Utilization Pattern and Effectiveness of IRS and ITNs/LLINs in High Endemic Districts in a North Eastern State of India: Issues and Challenges

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1 Volume 2 Issue AJHM 2 (1), (1 20) 2017 Utilization Pattern and Effectiveness of IRS and ITNs/LLINs in High Endemic Districts in a North Eastern State of India: Issues and Challenges V K Tiwari, Sherin Raj T P, Ramesh Gandotra & P D Kulkarni National Institute of Health and Family Welfare, New Delhi, India Abstract Mizoram is a North Eastern state of India and is co-endemic for Plasmodium falciparum and P. vivax malaria being the predominant and life threatening infection (>70%). The GFATM Round 9, IMCP-II aimed to scale up effective preventive and curative interventions in high endemic districts in the state. The provision of LLIN has proved to be an effective strategy in preventing spread of drug resistant malaria in the state. The present article assesses effective use of IRS and ITNs/LLINs in the community in the state. A cross-sectional malarial surveys comprising 880 HHs was conducted during July-August 2014 in high endemic blocks (API>2) across the states of Mizoram. In addition, programme activities data available in the website was also studied. It was found that more than 70% respondents were aware about malaria but the awareness in endemic far away districts like Logtlai and Lunglei was low compared to other Districts/ Blocks. Data revealed that supply of LLINs were reduced in the year , but about 93% LLIN, 81 % ITNs and 87% of ordinary bed nets were in the usable condition. The East and Longtlai districts were having less percentage of any type of usable bed nets. About 90% of households confirmed IRS in their houses and it was found that higher percentage of households confirmed IRS in most affected districts like Kolasib, Sahiya Lunglei West etc. Malaria mortality reduced from 119 in 2009 to 21 in the year 2013 in the state but again rise to 31 in 2014.There has been considerable decline in the state of Mizoram during 2009 onwards due to effective IRS, distribution of ITNs/LLINs among BPL population in high endemic districts. Due to reduced mortality, tendency of complacency also cropped up in some of the relatively better off districts. Key Words: Malaria, North Eastern States, Mizoram, Mortality, IRS, LLIN JEL Classification: I19 Paper Classification: Research Paper Introduction Malaria is a deadly parasitic disease caused by infective bite of Anopheles mosquito. Parasites responsible for malaria are known as Plasmodium viviax (P.vivax), Plasmodium falciparum (P.falciparum), Plasmodium malariae (P.malariae) and Plasmodium ovale (P.ovale). Infection with P.falciparum is reported as the most deadly form of malaria. 1

2 AJHM Volume 2 Issue According to the World Malaria Report 2017, out of the 216 million cases of malaria that occurred worldwide in 2016, India accounts for 6 per cent. 7% per cent of all the malaria-related deaths happened in India in India stands third in the list of 15 countries that contributed to 80 percent of the global malaria burden. India reported 85 percent of vivax malaria cases. It appears that India may not be able to reduce its malaria burden by half by The WHO Report 2017 also says that malaria mostly affects poor and vulnerable groups in tropical and subtropical areas, where the temperature and rainfall are conducive for development and spread of the causative parasite. Malaria is still endemic in North Eastern part of the country. The official figures for malaria in India, available at NVBDCP web site indicate 0.84 million confirmed cases, 63.39% were Pf cases and 105 deaths (NVBDCP, 2017). The NVBDCP countrywide data on malaria load (NVBDCP, 2015) shows that the state of Orissa is severely affected due to humid conditions, and contributes to one fourth of the total annual malaria cases in the country, more than two fifth of P. falciparum malaria cases and around quarter deaths due to malaria in India. The other severely affected states were Meghalaya, Mizoram, Maharashtra, Rajasthan, Gujarat, Karnataka, Goa, southern Madhya Pradesh, Chhattisgarh, and Jharkhand (NVBDCP, 2015). A study done by the Kumar et al., 2007 reported that the P. falciparum accounts for 30 to 90% of the infections in the forested areas inhabited by ethnic tribes and <10% of such malaria cases in indo-gangetic plains and northern hilly states, northwestern India, and southern Tamil Nadu. However, malaria is co-endemic for both Plasmodium falciparum and P. vivax malaria in North Eastern States causing high fatality. The country is unable to achieve good progress like Sri Lanka, Maldives etc as 80% malaria cases exist in just 20% of the population living in tribal, hilly, difficult and inaccessible areas (World malaria Report, 2017). Many researchers found complexity in handling malaria epidemic because of high concentration in tribal population, difficult terrain, high density forest and suitable climatic conditions for its growth and transmission (Dev, Bhattacharyya & Talukdar, 2003). The NVBDCP, 2015 also states that the malaria transmission is complex due to multi-species coexistence and variable species dominance and bionomical characteristics. Many scientists also found that the proportion of P. falciparum and P. vivax, had large variations greatly, inter alia, from one ecotype to another due to climatic conditions and malaria control activities implemented by the states (Joshi et al., 2008). In spite of hectic vector control activities by the Government of India with support from GFATM, WHO etc., malarial deaths and endemicity are continuously decreasing but malaria still remains major public health concern in India especially in NE States including Assam. For malaria prevention, government of India is also supporting for the low cost, wash-resistant and ready to use factory treated mosquito net (popularly known as LLIN) in the high endemic marginalized population groups living in remote inaccessible/forest areas which is more acceptable over indoor residual sprays (Guillet P et al, 2001). The LLIN is also advocated by WHO as sustainable key intervention for universal coverage against malaria in the programme (MOHFW, ). The National Vector Borne Disease Control Programme as on date is facing many challenges including some from supply side and some from demand side viz., (i) multiple insecticide resistance, (ii) emerging multi drug resistance and steadily rising proportions of P. falciparum to nearly 50% of reported cases, (iii) short supply of anti-malarial drugs and insecticides and lack of awareness on preventive measures and seeking prompt treatment (MOHFW, ). The GFATM Round 9, covered 86 districts in the seven NE (North-East) States aiming for universal use of LLIN so as to reduce malaria morbidity and mortality by 30% by 2015 in the project districts. 2

