1 Tribal Health Bulletin : Vol 10 (1&2) Jan & July 2004 · 2015. 8. 20. · acute phase response to...

Tribal Health Bulletin : Vol 10 (1&2) Jan & July 20041


Cover pages :Front - A painting of Primitive Birhor

women in their traditional rope making activity.

Back -“Bison-horn Maria” -a sculpture of Abujhmaria man in his traditional dancing crown.

Painting and Sculpture : R.C.Mishra

Editorial Board

Dr. V.G.Rao Deputy DirectorDr. R.B.Gupta Assistant DirectorDr. K.B.Saha Senior Research OfficerDr. A.R. Anvikar Senior Research OfficerDr. D. Das Senior Research Officer

Regional Medical Research Centre for Tribals, Jabalpur

A Biannual Publication on Tribal Health ( Published Simultaneously in English & Hindi)

Editor -in-Chief : Dr. A.P. DashEditor : Dr. Neeru SinghAssistant Editor : Dr. J. RoyCover designing : Dr. R.C.Mishra

Vol. 10 Nos.1& 2 Jan. & July 2004

ELIMINATION OF LYMPHATIC FILARIASIS : ADOPTION OF APPROPRIATE STRATEGY.

D. Das and A. P. Dash

38

FOODS AND BEVERAGES CONSUMEDBY ABUJHMARIAS - A PRIMITIVE TRIBEOF BASTAR IN CHHATTISGARH

Rekha Singh and Aruna Palta

30

CONCERN FOR POST- NATAL CARE SERVICES-USUALLY A LESSER VALUED SERVICE IN RURAL AREAS

Kalyan B. Saha and Uma Chatterjee Saha

23

GEOMATICS AND ECOEPIDEMIOLOGY

R. Jaishanker and C. P. Johnson

11

INFECTIOUS DISEASE IMPLICATIONS OF SUBCLINICAL ZINC DEFICIENCY INCHILDREN

Davidson Hamer

1

Published by the Editor, Tribal Health Bulletin,Regional Medical Research Centre for Tribals (ICMR), Nagpur Road, P.O. Garha,Jabalpur-482 003 (M.P.), India.Ph. : +91-761-2370800, 2370818Email : [email protected]


INTRODUCTION

Zinc is an essential trace element,required for the normal growth anddevelopment of children. Depending onthe extent of the deficit, deficiency of zincmay have many adverse consequencesincluding growth retardation,hypogonadism, and impaired cellmediated immunity. 1 Mild zincdeficiency, though often asymptomatic,may be characterized by impairedimmune function, memory impairment,decreased spermatogenesis in men,and impaired taste and smell.2 , 3 Incontrast, severe zinc deficiency ismanifested by severely depressedimmune function, growth impairment,

INFECTIOUS DISEASE IMPLICATIONS OFSUBCLINICAL ZINC DEFICIENCY IN CHILDREN

Davidson Hamer 1, 2, 3

Abstract. Zinc deficiency is highly prevalent in many developing countries,including India. Inadequate dietary intake, especially if the diet is rich in phytateswhich impair zinc absorption, and increased metabolic losses in the setting ofinfection predispose children to subclinical zinc deficiency. Compromised immunefunction, increased rates of serious infectious diseases, and impaired growthare potential consequences of zinc deficiency.

The efficacy of zinc supplementation has been clearly demonstrated for improvinggrowth and reducing the risk of developing diarrhoeal disease, pneumonia, and,possibly malaria in young children. In addition, zinc supplementation reducesthe duration of acute or persistent diarrhoea. Limited recent evidence alsosuggests that zinc may be a useful adjunct to the treatment of pneumonia inyoung children. In contrast, zinc is not effective in the treatment of malaria.Given the efficacy of zinc for the prevention of serious infections and improvinggrowth in young children, there is a need for broader programmaticimplementation of this simple, inexpensive intervention.

recurrent infections, alopecia, dermatitis,diarrhoea, and lethargy. These findingsare most commonly encountered inacrodermatitis enteropathica, a geneticdisorder of zinc absorption, which isassociated with severe zinc deficiency,immunological defects and increasedsusceptibility to infection.4 In thiscondition, oral zinc supplementsnormalize immune function anddramatically reduce infectious diseasemorbidity and mortality. Zincsupplementation has also producedsignificant increases in weight andheight in children, especially in thosewho were malnourished at baseline.5

1Center for International Health and Development, Boston University School of Public Health, 2Departmentof Medicine, Boston University School of Medicine, 5th floor, 85 East Concord St.Boston, MA 02118,3Tufts University Friedman School of Nutrition Science and Policy, E-mail : [email protected]


DIETARY ZINC DEFICIENCY

Dietary zinc deficiency is highly prevalentworld-wide with an estimated two billionpeople affected.6 Depressed immunityresulting from subclinical zinc deficiencyincreases the susceptibility of children todiarrhoeal disease, acute respiratoryinfection (ARI), and malaria. In fact, zincdeficiency is estimated to be responsiblefor approximately 18% of malaria, 16%of acute lower respiratory tractinfections (ALRI), and 10% of diarrhoealdisease while contributing to nearly amillion deaths world-wide each year.7 Asubstantial proportion of the morbidityand mortality associated with zincdeficiency occurs in the South East AsianRegion, especially South Asia.

Although many staple foods in resource-poor countries contain adequateamounts of zinc, compromised zincstatus is nevertheless common.8 Zincdeficiency usually results from theinadequate dietary intake of zinc, but canalso develop in populations consuminghigh phytate diets. Inositolhexaphosphates and pentaphosphates(phytates) bind zinc and form poorlysoluble complexes that lead to reducedzinc absorption.9 Plant products,especially legumes and grains, havehigh concentrations of phytates.Increasing amounts of protein in the diet,especially animal protein, help tocounteract the inhibitory effect ofphytates on zinc absorption.10 As aconsequence of the high phytate contentof the staples of the Indian diet: rice,wheat, and lentils, a substantial proportion

of the population is at risk for zincdeficiency.

In addition to factors that decrease thebioavailability of zinc, inadequate intakeof zinc due to undernutrition putschildren and adults at risk for zincdeficiency. Further aggravating thesituation is the risk of greater faecal andurinary excretion of zinc in the setting ofinfections, especially diarrhoea. Givenwidespread evidence of the prevalenceof nutritional disorders in children andadolescents in peri-urban and tribalareas of Madhya Pradesh11,12 and thewidespread prevalence of diarrhoea,subclinical zinc deficiency is likely to bevery common.

DIAGNOSIS OF SUBCLINICAL ZINCDEFICIENCY

Accurate assessment of zinc status isdifficult and ideally should involve theuse of multiple measures.13 However,many of the more sophisticatedmeasures of zinc status, such asplatelet, lymphocyte, or tissue zinc, arenot practical for large, field studies indeveloping countries. In addition, thesemeasures have not been validated asmarkers of zinc status. While plasmazinc concentrations are commonly usedas a surrogate marker of zinc status inmany clinical trials, plasma zincrepresents <0.2% of total body zincstores and there is a poor correlationbetween plasma zinc concentrationsand total body stores.14 Similar to thesituation with vitamin A, plasma zincconcentrations decline as part of theacute phase response to infections. This


has been clearly demonstrated inexperimentally induced infections in bothanimals and humans, with more severeinfections leading to a more significantdecrease in zinc concentrations.15

Three community-based studies in pre-school and school-aged children inGuatemala, Peru, and Zimbabwe foundthat plasma zinc concentration was notsignificantly affected by commonintercurrent infections such as diarrhoeaand respiratory tract infection.16 Incontrast, a cross-sectional study ofschool-age children in Papua NewGuinea demonstrated an inverseassociation between zinc status and P.falciparum malaria.17 In a recent multi-country, randomised, placebo-controlledstudy of the effect of zinc as an adjunctto treatment of malaria in pre-schoolchildren, zinc levels were low in allparticipants at baseline. However, withmalaria treatment, zinc levels rosesignificantly in all participants, with thosewho received supplemental zincshowing significantly larger gains.18

Therapy of malaria was thus associatedwith a rise in zinc levels, even in theabsence of zinc supplementation.Multivariable analysis of predictors in thisstudy showed that parasite density,admission C-reactive protein (CRP)level, and study site were the mostimportant predictors of admissionplasma zinc.19 Similarly among childrenin Nepal presenting with acutediarrhoea, plasma zinc was lower inchildren with dysentery, fever, andelevated CRP concentrations.20

Based on these data, it appears thatplasma zinc concentrations aretransiently reduced during an acuteepisode of malaria or other severeinfection, presumably as part of theacute phase response to infection, andthat treatment of the disease andsupplementation with zinc areindependently associated with anincrease in plasma zinc levels over time.Nevertheless, children with acuteinfections and low plasma zincconcentrations may still be at risk of zincdeficiency, and ascribing this depressionsolely to the acute phase responseseems unwarranted. Low plasma zinclevels should thus be interpreted withconcurrent measures of the acute phaseresponse such as CRP, when available,especially among children withmoderate to severe infectious illnesses.In children whose age, diet and/ornutritional status place them at risk ofzinc deficiency, those with low plasmazinc levels should be supplemented withoral zinc. Despite these provisos aboutthe limitations of plasma zinc as anindicator of zinc status in individuals, ata population level this measurementnevertheless remains a useful tool forfield studies given the ease with whichsamples can be obtained and analysed.

SUBCLINICAL ZINC DEFICIENCYAND RISK OF INFECTION

A prospective study of children aged 12to 59 months who had suffered from anepisode of acute non-dysentericdiarrhoea at least 10 days earlier wascarried out in an urban slum in New


Delhi.21 Thirty two percent of children hadlow plasma zinc concentrations (<_8.4µmol/L). Children with low baselineplasma zinc levels had a 47% higher riskof diarrhoea during the three-monthobservation period than those withnormal zinc. Although the overall risk ofALRI was not significantly higher in thelow plasma zinc group, boys with lowplasma zinc had a four-fold higher riskof ALRI. The prevalence of ALRI wasabout three-fold higher in zinc-deficientchildren, possibly as a result of longerduration episodes of ALRI in this group.

PREVENTION OF COMMONCHILDHOOD INFECTIONS WITHZINC SUPPLEMENTS

Numerous studies in recent years havefound that zinc supplementation inchildren normalises immune functionand dramatically reduce infectiousdisease morbidity and mortality.22-25 Apooled analysis of studies of zincsupplementation for the prevention ofdiarrhoea and pneumonia (ALRI) inchildren in developing countries foundthat, in trials that provided 1-2 times therecommended daily allowance (RDA) ofelemental zinc 5 to 7 times per week,the pooled odds ratios (OR) fordiarrhoeal incidence and prevalencewere 0.82 (95% CI 0.72 to 0.93) and0.75 (95% CI 0.63 to 0.88),respectively.26 The OR for pneumoniawas 0.59 (95% CI 0.41 to 0.83) for zinc-supplemented children. Similar effectson the incidence of diarrhoea andpneumonia were also seen with short-course trials of zinc supplementation.

This pooled analysis found a 33%reduction in the incidence of persistentdiarrhoea but this effect only trendedtowards significance (OR 0.67, 95% CI0.42 to 1.06). Similarly, zincsupplementation was associated with anon-significant reduction of dysentery of13%. A more recent study of zincsupplementation given for a period of14 days each time a child had anepisode of diarrhoea demonstratedreductions in the duration and incidenceof diarrhoea and a reduced incidenceof ARI.27 The non-injury death rate wasalso 51% lower in the zinc interventionclusters, suggesting that zincsupplementation reduced mortality.

