day. (1)

However, malaria is disproportionately concentrated in poorer countries (2) with many countries in Africa and South-East Asia the most vulnerable. In India, the incidence of malaria has stayed relatively similar over the last decade, however Mumbai has seen a dramatic increase over the last 10 years. Out of the four major cities in India, Mumbai is the only city where malarial deaths have been increased in the last decade,(3) as shown by the graphs below.

(4)

Mumbai is the world’s second most populous city, which has the highest number of people living in absolute poverty. (5)

(6)

The table above shows how Mumbai is by far the city with the most malaria related deaths in India, and how the amount of deaths rose sharply in 2009, and the 2010 data is incomplete. In 2002, Chennai and Delhi had recorded zero deaths from malaria whereas Mumbai had recorded 18 deaths. In 2007, Delhi and Chennai maintained their nil statistics in malarial deaths, while in Mumbai the deaths had increased dramatically to 122. (3) In the 70’s Maharashtra was declared a malaria free state by the world health organization. (7)

In 2010, Mumbai was hit by one of the highest cases of malaria so far. In July alone there were more than 17,000 cases of malaria in Mumbai, and in July 2009, there was just 4,380 cases. In a normal year, malaria deaths only start to appear in monsoon season (June – November), however in 2010, 19 people had died in Mumbai between January and May.(3)

Despite efforts to eradicate and control malaria, it is increasing in Mumbai. Factors contributing to this worsening situation includes:

- changes in population immunity

- climate change

- population movements

- increasing resistance to available drugs (2)

- increasing influx of migrants (8)

- lack of effective pesticides available

The Mumbai Health Service is struggling to cope with the increased numbers, and as a result the Brihanmumbai Municipal Corporation (BMC) have erected temporary sheds outside in which to treat the patients, due to lack of space. The sheds have 200 beds each, and will contain 200 doctors and nurses from each hospital. Dr Sanjay Oak said "Malaria wards are full. Forget beds, there are patients on the floor. The temporary shelters will ease the situation a bit. Turning away a patient is not an option." (9)

Construction sites are seen as a breeding ground for malarial larvae, with the increase in production activity proportional to the increase in malaria incidence. This could be because there are many stagnant water puddles at these construction sites, which the Anopheles mosquito requires to breed.(3) This could also be due to the idea that many migrants are carrying malaria with them into Mumbai, and many of the migrants work on the construction site.

What is Malaria?

Malaria is a disease that is caused by Plasmodium, a parasite carried by a female Anopheles mosquito. The parasite is transmitted by the mosquito by taking plasmodium from the blood of an infected person, and injecting it into the blood of another person. The parasite passes through the liver, and once released, attacks the red blood cells in the blood stream, eventually rupturing the red blood cells. When this happens, substances called pyrogens which causes the symptoms of malaria.

There are four different types of Plasmodium:

Plasmodium falciparum
Plasmodium malariae
Plasmodium ovale
Plasmodium vivax

It is this final type of parasite, Plasmodium vivax, that is the most common and is the most frequent in Mumbai, however there have also been cases of Plasmodium Falciparum, which is the most deadly strain of the disease.(10)

Solution - Insecticides

With malaria being a vector born disease, the easiest way of preventing the disease is to eliminate the vector, or in this case, the mosquito. This is done largely by the use of insecticides. An example of this is in Italy, who ‘made extensive use of insecticides as part of malaria eradication’ (11) Also many of the rest of the developed world used insecticides to kill mosquitoes in the second half of the nineteenth century, which is why many of these places are now almost malaria-free.

Mosquito nets are crucial in the fight against malaria as the Anopheles mosquito only generally bites in the night. Mosquito nets that are treated with insecticides can have an even greater effect as not only are the people inside protected, but they act as bait to the mosquitoes who then land on the net and are killed. In this way the population of mosquitoes is reduced, thus reducing infection rate. Insecticide treated nets can avert around 50% of malaria cases and reduce all-cause child mortality by approximately 18 percent. (12)

More than 200m insecticide-treated bed nets have been distributed since 2000, and are estimated to have saved 1m lives, according to the Roll Back Malaria Partnership. (13)

In March 2008, biologists from the ‘Vector Control Research Centre, India’ carried out a study into the feasibility and effectiveness of Insecticide – treated nets (ITNs) in one district in India. They found that ‘Since using ITNs 74.5% – 76.6% of the respondents observed reduction of mosquito bites and 7.2%-32.1% reduction of malaria incidence’. To find these results they distributed 24,442 ITNs free of charge to a population of 63,320 during July, August 2002. They then interviewed the respondents, to obtain their results. See table below for some results. 37% expressed willingness to buy ITNs if the price was lower.