3 Volume 2 Issue A study was conducted in the high prevalence areas in the state of Mizoram to assess (i) awareness among community about malaria prevention (ii) effective coverage of Indoor Residual Spray (IRS) (iii) utilization of ITNs/LLINs at community level by assessing (iv) household ownership of mosquito bed nets (v) use of bed nets among households, particularly by pregnant women and children under five. Sample Size Material and Methods Assuming 50 percent use of LLINs by the population (Households) at any point of time (in peak season) and allowable error of 5%, the sample size at 5% level of confidence is calculated as 384 (rounded off to 400). Assuming a design effect of 2 to cover heterogeneity in the population, the sample size doubles up to 800 Households. Next, adjusting for non-response of 10%, the final sample in the study was 880 Households (HHs). An equal number of sample fever cases in last two weeks were considered for the detailed investigations. Hence, the total sample size was 1760 HHs (880 HHs and 880 old fever cases) for the State. Sampling Design and Sampling Technique A two stage sampling technique for selection of blocks and villages within the selected state was followed in order to give a reasonable spread of the sample across the population and make it representative. At the first stage, 10 endemic Blocks (Sub-districts) were selected from the list using the PPS sampling technique. In each of the selected Block, all the Sub-centres with API >2 in the last three years ( ) were listed alphabetically. Then all the villages under those Sub-centres were listed along with their population and 8 villages were selected by PPS method, giving a total of 8 villages per Block. In the selected village, all the houses in the village (minimum 100 households) were listed using a pre-tested survey form and all same day fever cases were noted, for details to be taken on the next day. The same day fever cases were tested by the local health workers using RDT Kit and medicines were also provided as per the programme guidelines. A sample of 11 old fever cases during last 14 day was selected by systematic random sampling from the list of old fever cases prepared during house listing. Thus, for old fever cases during 14 days, total number of fever cases interviewed were 11 fever cases per village x 80 villages= 880 fever cases. For detailed study of utilization of LLIN bed nets/ Ordinary Bed Nets and Indoor Residual Spray, a sample of 11 households was drawn by using systematic random sampling from the list of all households in the village. Thus finally, sample of eight villages per block for total 10 blocks were studied to give a total of 80 villages for study in the State. For utilization of LLINs / Ordinary bed nets the total number of HHs interviewed were 11 HHs per village x 80 villages= 880 HHs. The primary data was collected from households in endemic districts of Mizoram during peak malaria season in the year The secondary data regarding programme activities were included from the web-site of state health department during the year and AJHM 3

4 AJHM Tools used for the Survey Volume 2 Issue The present survey utilized (i) Household listing schedule a day prior to survey (ii) Interview schedule for Head of Household / Respondent for use of LLINs and IRS (iii) Fever/chills in last 14 days of visit (iv) Fever/chills on the day of visit. Besides, programme data were also collected from the concerned officials in the State/District. Programme specific information available on the website of state health department was also downloaded and analysed. Data Collection and Analysis A survey team, consisting of 5 well trained members (1 Supervisor + 4 Field investigators), was responsible for survey in each village for 2 days. For each selected Block, there were two such teams and each team covered 4 villages in 8 days. Different sets of data were collected from the health functionaries and community members using different sets of pre-tested interview schedules. The data was analyzed using SPSS version The study was approved by the IRB of the Institute. Informed consent was obtained from all respondents. Quality Assurance The supervisor of local evaluation/survey team verified at least 10% of the completed interview schedule of 2 weeks fever cases and interview schedule for utilization of bed nets. In each block, one state level coordinator and one local/ block level coordinator were trained and made responsible for monitoring of survey in villages, quality and completeness of interview schedules. All completed schedules were rigorously checked before data entry. Study Limitations Due to the heavy rains, landslide and road blockade during data collection in the peak malaria season, team had to replace 2 inaccessible samples villages in one district in consultation with district health authority. Background Information Findings As per the details available on the website of Department of Health and Family Welfare, Government of Mizoram ( accessed on 5/1/2015), the State of Mizoram consists of 9 Districts and 925 villages with total population 10,87,160 according to Census As per the Annual report 2013 of the State Vector Borne 4

