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War Against Malaria
Text by GIRIRAJ AGARWAL Photographs by MUKESH JHA To view the article in magazine format,
Please click here for the PDF File  American and Indian scientists work to develop antimalaria vaccines and drugs. The World Health Organization estimates that more than 500 million people get malaria each year and more than a million of them die. Most of the victims are children in sub-Saharan Africa. The situation in India is not as bad, but there is cause for worry: rising cases of the dangerous Plasmodium falciparum parasite, increasing resistance to the traditional drug chloroquine, and the failure in some places of insecticides like DDT (Dichlorodiphenyltrichloroethane) to kill the mosquitoes responsible for the transmission of malarial parasites. This has forced Indian scientists to look at the problem afresh and reconsider their strategies. The United States is partnering India in several ways to fight malaria. The Centers for Disease Control and Prevention in Atlanta, Georgia, is involved in many research projects with India's National Institute of Malaria Research. The collaboration has resulted in an experimental vaccine for which human trials are expected to begin soon. How many people really come down with malaria in India every year? Nobody has the exact answer but scientists agree that there is huge under-reporting. "Non-reporting of malaria cases by private doctors and self-medication is a big bottleneck?in arriving at the right malaria data," says Praveen Bharti, a researcher with the Jabalpur field station of the National Institute of Malaria Research. Malaria cases in India have remained around two million each year in the last 10 years and have taken the lives of about 1,000 people, according to statistics of the National Vector Borne Disease Control Program. "The number of malaria cases in India is 10 to 40 times of what is reported," says Dr. Altaf Lal, health attaché at the U.S. Embassy and a malaria expert. There have been malaria outbreaks in pockets of many states of India but the disease is more severe in Orissa, Madhya Pradesh, Chhattisgarh, Jharkhand and the northeastern states. Areas of Madhya Pradesh and Chhattisgarh populated largely by tribespeople are badly affected. "The tribals are only 19 percent of the population but account for 50 percent of the malaria cases," says Neeru Singh, chief of the Jabalpur field station. Seventy percent of the malaria cases among the tribespeople of this region, she says, are caused by the Plasmodium falciparum parasite, which is responsible for more than 90 percent of malarial deaths in the world. India had historically more Plasmodium vivax cases than P. falciparum. Plasmodium vivax does not lead to death, says M.M. Shukla, deputy director at Jabalpur. The field station was established in 1986, specifically to study the malaria sensitivity of the tribal regions of Madhya Pradesh and Chhattisgarh. "Tribals live in forests and wear scanty clothes, which make them susceptible to malaria," says Singh. "In the rainy season, water pools make the situation worse," she says. Several research projects are being carried out in association with the Centers for Disease Control, which was established in 1946 to eradicate malaria in the United States. The National Institutes of Health in Bethesda, Maryland, and the U.S. Agency for International Development have funded research on cerebral malaria and the burden of malaria in pregnant women in the region, Singh says. In 2007, Dr. Eric Tongren, a visiting professor at the Centers for Disease Control, visited the Jabalpur station to study the progress of various projects. "Our major aim is try to reduce the number of cases and deaths due to malaria. We are also trying to understand the reasons behind the susceptibility of the region toward the disease," says Tongren. The center has helped the station with its expertise. "Researchers, technicians and epidemiologists have been provided training. Joint workshops have been organized," says Lal. An expert on malaria from the Centers for Disease Control, Venkatachalam Udhayakumar, has been coordinating the projects with Singh. What is the outcome of the joint research? "An interesting biological mechanism has been observed in the patients who had cerebral malaria," says Tongren. "Blood analysis of these patients showed some prognostic markers. Some markers were more pronounced in these patients. This can aid in the treatment of cerebral malaria patients and we can know who are more at risk," he says. Tongren adds that in Africa only 30 percent of the children with cerebral malaria survive. The study of malaria during pregnancy is another important joint research project at Jabalpur. The impact of the disease on the health of mother and baby is being studied. About 600 pregnant women were observed when they came to the health centers for a checkup. The field station is linked to hospitals in Katni and Maihar, and small laboratories have