In contrast to the extensive evidencebase for the efficacy of zinc in theprevention of diarrheal disease andALRI in children in resource-poorsettings, relatively limited data isavailable for zinc and malaria. A zincsupplementation trial in The Gambia,designed principally to measure theeffect of zinc on growth, found that thezinc supplementation was associatedwith a 32% reduction in health centrevisits for slide-confirmed malaria, thoughthis difference did not attain statisticalsignificance.28 While this finding wasprovocative, the study was not optimallydesigned for this outcome, and hadseveral important limitations includingsmall sample size, a twice-weekly zincdosing regimen, and no precisedefinition of malarial illness.Subsequent work from Papua NewGuinea was more convincing. In acommunity-based study, a 46-week


period of zinc supplementation inpreschool children significantly reducedP. falciparum-attributable health centreattendance by 38% (p=0.037).29

Episodes accompanied by any level ofparasitemia were also reduced by 38%(p=0.028) and episodes withparasitemia >>_100,000 per µL werereduced by 69% (p=0.009).

A community-based trial of zincsupplementation in Burkina Faso on theincidence of febrile episodes offalciparum malaria, the severity ofmalaria episodes, or anaemia in childrenaged 6 to 31 months demonstrated thatthe cross-sectional prevalence offalciparum malaria and of P. falciparum,P. malariae, and P. ovale parasitemiawere all significantly lower in childrensupplemented with zinc (p=0.001 for allcomparisons to placebo).30 In addition,the mean density of P. falciparumincreased significantly (p=0.001) duringthe study in the placebo group relativeto the zinc group. Thus, zincsupplementation appeared to providebenefits in terms of several keymalariometric measures. Otherbeneficial effects of zincsupplementation, such as a significantreduction of the number of days withdiarrhoea (p = 0.002) and a trendtowards reduced mortality (RR 0.41,95%CI 0.15-1.19, p = 0.1) were alsonoted. In contrast, this study failed to findany benefit of zinc on the incidence ofclinical malaria episodes. There areseveral potential explanations for thelack of a protective effect of zinc formalaria in this study. First, the sample

size was too small to measure this effect,since the proportion of febrile malariaepisodes of all children with positiveblood smears was quite small. Second,the prevalence of clinical zinc deficiencyin the population under study was low.Using a cut-off point for zinc deficiencyof 60 µg/dL26, only a small proportion ofthese children were zinc deficient atbaseline, as the mean zincconcentration was 76.5 µg/dL.Theoretically, zinc might have a greatereffect on clinical malaria if used in apopulation where zinc deficiency waswidespread.

Thus, in summary the evidence is strongthat zinc supplementation serves toprotect children against diarrhealdisease, ALRI, and potentially malaria.In addition, there is growing evidencethat zinc supplementation may reducemortality in young children.27,30,31 Zincalso appears to be effective as anadjunct to the treatment of seriousinfections in young children.

ROLE OF ZINC SUPPLEMENTATIONIN TREATMENT OF COMMON CHILD-HOOD INFECTIONS

Zinc supplementation, as an adjunct tooral rehydration therapy, reduced theduration and severity of acute andpersistent diarrhoea in severalrandomized controlled trials.24,32-36 Apooled analysis of randomized,controlled trials of zinc for acutediarrhoea found that zinc reduced themean duration of diarrhoea by 16%(95% CI: 7%, 26%).37 Zinc-supplemented children also had a 15%


lower probability of continuing diarrhoeaon a given day in the acute diarrhoeastudies and a 24% lower probability ofcontinuing diarrhoea in the persistentdiarrhoea trials. There was also a 42%lower rate of death or treatment failurein the persistent diarrhoea studies. Ananalysis of the cost-effectiveness of zincas adjunct therapy to standardmanagement of acute childhooddiarrhoea, including dysentery, foundthat the use of zinc significantlyimproved the cost-effectiveness ofstandard treatment for both dysentericand non-dysenteric diarrhoea.38

Two studies evaluated the efficacy ofzinc as an adjunct to antimicrobialtherapy for children with severe ALRI.39,40

In the first study, children aged 2-23months with severe pneumonia received20 mg of zinc per day plus standardantibiotics until hospital discharge.39

Children who received zinc had reducedduration of severe pneumonia includingshorter duration of tachypnea, hypoxia,and chest in-drawing. The overallduration of pneumonia was 4 days inchildren treated with zinc versus 5 daysin those who received placebo. Thesecond study involved the administrationof 10 mg of zinc twice daily for 5 days tochildren aged 2-24 months with severeALRI.40 Zinc treatment significantlyreduced the duration of fever and veryill clinical status as judged by the studypaediatrician in boys but not girls. Sincethis finding arose from post hocsubgroup analysis, it needs to bevalidated in a gender-stratified,randomized controlled trial. These two

studies provide early suggestions of apotential therapeutic effect of zinc forsevere pneumonia in very youngchildren. Whether zinc will prove to bea useful therapeutic adjunct for thetreatment of pneumonia in older childrenor for selected respiratory pathogensremain open questions

The utility of zinc supplementation forthe treatment of measles was evaluatedin only one study. 41 Children aged 9months to 15 years who werehospitalized in India for measles wererandomized to zinc or placebo inaddition to routine supportive care.Treatment with zinc had no impact onthe time to recovery or the proportion ofchildren who were judged to be curedby day six.

In order to evaluate the potential role ofzinc as an adjunct in the treatment ofacute, uncomplicated falciparummalaria, a randomized, placebo-controlled, multi-centre trial wasundertaken.18 Children (n = 1087)between the ages of 6 months and 5years with fever and ≥2,000/µL asexualforms of P. falciparum in a thick bloodsmear were enrolled at sites in Ecuador,Ghana, Tanzania, Uganda, and Zambia.Children were randomized to receivezinc (20 mg/d for infants, 40 mg/d forolder children) or placebo for four daysas well as chloroquine, the standard firstline treatment for malaria in all sites atthe time of study initiation. There wasno effect of zinc on the median time toreduction of fever (zinc = 24.2 h vs.placebo = 24.0 h, p= 0.37), reduction ofparasitemia by >75% in the first 72 h


(zinc group = 73.4%; placebo group =77.6%, p= 0.11), or hemoglobinconcentration during the three dayperiod of hospitalization or four weekfollow-up period. This carefullydesigned study thus failed todemonstrate any benefits of zinc as anadjunct to the treatment of malaria.

CONCLUSIONS

Subclinical zinc deficiency is highlyprevalent in many developing countriesas a result of inadequate dietary intake,impaired absorption secondary to highphytate content of grain-based diets,and increased faecal and urinary lossescaused by infections. During the last twodecades, there have been a largenumber of studies of zinc for theprevention and treatment of seriouschildhood infections.

The efficacy of zinc supplementationhas been clearly demonstrated forimproving growth and reducing the riskof diarrhoeal disease and pneumonia inyoung children. Zinc supplementationmay also serve to prevent malaria.When used as a therapeutic adjunct,zinc supplementation helps to reducethe duration of acute and persistentdiarrhoea. Limited recent evidence alsosuggests that zinc may be a usefuladjunct to the treatment of pneumoniain young children. In contrast, zincappears to offer no benefit as an adjunctto the treatment of malaria or measles.Given the body of evidence of theefficacy of zinc for the prevention ofserious infections and improving growthin young children as well as limited

evidence suggesting that zincsupplementation may reduce mortality,there is a need for broaderprogrammatic implementation of thissimple intervention.

REFERENCES

1. Shankar A.H. & Prasad A. S. (1998).Zinc and immune function: thebiological basis of altered resistanceto infection. American Journal ofClinical Nutrition, 68, 447S-463S.

2. Shankar A.H. & Prasad A. S. (1998).Zinc and immune function: thebiological basis of altered resistanceto infection. American Journal ofClinical Nutrition, 68, 447S-463S.

3. Hambidge M. (2000). Human zincdeficiency. Journal of Nutrition, 130,1344S-1349S.

4. Walsh C., Sandstead H.H, Prasad A.S., Newberne PM, & Fraker PJ (1994).Zinc health effects and researchpriorities for the 1990’s. EnvironmentalHealth Perspectives, 102, 5-46.

5. Brown K.H., Peerson J. M., Rivera J,& Allen L. H. (2002). Effect ofsupplemental zinc on the growth andserum zinc concentrations ofprepubertal children: a meta-analysisof randomized controlled trials.American Journal of Clinical Nutrition,75, 1062-1071.

6. Prasad A.S. (2003). Zinc deficiency.British Medical Journal, 326, 409-410.

7. World Health Organization. WorldHealth Report. 2002. Geneva,Switzerland, World HealthOrganization.


8. Gibson R.S. & Ferguson E. L. (1998)..Assessment of dietary zinc in apopulation. American Journal ofClinical Nutrition, 68 (suppl), 430S-434S.

9. Krebs N.F (2000). Overview of zincabsorption and excretion in the humangastrointestinal tract. Journal ofNutrition, 130, 1374S-1377S.

10. Lonnerdal B. (2000). Dietary factorsinfluencing zinc absorption. Journal ofNutrition, 130, 1378S-1383S.

11. Dubey B, Pathak S, & Tripathi R(2003). Nutritional status of pre-schoolchildren from low-income families ofJabalpur City. Tribal Health Bulletin, 9,30-35.

12. Damayanti K and Chakma T.Nutritional status of adolescents intribal areas of Madhya Pradesh. 23-25. 2005. Jabalpur, India, RegionalMedical Research Centre for Tribals(ICMR). Annual Report 2003-04.

13. Roth H.-P. & Kirchgessner M. (1999).Diagnosis of marginal zinc nutrition inhumans. Trace Elements andElectrolytes, 16, 1-11.

14. Jackson M.J. (1989). Physiology ofzinc: general aspects: In Zinc inHuman Biology ed. Mills CF, Springer-Verlag, London.

15. Milanino R., Marrella M., Gasperini R.,Pasqualicchio M., & Velo G. (1993).Copper and zinc body levels ininflammation: an overview of the dataobtained from animal and humanstudies. Agents Actions, 39, 195-209.

16. Brown K.H. (1998). Effect of infectionson plasma zinc concentration andimplications for zinc statusassessment in low-income countries.American Journal of Clinical Nutrition,68, 425S-429S.

17. Gibson R.S., Heywood A., Yaman C.et al. (1991). Growth in children fromthe Wosera subdistrict, Papua NewGuinea, in relation to energy andprotein intakes and zinc status.American Journal of Clinical Nutrition,53, 782-789.

18. Zinc Against Plasmodium (ZAP) StudyGroup (2002). Effect of zinc on thetreatment of Plasmodium falciparummalaria in children: a randomizedcontrolled trial. American Journal ofClinical Nutrition, 76, 805-812.

19. Duggan C., MacLeod W., Krebs N.F.et al. (2005). Plasma zincconcentrations are depressed duringthe acute phase response in childrenwith falciparum malaria. Journal ofNutrition, 135, 802-807.

20. Strand T.A, Adhikari R.K, ChandyoR.K, Sharma PR, & Sommerfelt H(2004). Predictors of plasma zincconcentration in children with acutediarrhea. American Journal of ClinicalNutrition, 79, 451-456.

21. Bahl R., Bhandari N., Hambidge K. M.,& Bhan M. K. (1998). Plasma zinc asa predictor of diarrheal and respiratorymorbidity in children in an urban slumsetting. American Journal of ClinicalNutrition, 68 (suppl), 414S-417S.


22. Sempertegui F., Estrella B., Correa E.et al. (1996). Effects of short-term zincsupplementation on cellular immunity,respiratory symptoms, and growth ofmalnourished Ecuadorian children.European Journal of Clinical Nutrition,50, 42-46.