(14)

However, supply of ITNs by Unicef is increasing rapidly as shown by the graph below.

Total number, in millions, of insecticide treated nets procured by UNICEF (2000-2006)

Note: Totals include both ITNs treated by the user and long-lasting insecticidal nets (LLINs); data since 2004 reflect mostly LLINs. UNICEF is one of the largest procurers of ITNs in the world. (15)

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(14)

However, supply of ITNs by Unicef is increasing rapidly as shown by the graph below.

Total number, in millions, of insecticide treated nets procured by UNICEF (2000-2006)

Note: Totals include both ITNs treated by the user and long-lasting insecticidal nets (LLINs); data since 2004 reflect mostly LLINs. UNICEF is one of the largest procurers of ITNs in the world. (15)

I think that the results of the ITNs nets survey are valid, as they test what the biologists set out to achieve, which was to look into the feasibility and effectiveness of the insecticide. However, I don’t think the results are reliable. This is because they were recorded 9 years ago, and with the rapidly progressing treatment for malaria, the opinions and figures may be out of date. Also there is no evidence of another scientist repeating the experiment and backing up the results, so for all we know the results could be made up. The data for the UNICEF graph should be reliable as they are straight from UNICEF, which is a one of the biggest charities in the world.

The methods used are appropriate because they assess and ask the people and areas that will actually be using the ITNs, and they are tested over a reasonable period of time. Also, for the UNICEF graph, the method was appropriate because it accurately compiled data for how many ITNs were distributed.

Another way insecticides can be used is through spraying. There are three different types of spray:

Indoor Residual Spraying – this spray is used on the inside of the home, so that when a female mosquito comes into contact with it, the mosquito invariably dies. This therefore will reduce the chances of infection.
Space Spraying – a short-term solution, generally used in epidemics, where a cloud of spay is emitted into the air. This particular spraying technique is currently used in Mumbai, to try and kill off the mosquitoes (16)
Larval control – as stated above, areas of stagnant water is found and sprayed with insecticides to eliminate the source.

A worker in Mumbai uses space spraying to try and combat malaria (3)

In Mumbai, 400 biologists (5) have travelled around the city looking for areas of stagnant water, and other signs of breeding of the malarial larvae. When the larvae are found, insecticides are commonly used to exterminate the larvae.

Evaluation – Insecticides

Insecticides are very effective when it comes to reducing the mosquito population, which in turn helps to control malaria. This is because insecticides can be used in a number of ways to help to kill the mosquitoes. When used properly, insecticides can wipe out malaria in whole regions, for example in western Europe, and most of the developed world, which is now practically malaria free – largely due to the use of insecticides.

However, the insecticides have wider environmental and social effects, and are not guaranteed to kill the mosquitoes in question. Also insecticide treated mosquito nets tend to work better in rural areas where there is more space, so may not be very effective in Mumbai. ITNs also carry with them an expense, so may not be as appropriate on a larger scale, unless supplied by UNICEF, which they are, as shown in the graph above. However, most of these go to sub-saharan Africa, and not Mumbai, as Africa is said to need it more.

Also the use of some insecticides such as space spray, is short-term, and therefore need to be sprayed more regularly. Also, there is a big problem with ITNs in that they to need to be regularly applied with insecticide to be effective. This therefore means training the community into applying the insecticide, and some users may forget, or not feel the need to re-apply, which puts them back at risk.

Implications – Environmental

Insecticides can cause damage to the wider environment as insecticides are not specific to the mosquito, and therefore, when applied to a wider area, other animals are killed. Another affect that can occur is when the insect is not quite killed, and is then eaten by another animal, then the animal that ate the insect can also become damaged due to the poison in the insecticide. This can travel up the food chain, and soon a whole species can be at risk. An example of this is the bald eagle, which had a large proportion of its population wiped out due to eagles eating fish which had been infected by insecticides through eating insects. (17)

Also with malarial sprays, according to weather conditions, the spray may spread and effect the wider environment. In order to solve this I think that weather conditions such as wind speed/direction should be taken into account when applying large amounts of insecticidal spray.

In my opinion, I think that because of the considerable environmental damage often caused, large-scale insecticide operations should be limited, and smaller scale insecticides should be used instead. Perhaps the only time when large scale insecticides should be used could be in an epidemic.

Insecticide-treated mosquito nets have a much less environmental effect than other forms of insecticide such as space spray. The nets specifically target the mosquitoes and therefore, it is very rare that any other species is affected by this technique.