5 Volume 2 Issue Disease Control Programme (SVBDCP), there were total 82 Malaria Centers (M./C), 57 PHCs, 12 CHCs, 5 Urban Health Centers, 370 Sub-Centers and 139 Clinics providing malaria treatment. The State posted MPWs (under NVBDCP) in remote areas and involved ASHA workers in malaria surveillance and prompt treatment. The LLINs were distributed in the year 2008, 2009, 2010, 2011 and 2012, thereafter stopped due to lack of supply in the programme. It was found that during , roughly 200 people out of every 1000 population were tested for malaria parasite under the State Vector Borne Diseases Programme and approximately 10 in 1000 population were found positive. In the year 2009, the total deaths reported from malaria were 119 which further reduced to 31 in 2010, 30 in 2011, 25 in 2012 and 21 in 2013 i.e. almost 84% reduction in deaths due to malaria in 5 years duration. Data revealed that Monthly Blood Examination Rate (MERB) decreased over years from 33.74% in 2010, 17.41% in 2011, 14.29% in 2012 and 20.9% in Probably due to decreased risk of death, less community was coming forward for voluntary blood examination. The API varied district to district; lowest in Champhai (0.68%) and Highest (35.96%) in with the state average as 10.67%. The Pf % was lowest (74%) in District and highest (95.5%) in the Mamit District with the state average as 88%. The malaria programme data in the year 2012 revealed that in the 0-14 age group, both males and females were equally affected (53% males and 47% females). However, in the adult age group (15 years and above) higher percentage of malaria cases were among males (61%) compared to females (39%). In overall, 12.5% cases were in 0-4 age group, 21.2% were in 5-14 age group and 66.4% were in the age group 15 years and above. Only 0.3% of pregnant women were tested positive for malaria. Socio-economic and Demographic Profile of Respondents In the survey, majority of the households (45%) belonged to the age group years, were males (73%) and literate (87%). The survey population was predominantly Christians (96%) and Schedule Tribes (98%). According to economic status, Non BPL population was 55%. As per the occupational details, 54% were engaged in agriculture and 16% were in government/private job. Awareness about Malaria in Community Table 1 describes that more than 70% respondents were aware about how person gets malaria, symptoms of malaria fever, how to prevent malaria and availability of ITNs/LLINs from the government. The awareness in endemic far away districts like Logtlai and Lunglei was low compared to other Districts/Blocks. AJHM 5

6 AJHM Volume 2 Issue Table 1.Awareness on Malaria and its Prevention among the Community in the State District East Block How a person gets Malaria? How to know Malaria fever? How Malaria? to prevent Aware of availability of LLIN / ITN bed net (Phullen n=88) West Aibawk (n=95) Kolasib (n=11) Kolasib Mamit Champhai Saihya Bikhawthir (n=57) Thingdowl (n=11) Zamuang (n=89) Ngopa (n=202) (n=176) Tuipang Total (n=905) Categories SC (n=7) ST (n=886) Awareness on Malaria OBC (n=5) OTHERS (n=7) LLIN (n=718) Non LLIN (n= 187) BPL (n=382) Non BPL (n=523) Describe how a person gets Malaria How malaria you know fever is due to What should be done to prevent malaria Were you aware of availability of LLIN / ITN bed net Total (n=905)

7 Volume 2 Issue The awareness about availability of ITNs/LLINs was also low (57%) in SC community. Awareness on various issues was low in BPL population and also in LLIN villages. Availability and Utilization of Different Types of Bed Nets in the Community Under the IMCP, government distributed Bed Nets; initially ITNs and later LLINs three to four years ago among BPL Households. It was found that even to BPL population, ITNs/LLINs were not available in sufficient quantity i.e. 1 bed net for 2 persons. Table 2. Availability and Usable Utilization of Bed Nets among Households in the State AJHM District Block Total plain bed nets Plain bed nest in usable condition (%) Total ITN Bed nets treated in last 6 months Total ITN bed nets treated in last 6 months and in usable condition (%) Total LLIN bed nets Total LLIN bed nets in usable condition (%) East West Aibawk Bikhawthir Ngopa Kolasib Mamit Champhai Saihya Phullen Kolasib Thingdowl Zamuang Tuipang Total Table 2 describes that about 93% LLIN, 81 % ITNs and 87% of ordinary bed nets were in the usable condition. The East and Longtlai districts were having less percentage of any type of usable bed nets. Use of Bed Nets among Vulnerable Groups Table 3 indicates that though quite high percentage (78%) children slept under plain bed net but less than half (47%) slept under ITN/LLIN, 24% under LLIN and 22% under the ITN bed nets. However, more than half (55%) of children were reported usually sleeping in any type of bed net (ITN/LLIN/ordinary). 7