23. Sazawal S., Black R. E., Bhan M. K.et al. (1995). Zinc supplemen-tation inyoung children with acute diarrhea inIndia. New England Journal ofMedicine, 333, 839-844.

24. Sazawal S., Black R. E., Bhan M. K.et al. (1997). Efficacy of zincsupplementation in reducing theincidence and prevalence of acutediarrhea—a community-based,double-blind, controlled trial. AmericanJournal of Clinical Nutrition, 66, 413-418.

25. Sazawal S., Black R. E., Jalla S. et al.(1998). Zinc supplementation reducesthe incidence of acute lowerrespiratory infections in infants andpreschool children: a double-blind,controlled trial. Pediatrics 102, 1-5.

26. Zinc Investigators’ CollaborativeGroup (1999). Prevention of diarrheaand pneumonia by zincsupplementation in children indeveloping countries: pooled analysisof randomized controlled trials.Journal of Pediatrics, 135, 689-697.

27. Baqui A.H., Black R. E., El Arifeen S.et al. (2002). Effect of zincsupplementation started duringdiarrhoea on morbidity and mortalityin Bangladeshi children: community

randomised trial British MedicalJournal, 325, 1-7.

28. Bates C.J., Evans P. H., Dardenne M.et al. (1993). A trial of zincsupplementation in young ruralGambian children. British Journal ofNutrition, 69, 243-255.

29. Shankar A.H., Genton B., Baisor M.et al. (2000). The influence of zincsupplementation on morbidity due toPlasmodium falciparum: arandomized trial in preschool childrenin Papua New Guinea. AmericanJournal of Tropical Medicine &Hygiene, 62, 663-669.

30. Muller, Becher H., van Zweeden A. B.et al. (2001). Effect of zincsupplementation on malaria and othercauses of morbidity in west Africanchildren: randomised double blindplacebo controlled trial. British MedicalJournal,,322, 1-5.

31. Sazawal S., Black R.E, Menon V.P ininfants born small for gestational agereduces mortality: a prospective,randomized, controlled trial.Pediatrics, 108, 1280-1286.

32. Sachdev H.P.S., Mittal N. K., & YadavH. S. (1990). Oral zincsupplementation in persistentdiarrhoea in infants. Annals of TropicalPaediatrics, 10, 63-69.

33. Sachdev H.P.S., Mittal N. K., Mittal S.K,& Yadav H. S. (1988). A controlled trialon utility of oral zinc supplementationin acute dehydrating diarrhea in infants.Journal of Pediatric Gastroenterology& Nutrition, 7, 877-881.


34. Sazawal S., Black R. E., Bhan M. K.et al. (1995). Zinc supplemen-tation inyoung children with acute diarrhea inIndia. New England Journal ofMedicine, 333, 839-844.

35. Roy S.K., Tomkins A. M., &Akramuzzaman S.M (1997).Randomised controlled trial of zincsupplementation in malnourishedBangladeshi chidlren with acutediarrhoea. Archives of Diseases ofChildhood, 77, 196-200.

36. Bhutta Z.A., Nizami S.Q, & Isani Z(1999). Zinc supplementation inmalnourished children with persistentdiarrhea in Pakistan. Pediatrics, 103,1-9.

37. Zinc Investigators’ CollaborativeGroup (2000). Therapeutic effects oforal zinc in acute and persistentdiarrhea in children in developingcountries: pooled analysis ofrandomized controlled trials. AmericanJournal of Clinical Nutrition, 72, 1516-1522.

38. Sommerfelt H, Robberstad B, StandT, Black R. E, & Sommerfelt (2004).

Cost-effectiveness of zinc as adjuncttherapy for acute childhood diarrhoeain developing countries. Bulletin of theWorld Health Organization, 82, 523-531.

39. Brooks W.A, Yunus M, Santosham Met al. (2004). Zinc for severepneumonia in very young children:double-blind placebo-controlled trial.Lancet, 363, 1683-1688.

40. Mahalanabis D., Lahiri M, Dilip P etal. (2004). Randomized, double-blind,placebo-controlled clinical trial of theefficacy of treatment with zinc orvitamin A in infants and young childrenwith severe acute lower respiratoryinfection. American Journal of ClinicalNutrition, 79, 430-436.

41. Mahalanabis D., Chowdhury A, JanaS, Bhattacharya M.K, & ChakrabartiM.K (2002). Zinc supplementation asadjunct therapy in children withmeasles accompanied by pneumonia:a double-blind, randomized controlledtrial. American Journal of ClinicalNutrition, 76, 604-607.


INTRODUCTION

Geomatics or geographic-informatics isthe synergy of multiple disciplinesnamely Geographic Information System(GIS), Remote Sensing (RS),Photogrammetry, Cartography andGeodesy. It is fundamental to all thedisciplines, which use data identified bytheir location. GIS and remote sensingfrom aerospace platforms aresophisticated and powerful technologiesthat are finding applications far beyondthose originally intended. Together, theyallow near real-time access to spatialdata on patterns of land use, phases ofvegetation, temperature, soil, elevation,precise geographic location of waterbodies, population centres, buildings,roads, and other infrastructures.

The advances in geographic informationand mapping technology have creatednew opportunities for public healthadministrators to enhance their

GEOMATICS AND ECOEPIDEMIOLOGY

R. Jaishanker1 and C. P. Johnson2

Abstract. Geomatics has transformed the way we describe and study the Earth.Together, Geographic Information System (GIS) and remote sensing haveremarkable potential to address public health issues. In India, a lag exists in theroutine applications of geomatics in health sector. Ecoepidemiological studiesare significant in the backdrop of global climatic changes. This paper provides acomprehensive description of GIS and remote sensing from a public healthperspective, lists some of the contemporary aerospace applications forepidemiology and concludes with a call for coherent multidisciplinary approachto reduce the prevailing technology-gap.

planning, management and monitoringcapabilities. The technology can helpplanners better access and analyze thespatial relationships of factors andconstraints in the implementation ofpublic health programs. Ironically, publichealth professionals in India, who are inthe best position to exploit geographicinformation and mapping technology,are less exposed to the technology. Thisis mainly due to lack of awareness ofthe potential of this technology, accessto the technology and financialconstraints.

Vector-borne diseases involve acausative agent (pathogen), usually amicroorganism that causes the diseasein the host. Disease vectors help in thedissemination of the causative agent.Most disease vectors belong to thephylum Arthropoda. Transmissioncycles of certain vector borne diseases

1, 2 Geomatics Solutions Development Group, Centre For Development of Advanced Computing

(C-DAC), Ganeshkhind, Pune-411 007E-mail : [email protected]


also include intermediate and reservoirhosts. Arthropods are very adaptive andecologically diverse phylum. They havesuccessfully adapted and evolved intovirtually every environment on Earth.

The Earth is being subjected to manyhuman-induced and natural changes,which are transforming global ecologicalsystems. The transformations manifestmainly as change in land cover, land useand climate. Many of these factors havebeen suggested as explanations forresurgence of infectious diseases

! .

‘Eco-epidemiology’ is emerging inresponse to a perceived need tobroaden the scope of assessment of theimpact of environmental changes

2. This

entails a shift in emphasis from a directstudy of an individual to an indirect studyof a region. Vector and host surveillanceand study of the ecology of infectiousdiseases are essential components ofany public health program. Ecologicalstudies are also significant because theymay give insight into factors that affectspatial (of space) as well as temporal(of time) cycles of infectious diseases

3.

In addition to the ecologicaldeterminants of vector-borne diseases,climate change also influences theworldwide spread of diseases.Climatologists predict a 2

0C rise in global

temperatures by the end of 21st century

4.

This is expected to directly affect vector-borne diseases by expanding thegeographical range, increasedreproduction and decreasing incubationperiod of the pathogen.

Emerging and re-emerging vector-bornediseases are a challenge that requiresa new proactive pragmatic responsefrom the public health professionals.Geomatics technology is ideally suitedfor renewed efforts to tackle the problemof vector-borne disease at differentspatial scales.

GEOGRAPHIC INFORMATIONSYSTEM

Many misconceptions exist as to themeaning of the term GIS, particularly indisciplines where the use of suchtechnology has not yet been firmlyestablished. The phrase ‘geographicinformation system’ was first used in the1960s to refer to a computerized systemfor asking questions of maps showingcurrent and potential land use inCanada

5. A GIS can be defined as a

‘set of tools for collecting, storing,retrieving, transforming and displayingspatial data from the real world for aparticular set of purposes’

6. A typical GIS

comprises an organized collection ofcomputer hardware, software,geographic data and personnel,designed to efficiently capture, store,update, analyze and display all forms ofgeographically referenced information.Each piece of information is related inthe system through specific geographiccoordinates to a geographical entity (e.g.health centre, school, dam, drainage,village or state). The information can bedisplayed in the form of maps, graphs,charts and tables. GIS adds thedimension of geographic analysis toinformation technology by providing an


interface between data and map. Thismakes it easy to present information todecision-makers quickly, efficiently andeffectively. The technology providestools for visualizing, integrating, andanalyzing spatial data with a uniquecapability to merge information frommultiple sources. By using a commonspatial framework, GIS enables theusers to analyze how the variousphysical, social, economic andecological factors interact.

GIS has several advantages overconventional methods used in healthplanning, management and research.

Data management: GIS provides theuser, the ability to store, integrate, query,display, and analyze data from themolecular level to that of satelliteresolution through their shared spatialcomponents obtained from diversesources. Surveillance of diseasesrequires continuous and systematiccollection and analysis of data. GIS caneliminate the duplication of effortinvolved in data collection across anorganization, and hence substantiallyreduce the cost involved. It can alsoserve as a common platform forconvergence of multi-diseasesurveillance activities.

Global positioning systems (GPS) canbe used to obtain locations of pointfeatures on a map, such as wells orseptic tanks, precisely. GIS can processaerial or satellite imageries to allowinformation such as temperature, soil

types and land use to be easily integrated,and spatial correlations between potentialrisk factors and the occurrence ofdiseases to be determined. Latest andaccurate, maps are essential forepidemiological surveillance. GPS, high-resolution satellite imageries and aerialphotographs can be used to obtainaccurate and up-to-date maps of anyregion. Multi-temporal satellite imageriescan be used to monitor land use andland cover changes over time.

Visualization: GIS offers powerful toolsto present spatial information to the levelof individual occurrence, and conductpredictive modeling. It determinesgeographical distribution and variationof diseases, and their prevalence andincidence. For example, in studying thesurveillance of malaria in India, it isimportant to find out which type ofmalaria is occurring in which parts of thecountry. Such studies have importantimplications for the disease eradicationstrategy to be employed. GIS can helpgenerate thematic maps - ranged colormaps or proportional symbol maps todenote the intensity of a disease or avector. In comparison with tables andcharts, maps developed using GIS aremore effective means forcommunicating messages clearly evento those who are not familiar with thetechnology. GIS keeps track of thegeographical locations of serviceproviders, customers, resources, andhealth plans and programs. It allowspolicy makers to easily understand and


visualize the problems in relation to theresources, and effectively targetresources to those communities in need.GIS permits dynamic link betweendatabases and maps so that dataupdates are automatically reflected onthe maps.

Overlay analysis: GIS can overlaydifferent pieces of information. Thishelps in decision-making and medicalresearch through techniques like multicriteria modelling (for e.g. inunderstanding the association betweenprevalence of certain diseases andspecific geographic features).

Buffer analysis: GIS can create bufferzones around selected features. Forexample, a radius of 10 km around ahospital to depict its catchment area or1 km around an effluent discharge siteor 50 m on both sides of sewerage toindicate the spread of hazardousmaterial. The user can specify the sizeof the buffer and then combine thisinformation with disease incidence datato determine how many cases fall withinthe buffer.