Implications – Economic

The use of space spray insecticides in Mumbai requires specialist equipment, and trained personnel in order to apply the insecticide. This equipment can be costly to purchase and therefore has a negative effect on the environment. This type of spraying is also a short-term solution, meaning that more insecticide may need to be applied frequently. Space spraying also requires large amounts of insecticide, and therefore this could cost more money to the economy. The pyrethroids is a new type of insecticide that is considered much safer, however pyrethroids cost substantially more than DDT (18)

Also, the decrease in the number of mosquitoes due to the use of insecticides, reduces the incidence of malaria and malarial symptoms in Mumbai. This is good for the economy as fewer people are off sick and therefore they are earning money for the economy. As a result Mumbai will have a generally stronger, healthier workforce in the long-term, which therefore will boost the Mumbai economy.

Insecticide treated mosquito nets cost a relatively small amount to produce, however once working, the effect will be similar to above, the residents will be healthier which is good for the economy. In comparison to the indoor residual spray, the nets ‘require much less insecticide, meaning the cost per family was lowered’ (2) Also a new technique is being used which incorporates the pyrethroid into the plastic before it is made into fibre, which makes the insecticidal nets longer lasting, which is an economic advantage, as nets will not need to be treated as often. (2)

Another economic advantage could be that with a reduction in malaria, there is less health costs, and less pressure on the health service as there is less people to treat.

Also if malaria is decreased in Mumbai dramatically, so much so that Mumbai is declared malaria-free, then it is likely that tourism in Mumbai would increase, as people feel a lot safer traveling to an area where there is less chance of them contracting a deadly disease. Therefore this increase in tourism can only aid economic growth.

Research was done by Gallup and Sachs in 2001 on the relationship between malaria and economic growth. The results show that ‘countries with a substantial amount of malaria grew 1.3 percent per year less than countries with little or no malaria between 1965 and 1990 (controlling for other influences on growth) and that a 10 percent reduction in malaria was associated with 0.3 percent higher growth per year.’ (19) This shows that malaria has a significant affect on the economy.

Impacts on Humans:

Benefits:

The largest benefit of insecticides to humans is the fact that with less mosquitoes, brings less chance of contracting malaria, which is a major health advantage. With this there is a better quality of life, as they do not have to worry about getting malaria.

Also, with the use of insecticides, a possible positive side effect could be that the spread of other vector born diseases is brought to a minimum.

Other benefits to humans, as mentioned above, could be that the economy could experience growth. This could be through increasing tourism, as many potential tourists will be much more attracted to visiting the area if there is no threat of contracting malaria, and there is no need for a vaccine. Also, lower health costs, due to less cases of malaria and related diseases, can also mean economic growth. Finally, less people will feel sick, meaning more people will be working, and therefore there will be higher levels of productivity. This increase in economic growth can only be an advantage to the inhabitants of Mumbai.

Risks:

With overuse of insecticides, there is a chance that mosquitoes could become resistant to insecticides, thus rendering them useless. However it is likely that a new insecticide would be developed. The impact of resistant malaria to humans could be that malaria increases, thus increasing the risk to humans of contracting the disease.

There is also a chance that insecticidal residues may run off into human water supply, which, if at dangerous levels, could carry with it significant health risks.

In Mumbai, the use of space spraying insecticides is also widely used, particularly in areas that are perceived to be hotspots, such as construction sites. This spraying has a health effect on many people, mainly those with existing respiratory problems. People who are at risk from symptom exacerbation includes ‘individuals who suffer from migraines, chronic sinus problems, asthma, reactive airway disease, autoimmune diseases and conventional allergies.’ (20)

Alternative Solutions:

Antimalarial Drugs

There are many different types of anti-malarial drugs. In the past, the main drugs used were quinine, chloroquine, mephloquine, sulfadoxine-pyrimethamine and amodiaquine. However, due to increasing resistance of these drugs as a result of misuse, biologists have been forced to develop new drugs, that are effective against the plasmodium that had become previously resistant.

(

The above graph shows areas that have become resistant to certain anti-malarial drugs, such as chloroquine and sulphadoxine. I think that the data is reliable as the source is a leading university in malarial research. Also, the data is supported by another map that I found from a research review which shows identical data. This therefore makes the data more reliable. It is also valid as it shows malarial resistance which is what it set out to do.