been established at both places to make blood smears for testing the placenta for malaria. Bharti, the researcher, says, "Women who had placental malaria had babies with low birth weight. Chances of a pre-term baby or still birth are also more. These women were also found to be more anemic." The women and children will be observed until the child is three years old. "This will help in understanding the impact of placental malaria on the development of the child," he says. Malaria affects all age groups in India, whereas in Africa it affects mostly children. "In Africa, children are exposed to malaria so many times that they develop immunity to the parasite, whereas in India malaria is more severe in some pockets," says Lal. Malaria was successfully eradicated in the United States by using the effective antimalarial drug and insecticide of that time: chloroquine and DDT. What can India learn from this experience? "India has the tools and knowledge to eradicate malaria," says Lal. "It has its own successful models. Dr. Neeru Singh and her team successfully controlled malaria in Betul, Madhya Pradesh." The number of malaria cases had increased 25-fold between 1990 and 2000 in Betul, reaching a high of 11.37 per 1,000 people. Singh says, "The state government asked for our help. We said DDT was not working. Synthetic pyrethroid was used for indoor spraying. Gambusia and guppy fishes [that eat larvae] were introduced in water bodies to check the spread of mosquitoes. A rapid diagnostic test was used to know within 10 minutes (whether the parasite was present). Only vivax malaria was treated with chloroquine. Falciparum malaria cases were treated with sulphadoxine pyremethamine." The project began in January 2001. "Within five years, malaria in Betul was reduced by more than 90 percent," says Singh. At several places resistance to chloroquine was dealt with by using artemisinin-based combination therapy, with insecticide-treated mosquito nets as a preventive measure. The war against malaria is also being fought on another front-the development of a malaria vaccine. The Indian center of the Trieste, Italy-based International Centre for Genetic Engineering and Biotechnology has succeeded in making experimental vaccines for both vivax and falciparum parasites. The Program for Appropriate Technology in Health, a U.S.-based nonprofit organization, has given funds through its Malaria Vaccine Initiative to the institute for developing a vaccine. The Bill and Melinda Gates Foundation has also contributed, along with the U.S. National Institutes of Health and the Walter Reed Army Institute of Research. The India director of the International Centre for Genetic Engineering and Biotechnology, Virander Chauhan, says: "We have successfully made vaccines at the laboratory and commercial level, using chosen antigens in collaboration with the Hyderabad-based pharmaceutical company Shanta Biotech. Toxicity in animals is being tested and our experience so far tells us that these are not toxic. After that we will seek the Indian Government clearance for phase one human trials, which we are planning somewhere near Mumbai." He says that both the vaccines are combinations of more than one antigen. If all goes well, these vaccines will be further tested at a vaccine field site near Jabalpur or at Sundergarh in Orissa, Chauhan says. At Jabalpur, the data of 35,000 people from 52 villages are being collected and their malaria profiles are being prepared. Their blood samples have been analyzed and they are being monitored, says Bharti, who regularly visits these villages, 18 to 75 kilometers from Jabalpur. The Centers for Disease Control is extending its expertise in developing this field site, not only for testing of future vaccines but also for testing of malaria drugs. Tongren says that the pharmaceutical company Glaxo Smithkline and the Walter Reed Institute have also jointly developed the malaria vaccine RTS,S/AS02 and second stage human trials are being done in Mozambique. So how soon can we expect a malaria vaccine? Nobody wants to set a date because of earlier failed promises. Until now, malaria parasites have proved to be much smarter than the scientists. But scientists are hopeful of success this time. Chauhan says, "Our vaccine is not such a type which is administered to everyone. It will be administered to children below age two who are at risk in malaria endemic regions." The International Centre for Genetic Engineering and Biotechnology is also working on developing new antimalarials using leaves and marine products to meet the challenges faced by existing antimalarial drugs. Lal says that if the center succeeds in making a vaccine that can be used as a public health tool, it will be an example of a major achievement through Indo-U.S. cooperation. Please share your views on this article. Write to editorspan@state.gov "The suffering caused by malaria is needless, and every death caused by malaria is unacceptable." -President George W. Bush February 18, 2008 |