Network analysis: GIS provides theability to quickly access the geo-demographic dynamics of anorganizations existing service area incontrast to the likely demand for servicesat a new location. It can identifycatchments areas of health centres andalso locate suitable site for a new healthfacility. Health services delivered athome (e.g. polio vaccination) can bescheduled in a more efficient manner byanalyzing transportation factors and

street patterns, and by recommending themost efficient route. GIS Providesaccurate and timely information aboutwhere health services are located, andinstructions and maps on how to getthere.

Statistical analysis: GIS can carry outspecific calculations, for example,proportion of population falling within acertain radius of a health centre or dam.It can also calculate distances andareas, for example, distance of acommunity to a health centre, and areacovered by a particular health program.

Query: GIS allows interactive queriesto extract information contained withinthe map, table or graph. It can answerqueries of location, condition, trends,spatial patterns and modeling.

Extrapolation: GIS provides a range ofextrapolation techniques. For example,vector distribution in inaccessible andnon-sampled areas can be mappedusing GIS.

Web GIS : One of the recentadvancements in GIS technology is web-based GIS. Health data is stored in acentral server, which can be accessedfrom various terminals connected to theserver through internet or intranet.

Internet based GIS technologyeliminates the traditional method of flowof information, and the information isinstantly available across the globe.Dynamic maps published on the weballow continuous monitoring for effectivehealth interventions.


POTENTIAL APPLICATIONS OF GISIN PUBLIC HEALTH

GIS is gradually being accepted andused by public health administrators andprofessionals, including policy makers,statisticians, epidemiologists, regionaland district medical officers. Some of itspotential applications in public health arelisted below:

D Determine the geographicaldistribution and variation of diseases

D Analyze spatial and temporal trendsof diseases

D Identify gaps in immunizations

D Map populations at risk and stratifyrisk factors

D Document community health careneeds and assess resourceallocations

D Forecast epidemics

D Plan and target interventions

D Monitor diseases and interventionsover time

D Manage patient care environments,materials, supplies and humanresources

D Monitor the utilization of healthcentres

D Route health workers, equipmentsand supplies to service locations

D Publish health information usingmaps on the Internet

D Locate the nearest health facility.

REMOTE SENSING

Remote sensing has been defined as:“the science and art of obtaininginformation about an object, area, orphenomenon through the analysis ofdata acquired by a device that is not indirect contact with it”

7. The ‘science’ of

remote sensing rests on the fact thatevery object, area, or phenomenonreflects and emits energy at specific anddistinctive wavelengths of theelectromagnetic spectrum. Acquisitionof remote sensing data forenvironmental monitoring is generallyrestricted to the visible, infrared, andmicrowave regions of the spectrum. The“art” of remote sensing lies in the abilityto exploit this basic matter and energyrelationship, in order to identify, map, ormonitor features of interest.

Several characteristics of remotesensing data make them especially wellsuited for studying environmentalprocesses: (1) imagery acquired fromaircraft or satellite platforms provides asynoptic view of the Earth’s surface; (2)sensors can be calibrated to record inspectral regions beyond those to whichthe human eye is sensitive; (3) data arecommonly available in digital format forcomputer analysis and integration withother digital databases; and (4) theyprovide a historical record of conditionsfor a particular area or region.

In order to understand how remotesensing data can be applied in diseasevector surveillance, it is necessary to


review a few basic principles. The digitalimage generated by multi spectralscanner system is actually a two-dimensional array of discrete pictureelements, or pixels. The sensors foreach array are calibrated to recordreflected and/or emitted energy in aspecific spectral region. Individual pixelsin this array may be from a few metersto several kilometers. The value (digitalnumber, DN) of each pixel, whichcorresponds to photographic gray level,represents the average reflectance overthe ground area being measured.

The interpretation of aerial photography,or enhanced multi spectral imagery thathas been photographically processed,involves the visual identification ofobjects and the determination of theirmeaning or significance based on color,shape, size, shadow, tone, texture,pattern, location and association. Incontrast, analysis of digital multi spectralscanner data requires both computerprocessing and human interpretation ofthe results of the processing. Thepromise of remote sensing technologyis to allow the user to extrapolate local-level measurements to a regional scaleand therefore to discern spatial andtemporal patterns that could otherwisenot be seen.

Selecting the appropriate remotesensing data for a given study requiresconsideration of the spatial, spectral,and temporal resolution of the data andthe phenomenon being studied. It is

important to determine if the data arebeing acquired (a) at an appropriatespatial scale, (b) in spectral regions thatwill allow features of interest to bedistinguished from their surroundings,and (c) at appropriate times of the yearto achieve the goals of the study.

Complex sets of inter-relationships existbetween remotely sensed imagery of theland surface and disease risk distributedspatially on that land surface. Since theamount of radiation reflected (at a givenwavelength) from a given point on theEarth’s surface depends on the natureof land cover type at that point, it ispossible to predict the land coverspatially from remotely sensed imagery.The spatial prediction of land cover isbased on explicit physical processes.Similarly, the links between otherenvironmental variables that have beenemployed in the remote sensing ofdisease risk (e.g., cold cloud duration,CCD) and remotely sensed imagery arebased on physical processes.

The link between land cover and vectordensity (or disease risk) is based onprocesses that are less easily describedin terms of the physics of the processesinvolved, but which may be describedwell by stochastic models.

ECOEPIDEMIOLOGICAL APPLICA-TIONS OF REMOTE SENSING DATA

The idea that place and location caninfluence health is an old concept. Asfar back as the time of Hippocrates (460-


370 BC), physicians had observed thatcertain diseases seem to occur in someplaces and not in others. First expressedby the Russian epidemiologistPavlovsky

8, the underlying concept of

landscape epidemiology is that byknowing the environmental conditionsnecessary for the maintenance ofspecific pathogens in nature, one canuse landscape analysis to identify thespatial and temporal pattern of disease-risk distribution. Environmentalelements, including elevation,temperature, rainfall, and humidity,influence the presence, development,activity, and longevity of pathogens,vectors, zoonotic reservoirs of infection,and their interactions with humans

9.

Vegetation type and distribution are alsoinfluenced by the environmentalvariables mentioned above, and can beexpressed as landscape elements thatcan be remotely sensed and whoserelationships can be modeled spatially.

Though not in the strict sense of a GIS,the use of mapping to solve public healthand epidemiological problems datesback more than a century whenepidemiologist John Snow employed thebasic mapping concepts in 1854 todetermine the cause of Soho choleraoutbreak

10. The use of aerial

photography and manual interpretationtechniques to identify and map diseasevector habitats can be traced to 1949

11.

Visual photographic interpretationtechniques that exploit tone and texture

have been used to identify and maplandscape units associated with tick-borne encephalitis and tularemia in partsof the former Soviet Union

12.

One of the first uses of multi-spectralscanner data was in the early 1970swhen investigators from NationalAeronautics and Space Administrations(NASA) and Mexico developed a remotesensing approach for monitoringenvironmental parameters required forthe propagation of the screwworm fly

13.

A number of studies have establishedthe potential of remote sensing fordetection of vector borne diseases(Table1). Studies on the use of remotesensed data to identify vector (mosquito)breeding sites have also been carriedout in India. The findings of the studiescited in Table1 illustrate how geospatialtechnologies can provide scientists witha new perspective with which to studythe factors influencing the patterns ofvector-borne diseases at a variety oflandscape levels. The diverse potentialof remote sensing applications in vectorsurveillance and control programs isbrought out in a special issue of theproceedings of the 1990 Internationalconference on Applications of RemoteSensing to Epidemiology andParasitology

14.

Successful application of remotesensing technology depends on theability to: (1) extrapolate measurementsmade at a local level to a regional orglobal scale; (2) formulate and test new


research hypotheses; and (3) develop“near-real time” models to predict thespatial and temporal patterns of vectorpopulations and disease transmissionrisk. Processes that operate at a varietyof landscape scales influence thedynamics of vector-borne disease at anypoint. Malaria, for example, can beviewed as local as well as globalproblem. Remote sensing imagery (fromhigh-resolution aerial photography tocoarse-resolution satellite imagery)when combined with GIS spatialanalyses techniques can play animportant role in existing and futurevector surveillance and control programsat local and regional scales.

CONCLUSIONS

The potential opportunities offered bythe use of remote sensing to measureassociations between environment andhuman disease were outlined as earlyas 1970

15. Despite many clarion calls

during the intervening years and theresults of many more studies, the publichealth community is yet to realize thefull potential offered by Geomaticstechnology for vector surveillance andcontrol. Isolated independent studiesthat are presently reported, no doubt,generate new knowledge. However,such spatially and temporallyintermittent knowledge has limited utility

in addressing societal problems. This isbest illustrated by the geospatial diseasesurveillance system in place in Dindigul,Tamil Nadu. The system is bound by thegeographical limits of Dindigulmunicipality, whereas the causativeorganisms, the vectors nor the affectedindividuals are. This severely restrictsthe effective large-scale utility of suchisolated attempts.

The ‘technology-gap’ between publichealth workers and geomaticsprofessionals limits the effectiveutilization of geospatial technology toaddress community health concerns.Technological change continues to drivethe evolution of geomatics therebycontinuously widening the gap. This hasserious implications for the successfulapplication of geospatial technologiesfor public health. Geomatics will play animportant and expanding role in oursocieties, and public health officials havethe responsibility to ensure that thepromise of this technology is wellrealized. Coherent efforts betweenadministrators, practitioners in publichealth agencies and researchers inscientific organizations will help utilizethe untapped potential of geomaticstechnologies for addressing publichealth problems.


Remote sensingdata used

Parameter derived fromremote sensed data

Disease/ vector Reference

Landsat TM Land cover African tick Hugh-Jones16

Color infraredAerial photography

Land and water cover Mosquito Welch et al. 17

TM Simulator/Landsat TM

Water andVegetation cover

Mosquito larvae Wood et al.18

Airborne SAR/Landsat TM

Topography Rift valley fevervirus/ MosquitoDambos in river

valleys

Pope et al.19

AVHRR NDVI(1.1km)

Vegetation amount Trypanosomiasis/Tsetse fly & Ticks

Rogers andRandolf 20

Landsat TM Land cover Malaria/Mosquito Beck et al. 21

Landsat TM Vegetation amount Guinea worm/Water flea

Ahearn andDeRooy 22

SPOT HRV Vegetation amount Malaria/Mosquito Roberts et al. 23

AVHRR NDVI,Temperature

Vegetation amount Trypanosomiasis/Tsetse fly

Rogers et al.24

AVHRR NDVI(1.1km)

Vegetation amount Trypanosomiasis/Tsetse

Robinson et al.25

AVHRR NDVI,(8km)

Temperature, MIR

Vegetation amount Malaria/Mosquito Hay et al.26

AVHRR NDVI(1.1km)

Vegetation amount Malaria/Mosquito Thomson et al.27

IRS 1A & 1B Vegetation/ Ecotype Malaria/Mosquito Sharma et al.28

IRS 1D Eco-epidemiologicalclasses

Malaria/Mosquito Srivastava et al.3

Table 1: Remote-sensing applications for disease / vectorsurveillance - A compilation of selected studies.


REFERENCES

1. Sharma, V.P. (1996). Reemergenceof malaria in India. Indian Journal ofMedical Research, 103, 26.

2. Hale, S., Weinstein, P. andWoodward, A. (1997). Public HealthImpacts of Global Climate Change.Reviews on Environmental Health,12, 191.

3. Srivastava, A., Nagpal, B. N.,Saxena, R., Wadhwa, T. C., ShivMohan., Siroha, G. P., Prasad, J.and Subbarao, S. K. (2004). Malariaepidemicity of Mewat region, DistrictGurgaon, Haryana, India: a GIS-based study. Current science,86,1297.