8 AJHM Volume 2 Issue Table 3. Use of Bed Nets among Children, Pregnant Women and other Female and Male Community Members in the State District East Block Phullen (N = 88) Total under 5 Children (N = 587) Total number of pregnant women (N = 69) West Aibawk (N = 95) Kolasib (N = 11) Kolasib Mamit Champhai Bikhawthir (N = 57) Thingdowl (N = 11) Zamuang (N = 89) Ngopa (N = 88) Under 5 Children (N = 587) Saihya Total Households (N (N = 202) (N = 176) Tuipang (N = 88) Under 5 children slept under plain bed nets (%) Under 5 slept under ITN bed nets which treated in last 6 months (%) Under 5 children slept under LLIN bed nets (%) Under 5 slept under ITN/LLIN bed nets (%) Under 5 usually sleeps under ITN/LLN/Ordinary bed nets (%) Pregnant Women (No.) Pregnant women slept under plain bed nets (%) Pregnant women slept under ITN bed nets which treated in last 6 months (%) Pregnant women slept under LLIN bed nets (%) Pregnant women slept under ITN/LLIN bed nets (%) Pregnant women usually sleeps under ITN/LLN/Ordinary bed nets (%) = 905) 8

9 Volume 2 Issue AJHM Total other Females (n= 1828) Other than Pregnant Women (No.) Other females who slept under plain bed nets (%) Other females who slept under ITN bed nets (No) Other females who slept under the LLIN bed nets (%) Other females who slept under ITN/LLIN/Ordinary bed nets (No) Total other males (n=1904) Other males (No.) Respondent s Use of Bed Net during last night Other males who slept under plain bed nets (%) Other males who slept under ITN bed nets (%) Other males who slept under the LLIN bed nets (%) Other males who slept under ITN/LLIN/ordinary bed nets (%) Respondent s slept under the Bed nets (%)

10 AJHM Volume 2 Issue It was found that high percentage (94%) of pregnant women slept last night under any ordinary bed net but less percentage under ITN bed net (26%) and under LLIN bed net (20%). Nearly 76% respondents confirmed use of any type of bed nets in the last night with minimum 35% in Sahiya district and 100% in Kolasib district which is high endemic. It is also evident less non-vulnerable population (about almost half of other than pregnant women and males above 5 years) was usually slept in any type of bed net. Use of Bed Nets among Community by Cast, Village Type and BPL Status It was found that on an average 88% plain bed nets were in usable condition which was lower in other than ST community, BPL population and Non LLIN villages (Table 4). Table 4. Use of Bed Nets among Community by Cast, Village Type and BPL Status in the State USE OF BED NETS SC ST OBC Others LLIN Villages Non- LLIN Villages Total plain bed nets Total ITNs treated in last 6 months % Plain Bed Nest in usable condition BPL Non- BPL Total % ITN treated Bed nets in usable conditions Total LLINs available Total LLIN/ITN/Plain Bed nets Total under 5 Children (N=587) % LLIN Bed Nets in usable condition % Total LLIN/ITN/Plain Bed Nets in usable condition % Total under 5 children slept under LLIN/ITN/Plain bed nets Total Pregnant Women(N=69) % Total pregnant women usually sleep under ITN/LLIN/Ordinary bed nets Total other Females (N=1828) % Total other females slept under ITN/LLIN/Ordinary bed nets Total other Males (N=1904) Avg Population per Bed Net % Total other males slept under ITN/LLIN/Ordinary bed nets Average number of Population per Bed nets in the Blocks Almost 94% LLIN bed nets were in usable condition but less percentage of ITN bed nets (83%) were in usable condition. 74% children and 84% pregnant women usually sleep in any type of bed 10

