Malaria and malnutrition together jeopardizes India’s tribal community and disease elimination

ABSTRACT

Malaria and malnutrition are major public health problems in India, especially in the rural and tribal communities, and also remain primary causes of morbidity and mortality among children younger than five years. Both diseases are synergistic with each other. It is essential to have a better understanding of the intricate relationships between malnutrition and malaria to target interventions in areas where both diseases coexist. This article highlights the synergistic relationship between malnutrition and malaria, and how malnutrition and malaria play a significant role in disease severity and eventually hinder the elimination of these diseases by 2030. The government and several private sectors have made a substantial dent through various programmes and schemes. However, supplementing nutrition-sensitive measures, including easy accessibility to a healthy balanced diet, safe drinking water and improved sanitation, is necessary. Therefore, if India really aims to achieve its dream of disease elimination (malaria and all forms of malnutrition) by 2030, it is imperative that tribal regions are given more attention and all possible strategies are applied in the country's remotest corners.

Malaria and malnutrition co-exist with synergism. The majority of malaria cases are found among the Indian rural tribal population, where malnutrition poses a serious threat [1]. These diseases are associated since malnutrition peaks during the rainy season when malaria cases spurt [2]. 8.6% of India’s total population belong to a tribal community, yet contribute 21% of Plasmodium falciparum infections and 29% of malaria-related deaths [3]. About 44% of tribal children are stunted, 45% are underweight, and 27% are wasted [4]. Seven indigenous tribal-dominated Indian states Odisha, Jharkhand, Madhya Pradesh, Chhattisgarh, Gujarat, West Bengal, and Uttar Pradesh represent 43 · 32% of the total population and contribute 90% of total malaria cases in the country [1].

About one-third of India’s children are malnourished, which is almost double that of Sub-Saharan Africa. According to UNICEF, daily nutrient consumption in tribal populations is below the recommended daily level, and has fallen over time, indicating rising food insecurity [2]. Tribal communities are typically destitute and malnourished, with inadequate water quality, sanitation, and hygiene (WASH). The concurrence and synergistic relationship of malnutrition, malaria, and poor WASH conditions in these areas create a vicious cycle [1] where infection caused by inadequate WASH conditions results in morphological changes in the villous (villous blunting, villous atrophy), malabsorption, mucosal inflammation, and changes in the gut microbiomes [2].

In 2020, children represented 77% of all malaria deaths (482,700) worldwide [1]. Nutritional factors were responsible for the deaths of 45% of children (under 5 years) globally [2]. The latest global data shows that 7.7% of children are severely wasted, 19.3% are wasted, and 35.5% are stunted [5]. Children with severe acute malnutrition are at an increased risk of infection, affecting the overall development of their immune systems [4].

Tropical splenomegaly is an indicator of malnourishment, especially in children. Besides children under 5 years, pregnant women are also affected by malaria and malnutrition. Undernutrition in pregnant women may exacerbate their already increased susceptibility to malarial infection, resulting in significant morbidity and mortality due to nutritional deficiency and anemia, which may impair the development of protective immunity to malaria in fetuses and results in adverse birth outcomes. Moreover, pregnant women are advised not to take artesunate plus sulfadoxine/pyrimethamine (AS-SP) and folic acid at the same time, because folic acid can antagonize the antimalarial activity of SP.

In addition, there are direct risks to the increased transmission of malaria via the reduced absorption of lipids and fats has the potential to specifically affect the lipid-soluble artemisinin-based combination therapies (ACTs) which might lead to the selection of resistant parasites over time, and indicate that treatment failure was highest among malnourished children aged 1–3 years [1]. There is a need to understand the pharmacodynamics and pharmacokinetics of ACTs in malnourished children [2]. Meanwhile, despite having severe malnutrition, children do not show typical symptoms of malaria (fever) even with repeated malaria episodes. This may trigger malaria transmission in the community as reservoirs [4].

Durgama Anchalare Malaria Nirakarana (DAMaN) in Odisha and Mandla-Malaria Elimination Demonstration Project (M-MEDP) are two ongoing malaria control projects to demonstrate the feasibility of malaria elimination in India. Both programmes are using the intensive test, treat and track strategy, and vector control measures for the distribution of long-lasting insecticidal nets (LLINs), indoor residual spraying (IRS) along with community engagement. DAMaN has integrated nutritional components to its programme, M-MEDP has not.

The United Nations Sustainable Development Goals (SDGs) and the Government of India have set the target for elimination of malaria and malnutrition by 2030. Many poverty alleviation and nutrition-sensitive flagship schemes have been initiated. Two very important schemes `Mid-day meal’ and `POSHAN Abhiyaan’ are aimed at improving nutritional outcomes among pregnant women, lactating mothers, and children by reducing the levels of wasting, stunting, underweight, micronutrient deficiencies, anemia and low birth weight by 2022. However, Integrated Child Development Services, the programme that encompasses these schemes, has not made a significant dent in child malnutrition. This is mostly because the programme has placed emphasis on food supplementation, targeting children after the age of three when malnutrition has already set in.

India’s large sanitation development drives under the Swachh Bharat Mission, Open Defecation Free, and National Rural Drinking Water Programme is projected to initiate a reduction in malnutrition due to WASH. Furthermore, employment guarantee acts like ‘MNGREGA’ (Mahatma Gandhi National Rural Employee Guarantee Act 2005) and ‘Ayushman Bharat’ (health insurance up to INR half-million (~US$6550.00) to families living below the poverty line) should be properly implemented for bringing socioeconomic as well as infrastructure development to rural and tribal India [4].

After decades of policy and programmatic efforts to address the persistent problem of malnutrition, the World Health Organization promotes nutrition policies and develops evidence-based essential nutrition interventions. A healthcare facility needs a holistic and comprehensive approach, and a preventive root to deal with severe acute malnutrition. On the other hand, malaria in tribal areas is a multifactorial problem and demands complex multisectoral interventions. It is the result of a range of socio-economic-political-cultural and environmental factors. Many potential NGOs (e.g. Swasthya Swaraj Society in Kalahandi, Odisha) are working 24/7 in some tribal dominated areas. All like-minded partners need to work in tandem, not in silos, if India really aims to achieve malaria and all forms of malnutrition elimination by 2030.

India’s tribal struggle today is not for their lands and forests ― their most important mortal danger today is malnutrition and infectious diseases like malaria. The first citizen (indigenous tribes) of India asked the question, ‘When will their lives be counted’ [6]?

Funding Statement

The author(s) reported there is no funding associated with the work featured in this article.

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