4. Anonymous. (1998). The RegionalImpacts of Climate Change. AnAssessment of Vulnerability. A SpecialReport of IPCC Working Group II[Watson, R.T., M.C. Zinyowera, andR.H. Moss (Eds.)]. CambridgeUniversity Press, Cambridge, UnitedKingdom and New York, 517.

5. Longley, P. A., Goodchild, M. F.,Maguire, D. J. and Rhind, D. W.(1999). Geographical informationsystems, principles and technicalissues. Vol. 1. 2

nd Ed. John Wiley &

Sons. New York.

6. Burrough, P. A. and McDonnell, R.A. (1998). Principles ofGeographical Information Systems.Oxford University Press, Oxford

7. Lillesand, T. M. and Kiefer, R. W.(1999). Remote Sensing and ImageInterpretation. Fourth Edition. John

Wiley and Sons Inc,

8. Pavlovsky, E. V. (1966) Natural

Nidality of Transmissible Diseases

with special reference to Landscape

Epidemiology of Zooanthroponoses

(Translated by F. Plous, Jr. and N.

Levine. University of Illinois Press,

Urbana, IL.

9. Meade, M. S., Florin, J. W. and

Gesler, W. M., (1988). Medical

Geography The Guilford Press,.

10. Clarke, K. J. C., McLafferty, S. L. and

Templaski, B.J. (1996). On

epidemiology and geographic

information systems: a review and

discussion of future directions

Emerging Infectious Diseases, 2,

85.

11. Audy, J. R. (1949). A Summary

Topographical Account of Scrub

Typhus 1908-1946, Bull. No. 1. The

Institute for Medical Research,

Kuala Lumpur, Federation of

Malaya.

12. Wagner, V. E., Rowley, H. R.,

Narlock, S. A. and Newson, H. D.

(1979). Remote sensing: a rapid and

accurate method of data acquisition

for a newly formed mosquito control

district Mosquito News, 39, 282.

13. Washino, R, K. and Wood, B, L.

(1994). Application of Remote

Sensing to Arthropod Vector

Surveillance and Control American

Journal of Tropical Medicine and

Hygiene, 50, 134.


14. Hugh-Jones, M (Ed). (1991).Application of Remote Sensing toEpidemiology and Parasitology.Preventive Veterinary Medicine(Special Issue), 2, 34.

15. Cline, B.L. (1970). New eyes forepidemiologists: aerial photographyand other remote sensingtechniques. American Journal ofEpidemiology, 92, 85.

16. Hugh-Jones, M. (1989). Applicationsof remote sensing to theidentification of the habitats ofparasites and disease vectors.Parasitology Today, 5, 244.

17. Welch, J.B., Olson, J.K., Hart, W.G.,Ingle, S.G. and Davis, M.R. (1989).Use of aerial color Infraredphotography as a survey techniquefor Psorophora columbiaeoviposition habitats in Texasricelands. Journal of the AmericanMosquito Control Association, 5,147.

18. Wood, B.L., Washino, R., Beck, L.,Hibbard, K.A., Pitcairn, M., Roberts,D., Rejmankova, E., Paris, J.,Hacker, C., Salute, J., Sebesta, P.and Legters, L. (1989).Distinguishing high and lowanopheline-producing rice fieldsusing remote sensing and GIStechnologies. Preventive VeterinaryMedicine, 11, 277.

19. Pope, K.O., Sheffner, E. J.,

Linthicum, K. J., Bailey, C. L. and

Logan, T. M., Kasischke, E. S.,

Birney, K., Njogu, A. R. and Roberts,

C. R. (1992). Identification of

central Kenyan rift valley fever virus

vector habitats with Landsat TM

and evaluation of their floodingstatus with airborne imaging radar.

Remote Sensing of Environment,

40, 185.

20. Rogers, D. J. and Randolph, S. E.

(1993). Distribution of tsetse andticks in Africa: past, present and

future. Parasitology Today, 9, 266.

21. Beck, L. R., Rodriguez, M. H., Dister,

S. W., Rodriguez, A. D.,Rejmankova, E., Ulloa, A. Meza, R.

A., Roberts, D. R., Paris, J. F.,

Spanner, M. A., Washino, R. K.,Hacker, C. and Legters, L. J. (1994).

Remote sensing as a landscape

epidemiologic tool to identify villagesat high risk for malaria transmission.

American Journal of Tropical

Medicine and Hygiene, 5, 271.

22. Ahearn, S. C. and De Rooy, C.

(1996). Monitoring the effects ofDracunculiasis remediation on

agricultural productivity using

satellite data. International Journalof Remote Sensing, 5, 917.

23. Roberts, D. R., Paris, J. F., Manguin,S., Harbach, R. E., Woodruff, R.,

Rejmankova, E., Polanco, J.,

Wullschleger, B. and Legters, L. J.(1996). Predictions of malaria vector

distribution in Belize based on

multispectral satellite data.American Journal of Tropical

Medicine and Hygiene, 54, 304.


24. Rogers, D. J., Hay, S. I. and Packer,M. J. (1996). Predicting thedistribution of tsetse flies in WestAfrica using temporal Fourierprocessed meteorological satellitedata. Annals of Tropical Medicineand Parasitology, 90, 225.

25. Robinson, T., Rogers, D. andWilliams, B. (1997). Univariateanalysis of tsetse habitat in thecommon fly belt of Southern Africausing climate and remotely sensedvegetation data. Medical andVeterinary Entomology, 11, 223.

26. Hay, S. I., Snow, R. W. and Rogers,D. J. (1998). Predicting malariaseasons in Kenya usingmultitemporal meteorologicalsatellite sensor data. Transactionsof the Royal Society of TropicalMedicine and Hygiene, 92, 12.

27. Thomson, M. C., Connor, S. J.,D’Alessandro, U., Rowlingson, B.,Diggle, P., Cresswell, M. andGreenwood, B. (1999). Predictingmalaria infection in Gambianchildren from satellite data and bednet use surveys: the importance ofspatial correlation in theinterpretation of results. American.Journal of Tropical Medicine andHygiene, 61, 2.

28. Sharma, V. P., Dhiman, R. C.,Ansari, M. A., Nagpal, B. N.,Srivastava, A., Manavalan, P.,Adiga, Radhakrishna, K. and.Chandrasekhar, M. G., (1996).Study on the feasibility of delineatingmosquitogenic conditions in andaround Delhi using Indian remotesensing satellite data. InternationalJournal of Malariology, 33, 107


INTRODUCTION

There is a general agreement that thehealth status of the tribal population inIndia is very poor. Different studieshave tried to establish this with the helpof morbidity, mortality and healthstatistics.

1-11 The tribal populations

have distinct problems, not becausethey have special kind of health, butbecause of special placement in difficultareas and the circumstances in whichthey live. Like antenatal care services,post-natal care services are alsoequally important for the mother andthe child especially from the viewpointof growth, monitoring and immunizing.There is a general feeling among therural women that once the child is born

CONCERN FOR POSTNATAL CARE SERVICES- USUALLY ALESSER VALUED SERVICE IN RURAL AREAS

(A study among the primitive Lodha tribe of West Bengal)

Kalyan B. Saha1 and Uma Chatterjee Saha2

Abstract. The study is a small attempt to understand the utilization of the postnatalcare services among 500 ever-married Lodha women in the reproductive agegroup in Medinipore district of West Bengal. About 47% (230 Nos.) of therespondents stated to have received some form of postnatal care within thepost-partum period of six months following their last delivery, which is higherthan antenatal services availed by these respondents (43%). Among these 230women, the actual postnatal care services received at Government health postsis only 32% and the remaining received some form of care either from familymembers, midwife, local medicine man or paramedical at private healthdispensaries.

there is no need for any checkup eitherfor the mother or for the child except incase of serious problem.

12 Routine

post-natal care is not readily availablein many developing country settingsand thus there is still fairly limitedsurvey experience of these studies.

13

Further, such studies among the tribalcommunities are very few. Thisprompted us to undertake this studyamong the Lodha, one of the primitivetribe of West Bengal and attempt wasmade to look into the level and sourcefrom which the postnatal care wasdelivered. The study also highlightedcertain indicators for improving theutilization of services among the tribe.

1 Senior Research Officer, Regional Medical Research Centre for Tribals (Indian Council of MedicalResearch), Nagpur Road, Garha, Jabalpur- 482 003, 2 Faculty, Xavier Institute of Development,Action and Studies, 4th Mile No. 8 Mandla Road,Tilhari, Goraiyaghat, Jabalpur - 482 021E-mail : [email protected]


MATERIAL AND METHODS

The survey was carried out during 1997among Lodha women in thereproductive age group. The studypertains to the tribe Lodhas of WestBengal who are overwhelminglyconglomerated in the Medinipore districtof the state.

14-20 Hence the survey is

restricted to Medinipore district (Fig.1).In the absence of any reliable populationinformation of the tribe the latest recordsavailable with the Tribal WelfareDepartment, Office of the DistrictMagistrate, Medinipore, the total Lodhapopulation in the district was recordedas 36,069 in 1990. A sample of 500ever - married Lodha women in the agegroup 15-49 years was drawn from 6blocks of the district proportionally to its

village was interviewed by canvassing apre-designed interview schedule. Theshort fall in the sub sample of a villageis adjusted from the next selectedvillage. This is done to bring the sampleclose to representativeness. A total of29 villages located in remote areascovered in the study. In order to obtaininformation on the utilization of post-natal care in the Lodha community, therespondents were asked to state if theyhad received any health checkup/service both for themselves or for theirnewly born child within the post-partumperiod of 6 weeks following their lastdelivery. The last delivery is consideredin the study to avoid recall lapse by therespondents. The community by andlarge, was found to be culturallyhomogenous. Not much variation isfound in the level of education andstandard of living. Even though thesevariables are important, but we havedropped them in our analysis. Asbackground variables, occupation,duration of married life and index ofreligiosity is considered. Occupation isbroadly categorized into two dependingon their subsistence related activitiesduring major part of the year, i.e., 183days in a year. The two occupationalcategories viz., ‘Agricultural’ refers tocultivating one’s own land and‘Gatherers’ subsists on collection andselling of forest produce. The index ofreligiosity is computed by using scalingtechnique and for this purpose followingstatements were asked to therespondents: believe in god; observereligious symbol; pray daily; visit

size. The 6 blocks were selectedrandomly and together it constitutesabout 60% of the total Lodha femalepopulation of the district. Villagespredominated by Lodha were identifiedand listed. A sub sample of randomlyselected 20 women per household per

Fig.1 :


religious places daily; impart religiouseducation to children; believe in hell andheaven and Lodha ritual superior thanothers. The responses for eachstatement were recorded in two pointscale- “Yes=1” and “No=0”. Test ofsignificance is done by computingCramer’s value.

21

RESULTS

A little less than half of the respondents(230; 47%) stated to have receivedhealth care service at any point of timewithin the 6 weeks following the deliveryof their last child. The informationcollected on the said aspect showed thatpostnatal health check-ups/serviceswere received mainly at home (42%)(Fig.2). The lactating mothers weretreated at home largely by elderly femalefamily members, midwives and even bylocal medicine man (Kabiraj). Servicesof paramedical at private healthdispensaries were also utilized at homebut in rare and serious cases only.

It is found that majority of the housewivesbelonging to households engaged inagricultural activities, largely visitedGovernment hospital/ PHC/ Sub centresfor postnatal services (42%), followed bythose visited paramedical at privateclinics (33%) and at home (25%). On thecontrary the gatherers received carelargely at home (51%) followed by servicereceived at Government hospitals/ PHC/SC (27%) and in private clinics (22%).The association between source ofreceiving post-natal services andrespondents occupational background isfound to be significant (Cramer’s value =0.199, p < 0.001).