11 Volume 2 Issue net. The higher percentage of children and pregnant women usually slept in any type of bed nets in Non-LLIN and Non-BPL category. However, even higher percentage (95%) of pregnant women in BPL category usually slept under any type of bed net. However, this percentage in respect of other than pregnant women and males>5 years was relatively far less (33%). Further, availability of bed nets was also analysed and it was found that on an average one bed net was available per 12 persons in the State and it was one bed net per 11 persons in LLIN villages and one bed net per 17 persons in Non-LLIN villages against norm of 1 bed net per 2.5 persons. Findings indicate that 78% children slept under plain bed net but less than half (47%) slept under ITN/LLIN, 24% under LLIN and 22% under the ITN bed nets. Even in the situation of nonsupply of LLIN in recent years, high percentage (94%) of pregnant women slept last night under any ordinary bed net but less percentage slept under ITN bed net (26%) and under LLIN bed net (20%). However, 84% of pregnant women usually sleep under any type of bed net (Ordinary/ LLIN/ITN). Washing Practices of LLIN/ITN Bed Nets in Households To assess effectiveness of ITN bed nets households were asked about washing of LLINs/ITNs and findings are presented in Table 5. Frequency of washing East Phullen Table 5. Frequency of washing Bed Nets in Households West Aibawk (n=95) Kolasib (n=11) Bikhawthir (n=57) Thingdowl (n=11) Zamuang (n=89) Ngopa (n=202) Kolasib Mamit Champhai (n=176) Saihya Tuipang Weekly AJHM Total (n=905) Monthly Once in 3 months Do not wash at all No Response It is found that majority of households (35%) did not wash but 19% washed quarterly,13% washed monthly and meagre 5% washed weekly. Almost one third (29%) did not respond. Findings reveal that households may not be educated by health workers about proper upkeep, usage and washing requirements of ITNs/LLINs distributed under the programme. Therefore, along with the distributions of ITNs/LLINs, beneficiaries may also be educated about effective usage and right washing practices. Difficulties in use of Bed Nets in Community In the study, difficulties faced by community members in use of LLINs/ITNs were asked and findings are presented in the Table 6. 11

12 AJHM Volume 2 Issue Table 6. Difficulties in using LLIN/ITN Bed Nets among Households District/Blocks East Blocks (Phullen n=88) Cannot Financially afford to buy Govt. issued less bed nets than the number of family members No replacement of the bed net by government workers No regular treatment of bed nets by government workers Working at night/ outside/ family in fields etc Sleeping outside house/room West Aibawk (n=95) Kolasib (n=11) Kolasib Mamit Champhai Saihya Total (n=905) Bikhawthir (n=57) Thingdowl (n=11) Zamuang (n=89) Ngopa Difficulties faced by Community in using LLINs/ITNs (n=202) (n=176) Tuipang Others

13 Volume 2 Issue It was found that almost one third gave financial reason as difficulty and it was more in Kolasib and West districts. Almost 50% replied reasons related to programme viz., less supply, no replacement and no regular treatment of ITN bed nets. Unfortunately such responses came from districts like Kolasib and which are having higher cases of malaria in the State. Suggestions to improve use of Bed Nets In view of low utilization of bed-nets, community was enquired about their suggestions for improving use of bed nets which are presented in Table 7. District East Block (Phullen n=88) Provide more bed nets More frequent replacement of the bed net Ensure regular treatment ITNs Table 7. Suggestions for improving use of LLIN/ ITN by Households West Aibawk (n=95) Kolasib (n=11) Bikhawthir (n=57) Thingdowl (n=11) Zamuang (n=89) Ngopa (n=202) Kolasib Mamit Champhai (n=176) Saihya Tuipang AJHM Total (n=905) It is found that more than 70% households suggested to provide more bed nets, frequent replacement of bed nets and to ensure regular treatment of ITN bed nets by the Government workers but interestingly higher percentage of community gave such suggestion from districts like West and Kolasib which are relatively better developed and not far away from State HQs. These clearly indicate need to improve availability of Bed Nets in the community but priority must be given to endemic districts. 13

14 AJHM Indoor Residual Spray (IRS) under the Programme Volume 2 Issue Under the programme at least two rounds of indoor residual spray were being done in the State as per the programme guidelines. About 90% of households confirmed IRS in their houses and it was found that higher percentage of households confirmed IRS in most affected districts like Kolasib, Sahiya, Lunglei West etc. Table 8 describes that almost 87% households confirmed spray during April to July which is also peak season for malaria. Almost 75% respondents informed 2 rounds of spray and about 20% informed three rounds of spray in their houses. Majority of respondents (75%) informed that spray was done by the government staff but almost one fifth (18%) informed it by others like Private agency/ngos etc. Quite high percentage (83%) replied that they were informed before IRS. Indoor Residual Spray (IRS) by Cast & other groups Attempts were made to assess the coverage of insecticide spray which is defined as percentage of rooms in the household (excluding kitchen, cattle sheds, and store room) which were sprayed last time during spraying session. Similarly, the effective coverage is defined as the total number of rooms in the household (excluding kitchen, cattle sheds, and storeroom) which were sprayed last time during spraying session and where after spray walls were not painted or plastered. The IRS coverage and effective coverage was assessed and findings are given in table 3.9. The overall coverage was very high (90%) but effective coverage (i.e. wall not painted/ plastered) was significantly low (65%). The coverage was lowest (79%) in Longtlai district which is far away from the state HQs and is one of the endemic districts. In view of the location and other differences due to social groups, economic status analysis is made considering all these aspects and presented in Table 8. It is also found that coverage is less among SC, OBC and other households compared to ST population. The effective coverage in SC and other households were far below than ST households i.e. less than one third which is a matter of concern. About 83% were informed before IRS in their houses but less SC people (43%) were informed before spraying. 14