These new drugs are artemisinin based drugs and are generally a combination of drugs in an attempt to reduce resistance as it is unlikely that the plasmodium will be resistant to both. This combination is called a Artemisinin Combination Therapies (ACTs). The artemisinin has been designed to combat malaria fast, and is also suitable for pregnant women, which previous drugs were not. (11)

These drugs are being produced by Aurochem, a laboratory around 150km from Mumbai. In response to increasing demand due to the rising rates of malaria in Mumbai, Aurochem have increased production on drugs such as artemisinin, and sales of antimalrial drugs have increased by 50% annually over the last five years. (16)

The only problem with artemisinin based drugs is the cost. On average, they cost 10 times more than chloroquine (13)

Solution – Vaccines

Another solution, which when combined with insecticides and anti-malarial drugs, could provide an effective overall treatment for malaria. Vaccines have contributed in the past to a reduction/elimination in the spread of many deadly diseases, such as smallpox, polio and measles.

A vaccine, once developed, would be effective at controlling malaria because it is suitable for large-scale protection, so will help the large numbers of Mumbai citizens effected by the disease.

A malarial vaccine is very difficult to develop, as the malarial parasite is much more complex than a virus. In fact it contains approximately 6000 genes, compared to 9 genes in HIV and roughly 500 in a bacterium. Therefore it would take decades and a lot of finance to identify the genes that should be targeted. There is also no current human vaccine in use for any parasite, which shows that it is a difficult task. The malarial parasite is also capable of evolutionary change, through drug resistance. Plasmodium also replicates at a fast rate, meaning ensuring transmission in to the parasite’s life cycle is difficult.

Despite these difficulties, the strategic goal from the malarial vaccine community is to ‘develop a 80% effacious malaria vaccine by 2025 that would provide protection for at least 4 years (22)

This time target shows that a malarial vaccine is still a long way off, but biologists are looking for a more immediate vaccinated solution. An ‘edible vaccine’ is being developed by researchers from two laboratories in France. It consists of a spoonful of genetically modified starch, and has successfully vaccinated and protected mice. The starch is derived from a green algae called chlamydomonas, which ‘can be grown on scales ranging from a few millilitres to 500,000 litres and the starch grain can easily be produced from the plant extract and purified in large quantities’.(23)

Researchers are also trying to produce a vaccine that recognizes the antigens associated with the most severe forms of malaria. This will hopefully be able to keep an infant alive long enough for a natural immunity to develop. A different approach is to prevent the infection of the mosquito, by vaccinating against the gamont forms of the plasmodium. This would block the transmission. (11) Some vaccine that are in development aim to prevent liver cells becoming infected. These vaccines are called pre-erythrocytic vaccines. Others aim to stop the reproduction of the parasite in red blood cells, which is called a blood-stage vaccine. Finally, the last type of vaccine in development seeks to kill the parasite after they have bitten an infected vaccinated-person. This is called a transmission-blocking vaccine.

Overall there is no single solution to the malaria problem in Mumbai, but a combination of insecticides and Antimalarial drugs is currently the most effective way of preventing and treating malaria. However, ways of combating malaria throughout the world is under constant review and research. This includes the development of a new vaccine, which is currently in the human trials phase of production. If this vaccine is successful, then there is hope that malaria can be eradicated on a global scale.

Bibliography

World Health Organisation, “10 facts about malaria”, March 2009, Publications, Accessed 17th January 2011

(http://www.who.int/features/factfiles/malaria/en/index.html)