Further the respondents having higherduration of married life had consultedmostly the service providers in Hospitals/PHCs/SCs for postnatal check-up andthose with lower duration of married lifemostly resorted to home remedies afterchildbirth. The association betweenpostnatal services received and durationof married life is not statistically significant(Cramer’s value = 0.134, p>0.05).

The respondents with higher level ofreligiosity (superstitions pertaining tochild birth) displayed greater reluctanceto visit any institutionalized health postfor postnatal check-ups but preferred tohave such health checkup at home.On the other hand respondents withlower religiosity visited largelyGovernment hospitals/PHC/ SubCentres for postnatal check-up. Theassociation between index of religiosityand source of receiving postnatalservices is found to be significant(Cramer’s value = 0.230, p<0.0001).

Private Dispensaries

26% Home42%

Govt. Health Posts32%

Sources of delivering postnatal serviceswith the background variables of therespondents are shown in table 1 andare mentioned below:

Fig.2: Sources of delivering post-natal care


Out of the total sample of 500 women,54% (270 respondents) did not availedpostnatal care services during post-partum period of 6 weeks following lastdelivery (data not presented in tabularform) and gave different reasons for thesame. Majority of the respondents didnot felt the need for such services asthey faced no serious problem afterdelivery (72%) and another 16%mentioned poverty as a cause, whichhad prevented them from undergoingany health check -up during the post-partum period. The remaining 12%attributed lack of time, unfriendly attitudeof the service personnel and no properknowledge of the services as reason,which forbid utilizing such services.

Table 1: Distribution of the respondents according to places of receiving postnatal checkup by various background characteristics

Background

Characteristics

Base Home Govt.

Hospital/

PHC/SC

Private Clinics

Occupation

Agricultural

Gatherer

83 (100.0)

147 (100.0)

21 (25.3)

75 (51.0)

35 (42.2)

39 (26.5)

27 (32.5)

33 (22.4)

Duration of Married

life (Years)

Up to 10

11-20

21+

111 (100.0)

92 (100.0)

27 (100.0)

53 (47.7)

34 (44.1)

9 (62.5)

26 (23.4)

38 (41.3)

10 (37.0)

32 (28.8)

20 (21.7)

8 (29.6)

Index of Religiosity

Low

Medium

High

55 (100.0)

127 (100.0)

48 (100.0)

10 (18.2)

56 (44.1)

30 (62.5)

27 (49.1)

41 (32.3)

6 (12.5)

18 (32.7)

30 (23.6)

12 (25.0)

Total 230 96 (41.7) 74 (32.2) 60 (26.1)

N. B. Figures in parenthesis indicate percentages

DISCUSSION

This study demonstrated that incontradiction to the general view asmentioned above, the higher number ofLodha women were found to haveconsulted one or the other source forpostnatal care compared to antenatalcare (43%). It is observed in the studythat these services among the Lodhawomen are usually received at homeindigenously and to a very lesser extentby Anganwadi worker or by AuxiliaryNurse Midwife. The other sources ofpost-natal services include services atlocal private dispensaries and areusually consulted during emergency.


The services by traditional healer at homeor private dispensaries are chargedeither in cash or in kind as per their will,burdening the Lodhas economically andrenders them skip their meals inexchange of health services. FurtherLodhas often discontinue the regularity oftheir visits to Government health posts foravailing such services, which ultimatelydilutes the service effectiveness. Furtherlack of Government health posts at easyreach and unfriendly attitude of the serviceproviders, as reported, also acts as ahindrance in the utilization of the services.So it is suggested that the healthauthorities need to act decisively in orderto strengthen the services in these remoteareas and make it accessible andaffordable to the tribal people.

The study also shows that Lodhas whohave adopted permanent agriculture arebetter than the gatherers in terms ofutilization of postnatal care services. Ithas been observed that among thegatherers there was a feeling that oncethe child is born there is no need toconsult any doctors unless they weresubjected to serious problems. So thereis a need to identify the areas of theirliving and launch special service to givea thrust to their health, which is hithertoneglected. Further it is found thatLodhas marry at tender age. Theanalysis of duration of married life alsopoints to the fact that young mothersshould be specially targeted to reachthese services. Again their attitudetowards life is very much molded by the

level of religiosity. Greater the religiositylesser is the utilization of the institutionalservices. The researcher made specificproposal with regard to the healtheducation round the year among thetribe particularly those residing in forestareas to generate a demand for suchservices by generating a sense ofrealization towards the importance ofpostnatal care services and its widerimplication to mother and the newly bornchild.

ACKNOWLEDGEMENTS

The authors sincerely acknowledge withthanks Prof. H.C.Srivastava ofInternational Institute for PopulationSciences, Mumbai, for his guidanceduring the period of the study. Authorsalso place on record and thank Mr. K.D.Saha, Ex. Dy. Director (East Zone), AllIndia Radio, Kolkata, who helped toenrich the manuscript. Authors are alsograteful to University GrantsCommission (UGC) for providingfinancial grant for the fieldwork of thestudy. Thanks are due to Dr. D. C. Jainand Mr. Shib Kumar of Regional MedicalResearch Centre for Tribals (ICMR),Jabalpur for providing different help atthe time of preparation of manuscript.Special mention may be made of Prof.A.P.Dash, Director, Regional MedicalResearch Centre for Tribals (ICMR), forhis continuous support, encouragementand provided the facility.

REFERENCES


1. Basu, S.K. ( 1987). Genetic, socio-cultural and health care among tribalgroups of Jagdalpur and Kota tehsilof Bastar district of MadhyaPradesh. In Anthropology,Development and Nation Building,eds. Kalla, A.K & Singh, S. ConceptPublishing Company, New Delhi.

2. Basu, S.K. & Kshatriya, G. (1989).Fertility and mortality in tribal popula-tion of Bastar district, Madhya Prad-esh, India. Biological Society, 6, 100.

3. Basu, S.K. (1990). Genetic, socio-cultural determinants of tribal health:Baster tribal group of MadhyaPradesh. In Cultural andEnvironmental Dimension onHealth, ed. Buddhadeb Choudhury.Inter-India Publication, New Delhi.

4. Bardhan, A. and Sinha S.K. (1989).A Diagnostic Study of FactorsResponsible for Lesser or NoUtilization of Health Facilities amongthe Bhils of Madhya Pradesh. PACReport, National Institute of Healthand Family Welfare, New Delhi.

5. Roy Burman, B.K. (1986). Morbidityand nutritional status of theScheduled Tribes of India. In TribalHealth: Socio-Cultural Dimensions,ed. Buddhadeb Choudhury, Inter-India Publication, New Delhi.

6. Roy Burman, B.K. (1990).Development hazards in health intribal India. In Cultural andEnvironmental Dimensions onHealth, ed. Buddhadeb Choudhury,Inter-India Publication, New Delhi.

7. Swain, S., Jena, S.C. and Singh, P.

(1990). Morbidity status of the

Kondha tribes of Phulbani (Orissa).

In Cultural and EnvironmentalDimensions on Health, ed.

Buddhadeb Choudhury, Inter-India

Publication, New Delhi.

8. Mukherjee, B.M. (1990). Health

status of Manipur women with

special reference to the tribals. InCultural and Environmental

Dimensions on Health, ed.

Buddhadeb Choudhury, Inter-IndiaPublication, New Delhi.

9. Mahapatra, S. (1990). Cultural

pattern in health care: a view from

Santal world. In Cultural andEnvironmental Dimensions on

Health, ed. Buddhadeb Choudhury,

Inter-India Publication, New Delhi.

10. Rizvi, S.N.A. (1986). Healthpractices of the Jaunsaries- a socio-

cultural analysis. In Tribal Health:

Socio-Cultural Dimensions, ed.Buddhadeb Choudhury, Inter-India

Publication, New Delhi.

11. Haque,M. (1990). Height, weightand nutrition among the six tribes ofIndia. In Cultural and EnvironmentalDimensions on Health, ed.Buddhadeb Choudhury, Inter-IndiaPublication, New Delhi.

12. Kapoor, R. (1994). Women, Workand Reproduction: A Study ofMuslim Chicken workers, A Ph.Dthesis of International Institute forPopulation Sciences, Mumbai.

13. Graham, W.J., Ronsmans, C.C.A.,


Filippi, V.G.A., Campbell, O.M.R.,Goodburn, E.A., Marshall, T.F. de C.,Sulman, C., Davis, J.L. (1995).Asking questions about women’sreproductive health in communitybased surveys: guidelines on scopeand content, Maternal and ChildEpidemiology unit Publication No.6.London School of Hygiene TropicalMedicine, London.

14. Risley, H.M. (1891). The Tribes andCaste of Bengal, Bengal SecretariatPress (reprint 1981), FirmaMukhopadhyay vol.II. Calcutta,

15. Census of India, (1951). DistrictHandbook, Medinipur, Calcutta.

16. Gupta, R. (1959). Lodhas revisited,Man in India, 39, 210.

17. Bhomick,P.K. (1964). The Lodhas ofWest Bengal: A Socio-EconomicStudy (reprint 1994), Rarh Samshriti

Sangrahalaya, Bidisa, West Bengal.

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19. Singh, K.S. (1994). The ScheduledTribe: People of India, vol.III,Anthropological Survey of India,Oxford University Press.

20. Jain, B.C. (1995). The Lodhas: astudy of their contemporary socialmilieu with special reference toFarrukhabad City (U.P.), Man inIndia, .21(3&4).

21. Hadderson, J. (1987). APSSX MADE

SIMPLE, Wadsworth PublishingCompany, Belmont, California.


INTRODUCTION

Tribes constitute an important segmentof the population of India. They aredistributed in three principal zonesnamely, North-Eastern, Central andSouthern zones with different dialects,cultural homogeneity and unifying socialorganization. Because of the scheduledliving of the groups, their pattern of living,food habits, dietary practices andattitude to various aspects of life ingeneral differs from non-tribalpopulation.

Tribal population is more concentratedin the central region of India. In Bastar,Abujhmaria tribe inhabits in Abujhmararea. Abujhmaria tribes live in forestecosystem and depend for their foodneed on local produce. Like their lifestyle their diet also offers tremendous

FOODS AND BEVERAGES CONSUMED BY ABUJHMARIAS -A PRIMITIVE TRIBE OF BASTAR IN CHHATTISGARH

Rekha Singh1 and Aruna Palta2

Abstract. Study was conducted on Abujhmaria tribe living in Orcha Block(Narainpur Tehsil) of district Bastar in Chhattisgarh list of Abujhmaria familieswas prepared and 100 Abujhmaria families were selected randomly. Aquestionnaire developed by NIN was used to collect information on diet surveyand socioeconomic status. It was found that they were consuming 3 meals aday and food intake was dependent mainly on availability of food. As they live inforest ecosystem their diet comprises of variety of unconventional foods viz;edible forms of flowers, fruits, tubers, reptiles, rodents and other flesh foodavailable from the forest. Variety of foods and beverage consumed by them areSalphi, Pej. Landa, Red ant chutney etc. Alcohol plays a significant role in thesocial and religious life of Abujhmaria tribe.

variations. Mostly the diet comprises ofvariety of unconventional foods viz.,edible forms of flowers, fruits, tubers,honey, rodents, reptiles and other fleshfoods available from the forest. Attemptsare at hand to understand the basis oftheir lifestyles, food habits, custom etc.through different surveys and studies.Food being the prime need of manrequires deep study in terms of quantityand quality. Very few scientists haveattempted to collect data from tribal livingin remote areas. Keeping this in view astudy was planned on Abujhmaria tribeof district Bastar to explore variousaspects of food, beverages and specialfoods consumed by them. Objectives ofthe study were as follows.