15 Volume 2 Issue AJHM Table 8 - Percentage Distribution of Spray Activities by Health Staffs in the State District East Block Phullen House visited by health stafffor spraying House sprayed with insecticide West Aibawk (n=95) Kolasib (n=11) Kolasib Mamit Champhai Saihya Total (n=905) Bikhawthir (n=57) Thingdowl (n=11) Zamuang (n=89) Ngopa (n=202) (n=176) Tuipang How many Months ago Houses were Sprayed (Ref period July 2014)? 0-1 months months & above How Many Times Sprayed in last 12 Months One Two Three & above Who Sprayed the House? Govt. Worker Pvt. Agency NGO Others Couldn t specified Were You Informed before Spraying? Yes

16 AJHM Volume 2 Issue Almost 75% respondents informed 2 rounds of spray and about 20% informed three rounds of spray in their houses. Majority of respondents (75%) informed that spray was done by the government staff but almost one fifth (18%) informed it by others like Private agency/ngos etc. Quite high percentage (83%) replied that they were informed before IRS. Under the programme at least two times insecticide spray is done in the community. Attempts were made to assess the coverage of insecticide spray which is defined as percentage of rooms in the household (excluding kitchen, cattle sheds, and store room) which were sprayed last time during spraying session. Similarly, the effective coverage is defined as the total number of rooms in the household (excluding kitchen, cattle sheds, and storeroom) which were sprayed last time during spraying session and where after spray walls were not painted or plastered. Table 9 - Coverage of Indoor Residual Spraying (IRS) in the State District Block Coverage of Indoor Residual Spraying (IRS) Effective coverage (IRS) East Phullen (N =167) West Aibawk (N =173) Kolasib (N =26) Bikhawthir (N =98) Thingdowl (N =22) Zamuang (N =187) Ngopa (n=224) (N =416) Kolasib Mamit Champhai (N =319) Saihya Tuipang (N =220) Total number of rooms (N =1852) SC (n=10) Coverage of Indoor Residual Spray (IRS) by Cast & other groups(n=1852) ST (n=1820) OBC (n=12) Others (n=10) LLIN (N=1448) Non LLIN (N=404) BPL (N=723) Non BPL (N=1129) Total (N=1852) Effective Coverage (IRS) (N=1852) Were you informed before spraying? The IRS coverage and effective coverage was assessed and findings are given in Table 9. The overall coverage was very high (90%) but effective coverage (i.e. wall not painted/plastered) was significantly low (65%). The coverage was lowest (79%) in Longtlai district which is far away from the state HQs and is also one of the endemic districts. Discussion The State of Mizoram is bound by Assam in the north, Manipur to the north-east, Bangladesh to the south-west and Myanmar to the east and south. The state topography poses many challenges in implementation of SVBDCP. Areas bordering with Bangladesh had high API and high malarial deaths due to geo-climatic conditions. The programme data (SVBDCP, 2016) is used with findings from community leaders and community surveys to bring out issues and challenges in the programme. Under the State Vector Borne Disease Control Programme (SVBDCP), 16

17 Volume 2 Issue AJHM awareness about preventive measures and compulsory blood test and to start treatment for malaria within 24 hours was key strategies (SVBDCP, ). Raising awareness is the key to success of all programme. In the East District, a total of 38 awareness campaign, 38 infotainment activities, and 139 Miking and 58 hoardings were constructed during last 3 years. In one of most developed Champhai District, there was high awareness about malaria in the community. But in the PHCs/CHCs, supply of RDTs, Slides and Medicines were inadequate. Saiha is one of the farthest and backward districts in the state where inadequate human resources and lack of awareness regarding malaria in the community is major constraint. However, contribution of NGOs in raising awareness is found very useful. Mamit is one of the backward and high prevalence districts where low knowledge and awareness regarding preventive aspects of malaria is the major constraint. However, lot of initiatives have been taken by the health department to combat malaria through awareness generation, distribution of LLINs and DDT spray. The Longtlai is also a faraway district, where lots of IEC activities were done in the year It included hoardings (28), Awareness campaigns for schools (14), Miking (20), Infotainment (10), Awareness campaigns to NGOs/FBOs (10), Malaria Clinic cum Awareness Campaigns (2) and Dengu Awareness campaign to NGOs (12). These activities were continuing in future years, also. World Vision NGO is very active in the area for raising awareness about malaria prevention activities. Through community surveys, we found high awareness (70%) but in endemic far away districts like Logtlai and Lunglei awareness was low. Besides Chakma migrants are more vulnerable to disease and deaths due to social backwardness, low awareness and poverty. In the West District (Aibawk Block), it was found that number of blood samples collected decreased during 2009 to 2012 may be due to decrease in prevalence rate and decreased participation. It was 1598 during 2009, 1121 in 2010, 1084 in 2011 and 687 in However, it increased to 2635 in The number of Pf cases was 18 in 2009 but in 2010, no Pf cases were reported. However, number of Pf cases was 2 in 2011, 4 in 2012 and were 8 in Because of difficult terrain and landslide, bad road conditions specially during peak malaria season people in backward districts like Mamit faced tremendous difficulty while travelling to PHC or CHC in case of emergency treatment for malaria. In the far away Longtalai district poor communication & transportation facilities, scarcity of human resources, logistics and supply of medicines & test kits always hampered treatment during peak malaria season. Low awareness and poor literacy and communication are constraints in the programme implementation in the district. Lunglei was one of the better performing districts. However, the staff crunch was major hurdle for implementation of activities at community levels. The post of Community Health Officer (CHO), male and female health supervisors were empty in many malaria centers. IRS Operations in the State As per the details of the year available on the website of Department of Health and Family Welfare, Government of Mizoram, two rounds of IRS operations were carried out in the entire 9 districts in the State. Lowest percentage of households (53%) sprayed were in West and Saiha District and highest percentage was (81.3%) in Champhai District and the state average was 64%. Similarly, rooms completely sprayed were lowest (25.8%) in East and highest (78%) in Champhai. The state average was 43.9%. The population protected through IRS was lowest (49.3%) in East District and highest (73.4%) in Champhai District with state average as 59%. During the second round, percentage household remained same as 64%, percentage rooms completely sprayed increased from 44% to 49.9% and percentage population protected increased from 59% to 63%. This clearly shows disliking for IRS in developed districts like East and 17