Malaria – a hand book for health professionals – The malaria consortium (2007), Published in Malaysia by Macmillan Education
Rediff News, published August 5th 2010, News section, Accessed 18th January 2011 http://news.rediff.com/slide-show/2010/aug/05/slide-show-1-malaria-in-mumbai.htm
National Vector Borne Disease Program, published 2010, accessed 17 January 2011 http://nvbdcp.gov.in/Doc/Malaria-Situation-Nov10.pdf
Dr. Rhona Mcdonald (2010) Mumbai’s Malaria Outbreak, Speaking of Medicine,(http://blogs.plos.org/speakingofmedicine/2010/08/06/mumbai%E2%80%99s-malaria-outbreak/)
National Vector Borne Disease Program, Urban Malaria Scheme (UMS), accessed 19th January 2011 http://nvbdcp.gov.in/UMS.html
Bolohealth.com, Malaria on the rise in Mumbai, August 3rd 2010, accessed Thursday 20th January 2011 http://www.bolohealth.com/news/2970-malaria-on-the-rise-in-mumbai
DNAindia.com, Migrants bringing malaria to Mumbai, published July 24th 2010, accessed 18th January 2011 http://www.dnaindia.com/mumbai/report_migrants-bring-malaria-to-mumbai-says-uddhav-thackeray_1413789
The Med Guru, Mumbai grappling with malaria, by Neharika Sabharwal, August 6 2010, accessed 17th January 2011 http://www.themedguru.com/20100806/newsfeature/mumbai-grappling-malaria-86139002.html
What is Malaria by Arlene Goldman, accessed 19th January 2011 http://priory.com/malay.htm
Biological Science Review Volume 23 Issue 1 September 2010 – Malaria by Mark Carrington.
Malaria Consortium , Prevention, accessed 14th January 2011 http://www.malariaconsortium.org/pages/solutions_prevention.htm
The Independent, Thursday 5th August 2010, Can Malaria be beaten?, accessed 14th January 2011 http://www.independent.co.uk/life-style/health-and-families/features/can-malaria-be-beaten-2043383.html)
Sci-Elo, ITNs for malarial control in India, P. Jambulingham, K. Gunaserkaran, published March 2008, accessed 17th January 2011 http://www.scielo.br/pdf/mioc/v103n2/81.pdf
UNICEF, Progress for Children, Malaria prevention and Treatment, accessed 18th January 2011. http://www.unicef.org/progressforchildren/2007n6/index_41839.htm
BBC News, ‘Mumbai tackles malarial mosquitoes for economic growth, Ben Richardson. 13th August 2010. Accessed 12th January 2011 http://www.bbc.co.uk/news/business-10965062
The American Journal of Tropical Hygiene and Medicine, Inscecticides and the Environment, Raymond E. Johnson. Accessed 20th Jan 2011 http://www.ajtmh.org/cgi/content/abstract/21/5_Suppl/825
. The World Bank and the use of DDT in India, October 2000, accessed 14th January 2011 (
Disease Control Priorities in Developing Countries | Joel G. Breman, Anne Mills, Robert W. Snow, and others Chapter 21 Conquering Malaria
PubMed, Ziem Grace, Pesticide spraying health effects, March 2005, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1253779/
Stanford University, Malaria Treatment and Prevention, accessed 17th January 2011 http://www.stanford.edu/group/parasites/ParaSites2003/Malaria/treatment.htm#_Drug_Resistance
Malaria Vaccine, 10 years of malarial pdp’s, published November 2nd 2009, accessed 19th January 2011 http://www.malariavaccine.org/files/11022009_MIM_Birkett_FINAL2.pdf
Times of India, ‘Edible Vaccine on the way’ December 13th 2010, accessed 17th January 2011 http://articles.timesofindia.indiatimes.com/2010-12-31/health/28259004_1_malaria-vaccine-malaria-researcher-malaria-parasite/2

Evaluation of References

1) Biological Science Review, Volume 23, Issue 1, September 2010 (11)

The biological science review is a flagship magazine for a-level biology. It is published by Philip Allan updates, which is one of the largest publishers in the UK for educational material. The magazine is produced by the University of Manchester, which is one of the leading universities in the UK for the faculty of life sciences.

The article that I used in my report was entitled ‘Malaria’ and was written by Dr. Mark Carrington who is a reader in molecular biology at the University of Cambridge. His research interests are in protozoa. Work done in Dr. Mark Carrington’s laboratory is supported by the Wellcome trust. The wellcome trust is ‘a global charitable foundation dedicated to achieving extraordinary improvements in human and animal health.’ That is ‘independent of both political and commercial interests.’

All this considered, I think that the biological science review is a valid and reliable source. Also, biological science review states that ‘Plasmodium falciparum…causes about 90% of malaria cases today’ which is supported by

Which confirms that ‘Most of these [malaria cases] are attributable to P. falciparum (90 percent)’. This proves that the source is giving reliable and valid information.

On the other hand, the magazine is written for a-level students (16-18 years) so the information given may not be in full detail, so that it is easier to understand, and therefore it may not be as accurate as possible. But overall I think that this source is valid and reliable

2) BBC News Video Article, ‘Mumbai tackles malarial mosquitoes for economic growth’ – (16)

The BBC (British Broadcasting Company) is ‘the largest broadcasting organisation in the world. Its mission is to enrich people's lives with programmes that inform, educate and entertain.’ Therefore it should be reliable due to the sheer size and experience of the company.

The video is also relatively recent (13th August 2010), and although science moves fast, information is unlikely to have changed drastically during this time period. This makes the source more valid and reliable.

The video stated that ‘in July, Mumbai has had more than 17,000 malaria cases’, which is confirmed by

Which states that ‘The hospital registered 17,000 malaria cases in the city in July.’ This confirms the facts shown in the video, and shows the source to be valid and reliable.

However, the video was aimed at the mass population, and therefore may be somewhat simplified so that everyone can understand. However, this should not prevent the facts from being correct so overall I think that the source is reliable and valid.

The problem of rising deaths due to Malaria in Mumbai, India

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