1, 2 Department of Foods and Nutrition, Govt. D. B. Girls Autonomous P. G. College,

Raipur- 492 001, Chhattisgarh.E-mail : [email protected]


OBJECTIVES

(i) To study the meal pattern ofAbujhmaria tribe.

(ii) To know the typical food andbeverages consumed by themand their method of preparation.

(iii) To know about their special foodsfor various occasions like births,deaths, marriages etc.

METHODOLOGY

Area: Bastar district of Chhattisgarh wasselected for the present investigationand study was conducted on theAbujhmaria tribes living in Orcha block(Narainpur Tahsil).

Sample: List of Abujhmaria householdswas prepared and 100 Abujhmariafamilies were selected randomly.

Data collection: An interview scheduledeveloped by NIN for tribals was usedto collect information for diet survey.Interview schedule was pretested andnecessary changes were done. Thedata was collected by paying repeatedvisit to the study area. In the initialstages, friendly discussions were donewith the help of interpreter. Situation wasbuilt up so as to develop efficient rapportwith the tribals. Information wascollected from the head of the familyregarding the nature of food consumedduring past 48 hours and the entrieswere made in the schedule.

RESULTS AND DISCUSSION

Socio-economic status: All the tribalfamilies surveyed were Abujhmarias,they were all non-vegetarians. All of

them were illiterate and were residing in“Kaccha” house. Majority of them had apet dog. Abujhmarias followed “Penda”cultivation i.e. occupying certain land,clearing the trees, bushes etc. and thensowing seeds in rainy season. Theydon’t use plough for farming. Majority ofthem belongs to joint family.

Meal pattern: Food habits of tribals aresaid to be unique.

1 Abujhmaria tribes

surveyed were generally consuming 3meals a day. Food intake wasdependent mainly on availability of food.Morning meal consisted of Pej or leftover rice of previous night (Table-1). Inafternoon Pej, Rice, Amat/Dal/Fleshfood, Red ant chutney was consumed.Dinner consisted of Pej, Rice or left overvegetable from lunch. Abujhmaria tribepredominantly eats Kosra (Kutki). Kosrais the most inferior minor millets grownin India. The Abujhmaria tribe has notyet progressed to the stage of ricecultivation that requires the use ofplough. The morning meal all overBastar is taken in liquid form called Pej,Java or Gato. It is a saline puddingchiefly of rice, together with smallproportion of various millets. Theadvantage of taking this preparation toforest is that, where there is no watersource, it quenched the thirst also. Themen usually go out with their gruel in agourd flask, to the fields or forest wherethey work and have their lunch inbetween. In the afternoon also somestale gruel is taken. Similarly uniquecooking practices were reported amongthe tribals of Madhya Pradesh.

2 They

prepare a beverage “Pej” by boilingcereals with buttermilk for long time.


Table 1: Meal Pattern of Abujhmaria Tribals

The evening meal is of boiled rice or millettaken with pulse of either Kulthi (horsegram), Urad (Black gram) or Mung (greengram) and vegetables. Abujhmarias arefond of a sauce made of Tamarind, Mango(amat), Mahua or Red or White ants. Pigsare reared for eating on festiveoccasions. Poultry is kept for frequentsacrifice and associated eating. Thesetribes does not consume milk at all. Useof spices, Salt, Chillies, Garlic, Turmericare made to limited extent. In addition tothese, drinks occupy a very importantplace in the life of the tribes of Bastar. Theuse of Mahua spirit is universal in Bastar.Other important drinks are Salphi andChind rus, which are a fresh or fermentedjuice of Sago palm (Caryota urens) andwild date palm. Landa (rice beer) an otherbeverage, which is very common andmade by boiling equal proportions of riceor Kosra (Kutki) and Madia (Ragi) flourand then fermenting it (Table-2).Seasonality and availability of fooddetermines the source of food in thepreparation of alcoholic beverages. Itwas reported that, millet based lessalcoholic beverages were said to benutritious providing proteins, mineralsand vitamins.

3 Similarly, it was also

found that favorite drink of “fulani herdsmans” was a type of milk beverage thatwas prepared by souring milk in theshade.

4 Studies on diet and nutritional

status of tribals indicate prevalence of

varying degrees of malnutrition.5

Madia Pej, which is very popularbeverage among tribes, is verynutritious. The protein content in madiais 8.79, fat 9.05g, carbohydrate is 47.44,calcium 500mg, iron 12mg, zinc 2mgand magnesium 110mg/100g.

6.

Abujhmaria tribe use fresh rhizomes oftikhur to prepare starchy flour, which hasa medicinal potential and is consideredgood for peptic ulcer patient, as itprovides cooling effect. This starchy flouris mixed with water and consumed in theform of sherbat. It is used as an energydrink and medicinal beverage for coolingeffect during hot summer.

Barring some tribes of Kerala and Nilgiri,the tribals are generally habituated totheir alcoholic drinks.

7 An alcoholic

beverage “bang chang” was reported tobe prepared by Monpas tribes ofArunanchal Pradesh with ground cerealor millet. Mahua flowers were said to bebasic ingredient in the preparation ofliquors.

8,2 Liquors prepared from

fermented mango juice were taken bytribals of Srikakulam district and itsconsumption was about 1-2 ltr./day.

9

Home made alcoholic beverages werealso prepared by tribes outside India.Amazonas of Peru use cassava in thepreparation of beers nijamashsubstance about the consistency ofbuttermilk.

10 Consumption of toddy,

Meals ItemsBreakfast Pej/ Salphi / Landa / Left over rice of previous night.Lunch Pej, Rice / Amat / Flesh food / Red-ant Chutney.Dinner Pej, Rice / Left over vegetable from lunch / dal.


tapped from palm and Sago trees was acommon practice among the tribes insouthern and central India.

11 The tribes

of Manipur and Nagaland consumed“Zu” a beer, brewed from rice andflavored with different herbs, collectedfrom the surrounding forest. Whereas,tribals of Andaman and Nicobar Islandsdid not distill any liquor but consumedthe Indian make foreign liquor, whichthey procured from the non-tribals of theplains.

11 Tribals of Orissa take rice in the

form of “Pak hal” i.e. cooked rice, soakedin water .

12 Wheat was consumed during

festival or sickness. Maize wasconsumed according to availability. Otherresearchers also observed similarfindings.

13,14 Studies on fisherman

community revealed that cereals was theirmajor food item.

15

Like non-tribals, Abujhmarias alsoprepare special foods on variousoccasions like births, marriages,festivals and deaths. Non-vegetarian food

Table 2: Food and beverage of tribals

Food item Ingredients Methods of preparationPej (Kosra) Kosra / Kutki

(Minor millet)In 2 It. water 100g Kosra is added and boiled.Salt is added to taste

Pej (Rice) Rice In 2 It. water 100g Rice is added and boiled.Salt is added to taste.

Madia Pej(Ragi)

Ragi (Minor millet)and Rice

In 2 It. water 50g Rice and 50g Ragi is addedand boiled. Salt is added to taste.

Maize gruel Maize Maize is grounded and soaked in waterovernight. Next day it is boiled and in the form ofthick gruel it is consumed.

Salphi Sap of Salphi tree(Caryota urens)

It is a fresh or fermented juice of Sago palm.

Chind Rus Sap of tree(Wild date palm)

It is fresh or fermented Juice of Wild date palm.

Fulee / mand(alcoholicbeverage)

Mahua flowers, Rice,Kutki, Ragi or sap takendirectly from forest.

Mahua flowers are collected and with otheringredients allowed to ferment for a few days.Then spirit is distilled by own indigenousdistillation plant.

Red-ant chutney Red ants, Ginger, Garlic,Chillies and Salt

All ingredients are grinned and consumed in theform of paste.

Tikhur sherbet Tikhur (Curcumaangustifolia) Starchwater and sugar

Tikhur starch is mixed with water and ifavailable sugar is added.

Rice amat Rice flour, Tamarind,Cowpea,Ginger,Garlic,Chilies & Salt

Rice flour, Tamarind, Cowpea and Salt is addedand cooked. It has a poring consistency.

Imlijhor Tamarind-pulp, Water,Salt and Dried fish

In approx. 2 It. Water 50g Tamarind, Salt and ifavailable Dried fish called Suksi is added andboiled. This preparation is very common insummer season. This Imlijhor is consumed withRice or Kosra rice.

Landa (Ricebeer)

Rice & minor millet(Kosra / Kutki andMadia)

Boiling equal proportions of Rice with Kosra orMadia flour makes thin paste and then it isfermented.


items like suksi (dry fish), mutton andchicken were special items prepared on

Table 3: Food for various occasions

S. No. Occasions Food items

1. Festival Pej, Rice, Bengalgram, Mutton, Chicken, Chappati, Wheat flourpakora, Bobo (Rice flour and Jaggery is kneaded together anddifferent shapes of vada are made and deep fried).

2. Marriages Pej, Bengalgram, Red gram dal, Rice, Chappati, Mutton, Chicken,Rice amat (puffed rice, jaggery, banana are mixed in water andserved as such).

3. Births Pej, Rice, Mutton, Chicken, Fish.

4. Deaths Rice, Pej, Rice amat, Lentil, Blackgram dal.

such occasions (Table-3).

Alcoholic drinks play a significant role inthe social and religious life of tribals.Alcoholic drinks like sulphi, chind andlanda are taken on all occasions.

Frequency of food intake: Data on foodintake frequency of Abujhmarias revealedthat among cereals, minor millets viz.,kosra (minor millet) and madia (Ragi) werethe main staple in the diet and were

not consumed daily by majority of them.Abujhmarias grew leafy vegetable either intheir own compound (Homestead) or in thefield. They also collected the vegetables fromnearby streams, penda fields and also fromplaces where they grow wildly. The leafyvegetables were known as “Bhaji”. This wasconsumed as per availability (Table 4).