18 AJHM Volume 2 Issue West (SVBDCP, n.d). It is also due to reduced API in both the districts over years. Our findings indicate that about 90% of households confirmed IRS in their houses and it was found that higher percentage of households confirmed IRS in high endemic districts like Kolasib, Sahiya, Lunglei, West etc. The information on district wise distribution of ITNs/LLINs as available from SVBDCP site is also studied. The Long lasting insecticidal net (LLIN) can be washed many times but still retain bio-efficacy against target disease vector species. In the East District approximately 4800 LLINs were distributed during last 3 years but not sufficient to cover all the people in rural areas. Champhai is one of the faraway districts in the state. In this district, LLINs helped to reduce malaria cases. LLINs were distributed during last 4 years (2009, 2010, 2011and 2012) only to BPL population and it did not cover whole population in villages. Moreover, it was informed by the community members that width of LLINs was less, so two persons cannot sleep in 1 LLIN provided. However, other than BPL card holders were also poor and they could not buy even ordinary mosquito net. There was high unmet demand of LLINs in the villages as people still stay in their agricultural field. Kolasib is one of the high prevalence districts in the state pieces LLINs, were distributed in 2009, in 2010, nil in 2011, in 2012 and nil in In Mamit District LLINs were distributed in 2011 but thereafter no further distribution took place. The LLINs are not properly used by the community as they informed that holes in LLINs are big so mosquitoes easily enter in the LLIN. In Longtlai no LLINs were distributed in the year 2013 but there is high demand in the community (SVBDCP, 2016). Our survey revealed that very high percentage (92.6%) of LLINs were in usable condition. People who did not get LLINs were also using normal bed nets. We found one fifth households (18.7%) were washing ITNs/LLINs once in three months and one third (34.9%) did not wash at all. It was found that high percentage (94%) of pregnant women slept last night under any ordinary bed net but less percentage under ITN bed net (26%) and under LLIN bed net (20%). The state of Mizoram shares vast international borders with neighbouring countries like Myanmar and Bangladesh. Studies revealed that northeast region is an established route for spread of drug-resistant P. falciparum malaria to rest of the country due to the migration (Shaw et. al, 2013). We need to learn from success of anti-malaria activities in neighbouring countries like Sri- Lanka where the malaria menace was eliminated during 1999 to Strategies like indoor residual spraying and distribution of long-lasting insecticide-treated nets have contributed to the low transmission of malaria during this period. A good entomological surveillance was established and maintained for effective action. A strong case detection system was introduced which resulted in prompt treatment and case monitoring (Rabindra et al., 2012). At present, Sri Lanka is the only country in South Asia, which has almost accomplished the elimination of indigenous P. falciparum malaria by year 2012, elimination of indigenous P. vivax malaria by 2014, maintenance of a zero mortality of malaria cases and prevention of re-introduction of malaria into the country (Sri Lanka MOH, ). Conclusions and Recommendations From the year 2009 to 2013, almost 84% reduction in deaths due to malaria is recorded. Because of resistance by the community due to the harmful effect of pesticides, LLINs should be provided in sufficient numbers for personal protection among outreach marginalized population groups living in 5 (out of 9) remote, inaccessible and malaria endemic districts (API>2) viz., Mamit, Kolasib, Lunglei, and Saiha District reporting most cases and deaths. Government 18

19 Volume 2 Issue may provide subsidized LLINs to Non BPL population in NE states to ensure universal access to population. Along with up-scaling LLIN supply through NGOs and other innovative approaches like social marketing etc, timely and appropriate drug supply also need to be ensured right from ASHA workers to Sub-centers, PHCs, CHCs and District Hospitals to combat the malaria illness. A well-focused action plan prioritizing preventive, and universal access to malaria treatment and prevention in the high malaria endemic districts is needed. Besides pre-monsoon stocking of anti-malaria drugs and IEC material in remote and inaccessible districts, improved surveillance, strengthening and retaining trained human resources are pre-requisite to meet the GOI Strategy of eliminating Malaria by References Dev, V., Bhattacharyya, PC., Talukdar, R.(2003). Transmission of malaria and its control in the Northeastern Region of India. Journal of the Association of Physicians of India, 51, Guillet, P., Alnwick, D., Cham, MK., & Neira, M.et al.,(2001). Long-lasting treated mosquito nets: A Breakthrough in Malaria Prevention. Bull. World Health Organisation, 79(10), 998. GFATM Round 9, India Country Proposal Intensified Malaria Control Project-II, to Global Fund to Fight AIDS, Tuberculosis and Malaria (2009). Retrieved from Round-9-proposed.pdf. Joshi, H., Prajapati, SK., Verma, A., Kang, S., Carlton, JM. (2008). Plasmodium vivax in India. Trends Parasitol, 24, Kumar, A., Valecha, N., Jain, T., Dash, A P. (2007). Burden of Malaria in India: Retrospective and Prospective View. American Journal of Tropical Medicine and Hygiene,77(6_Suppl), National Vector Borne Disease Control Programme, Malaria Situation in India (2015). Government of India, Ministry of Health & Family Welfare. National Vector Borne Disease Control Programme, Malaria Situation in India (2017). Government of India, Ministry of Health & Family Welfare. Rabindra, RA., Gawrie N. L.G., Cara, SG., James GK., Richard, GAF (2012). Malaria Control and Elimination in Sri Lanka: Documenting Progress and Success Factors in a Conflict Setting. PLOSOne 2012, 7(8): e doi: /journal.pone Shah, NK., Dhillon, GPS., Dash, AP., Arora, U., Meshnick, SR., Valecha, N. (2011). Antimalarial drug resistance of Plasmodium falciparum in India: Changes over time and space. The Lancet Infectious Diseases, 2011, 11, Sri Lanka Ministry of Health Anti-Malaria Campaign. Strategic Plan for Phased Elimination of Malaria State Vector Borne Disease Control Programme and NHM, Mizoram. Retrieved from nhmmizoram. org (accessed on 25 June 2017) Strategies Plan for Malaria Control in India, (2012). A Five year Strategic Plan, Directorate of National Vector Borne Disease Control Programme, Directorate General of Health Services. Ministry of Health & Family Welfare, Government of India. Retrieved from /Doc/Strategies- Action-Plan-Malaria %20 pdf. World Malaria Report (2017). Geneva: World Health Organization. AJHM 19

20 AJHM Volume 2 Issue Authors Profile V K Tiwari holds a Ph.D in Statistics from University of Allahabad, Allahabad, India. He did Certificate Course in Health Policy, Planning and Health Economics from Nuffield Institute of Health, University of Leeds, UK. He is also honored with the Fellow of the Royal Statistical Society, UK. He has received six international fellowships/awards, important ones are by East-West Centre, U.S.A; UNFPA; PPD; WHO (SEARO); GTZ, Japanese Foundation of AIDS Prevention and Research, Endeavour Executive Award from Government of Australia etc. He is currently working as Professor & Head, Department of Planning and Evaluation at the National Institute of Health and Family Welfare, New Delhi. He has 25 years of experience in the public health in India and abroad. He has 75 research papers, published in national and international journals in the field of Demography, Public Health, HMIS etc and authored 7 modules for distance learning programmes. Sherin Raj T P has done his Post Graduation and M.Phil in Demography from University of Kerala, Kerala, India and done his Ph.D from King George Medical Universtiy (KGMU), Lucknow, India. He has an experience of more than 15 years in research, teaching and training. He has more than 50 publications in his account in various National and international journals in the field of Demography, Public Health, HMIS etc. He also has presented more than 20 papers in various conferences and attended several workshops. He is working as Assistant Research Officer in National Institute of Health and Family Welfare, New Delhi, India. Ramesh Gandotra has done his Post Graduation and M.Phil in Management Science and done his Ph.D from Indira Gandhi National Open University (IGNOU), New Delhi, India. He has an experience of more than 22 years in research, teaching and training. He has more than 15 publications in his account in various national and international journals. He also attended several workshops and conferences. He is working as Assistant Research Officer in National Institute of Health and Family Welfare, New Delhi, India. P D Kulkarni has done his Post Graduation in Statistics from Aurangabad University, and worked as computer programmer at NIHFW. He has done his Ph.D from King George Medical University (KGMU), Lucknow, India. He has more than 10 publications in his account in various national and international journals. He also attended several workshops and conferences. 20