Varieties of fruits like Maruha, mango,jamun, guava, custard apple, tendu, chind,

Table 4: Frequency of food intake (%)

Food stuffs Daily Twice aweek

Fortnightly Monthly Rarely Nil

Cereals

Rice - 100 - - - -

Wheat - - - - 100 -

Madia (Minor millet) 100 - - - - -

Kosra (Minor millet) 100 - - - - -

Kodo (Minor millet) - 10 45 10 35 -

Maize - - 100 - - -

Pulses / LegumesLentil 30 17 10 5 38 -Redgram - 40 20 40 - -Blackgram 40 3 57 - - -Bengalgram 40 1 59 - - -

Cowpea - 50 50 - - -Horse gram 35 31 34 - - -

consumed daily. Wheat was consumed onlyon certain special occasions, pulses were

Festival

Fortnightly Nil

Cereals

Pulses / Legumes


Green leafy vegetablesColocasia leaves - - 85 15 - -Amaranthus 24 32 36 3 5 -Bathua (C. album) - - 36 34 30 -Methi leaves - - - 100 - -Radish leaves - 100 - - - -Cabbage 20 - - - 80 -Spinach 20 - - - 80 -Koliaribhaji(Bauhinia) 80 20 - - - -

Chezbhaji 75 25 - - - -FruitsMahua - 10 - 80 10 -Mango - - - 100 - -Banana - - - 100 - -Jamun - 35 65 - - -Guava - 65 - 35 - -Custard apple - - - 100 - -Tendu / Chind / Char - - - - 100 -Other vegetablesBamboo shoots - 62 38 - - -Boda(Wildmushroom) - - 40 35 25 -Futto(Wildmushroom) - - 45 - 55 -Mushroom - 57 - 43 - -

Brinjal - - - 30 70 -Pumpkin - 57 - 43 - -Ladyfinger - - 15 13 - 72Tomato - - 10 60 30 -Bottle gourd - 20 35 45 - -Snake gourd - 40 53 7 - -Drumstick - 62 38 - - -Roots and tubersColocasia 2 4 10 24 60 -

Yam (Zimikand) 8 10 32 50 - -

Ginger 10 - 20 70 - -

Garlic 10 - 20 70 - -

Radish 10 - 20 70 - -

Tikhur 63 37- - - - -

Carrot - - - 70 30 -

Potato 80 20 - - - -

Onion 50 50 - - - -

Baichandi (Dioscoreahispida)

4 2 10 24 60 -

Other vegetables

Green leafy vegetables

Roots and tubers


Alukanda (Tapioca) 8 10 32 50 - -

Kalmal Kanda (Sweetpotato)

4 2 10 24 60 -

Nagarkanda (Dioscoreaalata)

10 - 20 70 - -

Dangkanda (Dioscoreabulbifera)

20 10 40 30 - -

Milk and milkproducts

- - - - - 100

Meat/Fish/Poultry/Mutton

2 54 18 26 - -

Crab 2 54 18 26 - -

Rodent 52 48 - - - -

Rat - - - 100 - -

Duck - - - 100 - -

Chicken - - - 50 - -

Pigeon - - 50 50 -

Fish 7 2 50 41 - -

Pork - - 3 97 - -

Egg 2 1 - - 87 -

Sugar / Jaggery 3 7 10 - 80 -

Fats and OilsMustard oil 3 7 10 - 80 -

Tora (Mahua seed oil) 3 3 7 10 - 80

Spices and Chillies 20 - 10 - 70 -

Tamarind 25 - 15 60 - -

chirongi etc. were collected from forestby tribals. Its consumption was dependedon its availability. As regards to roots andtuber tapioca, colocasia, bachandi, etc.were consumed frequently. Consumptionof milk was nil. Meat, fish and poultryformed an essential part of the tribalhousehold. Duck, pigeon, small chickswere reared so that they can be used assacrificial animals during family rituals.Intake of sugar and jaggery, fats and oil,species were almost negligible.

On the basis of this study, it is concludedthat Abujhmarias are the most primitive

tribes of Bastar. Their food consumptionpattern is different from ours. Alcoholplays a significant role in the social andreligious life of the Abujhmarias. Milletbased, less alcoholic beverages areconsumed by them which are said to benutritious, providing protein, mineralsand vitamins. Food intake is dependenton availability of food. Thus the studyprovided scope for conducing furtherstudies for analyzing nutritionalcomposition of variety of rare foodsconsumed by them like red ant chutney,

Milk & MilkproductsMeat/Fish/Poultry/Mutton

Crab

Milk & Milkproducts

Sugar / Jaggery

Fats and Oils


perennial leafy vegetables, landa, sulphi,tikhur sherbat etc.

ACKNOWLEDGMENTS

The authors are grateful to the Council ofScientific and Industrial Research, NewDelhi for providing financial assistance inthe form of Senior Research Fellowship.

REFERENCES

1. Rajyalakshmi, P. (1991). Tribal foodhabits. Ph.D. thesis submitted toAndhra Pradesh AgriculturalUniversity, Hyderabad, 134.

2. Rao, D.H. and Satyanarayana (1974).Nutritional status of tribal preschoolchildren of Andhra Predesh. IndianJournal of Nutrition and Dietetics, 11,328-334

3. Sen Gupta, P.N. (1962). Dietaries ofprimitive tribes. The Adibasis, RevisedEd. Publications Division, Delhi, 87-95.

4. Benefice, E.S., Chevassos-Agnes andBarrel, H. (1984). Nutritional situationand seasonal variations for part ovalistpopulation of the sahel (senegaleseferlo). Ecology Food and Nutrition, 14,229-247.

5. Patnakar. (1994). Tribal economyhealth and wasteland development.Inter India Publication, New Delhi. 152-157.

6. Vishwakarma, Meenakshi (2000). Astudy of food consumption pattern andfood analysis of rare foods eaten byKamars-A primitive tribe of MadhyaPradesh. Ph.D. thesis submitted toPandit Ravi Shankar Shukla University,Raipur. 231-232.

7. Rao, D.H. (1971). The tribal diets,Nutrition, National Institute of Nutrition.Indian Council of Medical Research,Hyderabad.6, 2-9.

8. Pingale, U. (1973). Some studies intwo tribal groups of central India. Part-2. Nutritive importance of foodsconsumed in two different seasons.Plant foods for man. 1, 195-208.

9. Pratap, D.R. (1975). Tribes of AndhraPradesh. World Telugu conferencepublication. 1

st World Telugu confer-

ence office, Hyderabad, India, 1-63.

10. Berlin, E.A. and Markell, E.K. (1977).An assessment of the nutritional andhealth status of an Ayuaruna Jivarocommunity Amazonas, Peru, EcologyFood and Nutrition, 6, 69-81.

11. Nutrition News (1996). NationalInstitute of Nutrition.. Hyderabad. 17:2.

12. Chandrashreelenka, (2002).Formulation and evaluation of low-costdiet for tribal children (1-5 years) ofOrissa. Ph. D. thesis submitted toBehrampur University.

13. Tamilarasi, Murugesan, P. andAnanthalakshmi, A. (1991). Dietarypractices of the paliyar tribal group andthe nutrient content of unconventionalfoods consumed. Indian Journal ofNutrition and Dietetics, 28 (11), 297-301.

14. Ali, A. (1987). Food habits, nutritionhealth status of the lanjia saora-Aprimitive tribe of Orissa. Proceedings of.Nutritional Society of. India. 33, 56-69.


INTRODUCTION

Lymphatic filariasis caused by threeclosely related filarial nematodes(Wuchereria bancrofti, Brugia malayi,and Brugia timori), are transmitted bymosquito vectors. It is estimated that atleast 120 million people in 83 countriesof the world are infected primarily byWuchereria bancrofti and to a lesserextent by B. malayi and B. timori

1. In

many urban areas of the world includingIndia, Culex species is the major vectorof W. bancrofti. Current estimatesindicate that about 467 million peopleare living in filariasis endemic zones. Ofthese, 109 million are living in urbanareas and the rest in rural areas. Thecommon manifestations of lymphaticfilariasis like lymphoedema,elephantiasis and hydrocele result fromirreversible damage caused to thelymphatics by the adult worms.

ELIMINATION OF LYMPHATIC FILARIASIS: ADOPTION OFAPPROPRIATE STRATEGY

D. Das1 and A. P. Dash2

Abstract. India is one of the signatories for the WHO programme on eliminationof lymphatic filariasis and planned to eliminate the disease by 2015. Under thisprogramme an individual (except children < 2 years and pregnant women) hasto consume a single dose of Diethyl Carbamazine Citrate (DEC) at a dose of 6mg per kg body weight annually for a period of 5-6 years, which will ultimatelyblock the transmission of the disease. Another aspect of this programme is toreduce the LF related disabilities by appropriate IEC. To achieve the goal of LFelimination, area and culture specific IEC strategies and programme monitoringshould be planned diligently.

The World Health Organization (WHO)initiated the Global Programme toEliminate Lymphatic Filariasis (GPELF)in 1998. Two major developments infilariasis research were instrumental forthis: Availability of newer diagnostic toolslike Og4C3 ELISA and ICT card test inthe detection of filarial infection

2, 3,4 and

the ability of Diethyl Carbamazine Citrate(DEC) to remove microfilariae fromcirculation even at a single dose. It wasplanned that DEC at a dose of 6 mg perkg body weight, if given as mass therapyalone or in combination withalbendazole, for a period of 4-6 years(fecund period of filarial worm) can blockthe transmission cycle of LF. Currently,this programme is largely based onrepeated annual cycles of Mass DrugAdministration (MDA) to endemicpopulations. These are based on rounds

1 Senior Research Officer,

2 Director, Regional Medical Research Centre for Tribals., Nagpur Road,

Jabalpur - 482 003.E-mail : [email protected]


of community-wide distribution of singleannual doses of combined drugregimens. The plan which was based notonly on the interruption of transmissionbut also prevention of LF relateddisabilities, was endorsed and adoptedby the Global Alliance for Elimination ofLF when it met for the first time inSantiago de Compostela in May 2000.

Till date, more than 32 out of 83 endemiccountries are in the eradicationprogramme globally. India has becomea signatory to it and initiated theprogramme in 13 districts in sevenendemic states namely AndhraPradesh, Orissa, Tamil Nadu, Bihar,Uttar Pradesh, West Bengal and Kerala.In Madhya Pradesh, first round of MDAwas started in 2004.This year, the StateGovernment is planning to implementthe programme in 11 districts. TheGovernment of Madhya Pradesh isgoing to start the second round of MDA,on 11

th November 2005 . High

compliance in the intake of drug byeligible population and consistency ofmass drug administration programmeare the key factors behind the successof LF control/elimination programme.

Appropriate strategies have to beplanned and the problems at planninglevel should be solved with propermobilization of resources and advocacy.The key factors, which should bestressed, are strong information,education and communication (IEC)strategies and prgramme evaluation

(short term and long term). IEC is animportant tool to achieve the desiredbehavioral change of the people toaccept the drug. While developing theIEC strategies, the strengths andweaknesses of the targeted groupsshould be taken into consideration. Forexample, in certain rural areas ofMadhya Pradesh, the knowledge aboutthe disease is low and they give lowpriority to its prevention

9. It was observed

that in some households, thesymptomatic individuals having filarialdisease in the family consume the drug.The other asymptomatic members(many of them may be microfilaraemic)give their quota to the affected individualand do not consume the drug.Considering these observations IECshould be more culturally oriented andarea specific. The IEC activities shouldnot be limited to the hands of theprogramme implementing agencies andall sorts of communication techniques,advocacy tools, and media outletsshould be exploited.

Evaluation of the MDA programme hasto be made to monitor its effectivenessin achieving the goal of lymphaticfilariasis elimination. In the absence ofdata regarding filariasis prevalence it willbe really difficult to monitor theprogramme and in such cases Og4C3ELISA/ ICT Card test can be used.However there are a few publishedreports in Madhya Pradesh and theprimary data came from health delivery


systems. These data though form thebasis of MDA programme in the State itunderestimates the real problem due tothe disease. In this context, data shouldbe generated prior to and after MDA bynight blood smear examination formicrofilaraemia and Og4C3 ELISA/ ICTCard test for antigenaemia estimation.In parallel with the above methods,xenomonitoring of mosquito populationby PCR can be used for detection offilarial infection. For measuringtransmission potential, specific PCRbased assays that detect only third-stage larvae can also be used.

REFERENCES

1. Michael E, Bundy D.A.P.(1997).

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filariaisis. Parasitology Today, 13:472-6.

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Luquiaud P, Plichart C, et al. (1994).

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3. Schuetz, A, Addiss, D.G., Eberhard,M.L. & Lammie, P.J. (2000)..

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6. Goverdhani P & Gyanchand. (1998).

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(1994). Preliminary findings from an

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of Madhya Pradesh Journal of

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10. Das, D., Kumar, S., Dash, A.P. and

Babu B.V. (2005). Knowledge oflymphatic filariasis among the

population of an endemic area in

rural Madhya Pradesh, India. Annalsof Tropical Medicine and

Parasitology, 99: 101-104.

11. Das, D., Kumar, S., Sahoo, P.K.,

Dash, A.P. (2005). A survey of

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12. Park J.E (1961) Filariasis in RewaDivision, Madhya Pradesh.

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district, Madhya Pradesh. Journal ofAssociation of Physicians India, 10:

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