Journal of Immigrant and Minority Health

https://doi.org/10.1007/s10903-018-0767-9

ORIGINAL PAPER

Prevalence of Neglected Tropical Diseases (Leishmaniasis

and Lymphatic Filariasis) and Malaria Among a Migrant Labour
Settlement in Kerala, India
Sobha George1 · Teena Mary Joy1 · Anil Kumar2 · K. N. Panicker1 · Leyanna Susan George1 · Manu Raj3 ·
K. Leelamoni1 · Prem Nair4

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Abstract
Neglected tropical diseases (visceral leismaniasis, lymphatic filariasis) and malaria are endemic in northern states of India.
Kerala has become a hub of construction activities employing a large number of migrants from these endemic states. Stud-
ies on morbidity pattern among migrants in Kerala are lacking. It is essential to look into the burden of these infections
among migrant laborers who can act as reservoirs and are a threat to native population. A cross sectional study was done
among migrant laborers in Ernakulam district, Kerala. After getting informed consent, a questionnaire was administered to
each participant to collect sociodemographic details and 5 ml of blood was collected for detection of antigens using rapid
diagnostic tests (RDT). Of the 309 migrants tested, none of them were positive for leishmaniasis, while 3.8% were positive
for malaria and 3.6% for filariasis. With 2.5 million migrant laborers in Kerala, the magnitude of the problem in absolute
numbers is enormous. Active surveillance and treatment is needed to prevent the reemergence of these diseases in Kerala.

Keywords  Migrants · Neglected tropical diseases · Kerala · Malaria · Leishmaniasis · Filariasis

Introduction strategies, inadequate research and limited resource alloca-

Neglected tropical diseases (NTDs) are a diverse group
of communicable diseases that mainly affect people liv-
ing in poverty, without adequate sanitation and in close
contact with infectious vectors. Nearly one billion people
in the world suffer from NTDs, which are referred to as
“neglected” because they are characterized by little atten-
tion from policy-makers, lack of priority within health
* Anil Kumar
vanilkumar@aims.amrita.edu
1
Department of Community Medicine, Amrita Institute
of Medical Sciences, Amrita Vishwa Vidyapeetham,
Ponekkara, Kochi, Kerala 682041, India
2
Department of Microbiology, Amrita Institute of Medical
Sciences, Amrita Vishwa Vidyapeetham, Ponekkara, Kochi,
Kerala 682041, India
3 Heavily infected areas in India are found in the states of
Department of Public Health, Amrita Institute of Medical
Sciences, Amrita Vishwa Vidyapeetham University,
Ponekkara, Kochi, Kerala 682041, India
4
Amrita Institute of Medical Sciences, Amrita Vishwa
Vidyapeetham, Ponekkara, Kochi, Kerala 682041, India
tion [1]. Elimination programs for vector borne disease like
malaria, filaria and leishmaniasis is severely impacted by
migration from endemic areas to the areas that have achieved
control/elimination of these disease like the state of Kerala,
migration from endemic areas to nonendemic areas, trans-
border migration and migration from endemic rural areas to
endemic urban areas [2].
Visceral leismaniasis (VL) is a neglected vector-borne
parasitic disease which is endemic in 88 countries, mostly
least developed in the world. India, Nepal, and Bangladesh
harbour an estimated 67% of the global VL disease burden.
The disease was reported from 52 districts in four states
of India namely Bihar, Jharkhand, Uttar Pradesh and West
Bengal [3].
Globally there are about 120 million people with infec-
tion or lymphatic pathology due to lymphatic filariasis (LF).
India alone bears 40% of the global burden of this disease.
Uttar Pradesh, Bihar, Jharkhand, Orissa, Kerala, Gujarat [4,
5]. The total disability adjusted life years lost in India due
to this disease is around 2.06 million, resulting in an annual
wage loss of US $811 million [6]. The formal goal of the

13
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global lymphatic filariasis program is to eliminate the dis-
ease “as a public health problem” and 2020 is the target date
for interrupting transmission. The strategy calls for mass
administration (MDA) of a two drug regimen, diethylcarba-
mazine (DEC) and albendazole as a single dose annually for
4–6 years [7]. MDA has reduced microfilaraemia more than
95%, after two annual rounds. The MDA coverage in Kerala
in 2015 is reported to be 88.96%. Average microfilaria rates
in 2015 is reported as Kerala 0.10, Orissa 0.38, West Bengal
0.64, UP 0.07, Jharkhand 0.36 [7].
About 3.2  billion people, almost half of the world’s
population, are at risk of malaria. SEAR (South East Asia
Region) reports 1.3 million malaria cases in the world and
India contributes 70% of these [8]. National government in
the strategic action plan for malaria control in India 2012-
17 aims at scaling up malaria control interventions with a
focus on high burden areas. Malaria elimination is defined
as no indigenous transmission i.e. annual parasite incidence
(API) < 1. The API wise distribution of the states in 2011
shows Orissa 5–10 and Kerala < 0.1 [9]. The incidence of
malaria cases are on the rise all over Kerala due to the influx
of migrant laborers from endemic states.
Commercial, point-of-care immunochromatographic tests
also called rapid diagnostic tests (RDT) has allowed antigen
testing to be reliably done in small laboratories or in field
settings and has assumed an important role as a tool for
public health use. RDT’s are preferred due to their rapidness
(test results were available in < 15 min), simplicity (requires
minimal training and equipment), and ease of interpreta-
tion (results can be visually read). WHO has even recom-
mended RDT for epidemiological studies such as to detect
and monitor the incidence or prevalence of NTD for target-
ing prevention and evaluating health programmes [10–13].
RDTs have made obsolete the sole dependence on clinical
diagnosis for NTD in developing countries where access
to good microscopy is very poor [11]. RDTs for malaria,
filariasis and leishmaniasis have been extensively evaluated
in field trials and found to have acceptable sensitivity and
specificity [12].
Migration due to uneven development is an important
feature of human civilization. The landless poor who mostly
belong to lower socioeconomic class from rural areas con-
stitute the major portion of migrants in India. According
to a 2013 survey, there are over 2.5 million lakh domestics
migrant labourers in Kerala from other states of India, with
an annual arrival rate of 235,000 [14]. Ernakulam being a
hub of construction activities has a large influx of migrants
consisting of young adults who are highly mobile within
Kerala. They come mainly from the northern states of West
Bengal, Bihar, Assam, Uttar Pradesh, Jharkhand and Odisha.
Studies on morbidity pattern regarding NTDs (leishma-
niasis and lymphatic filariasis) and malaria among migrants
in Kerala are lacking. It is highly essential to look into the
13
Journal of Immigrant and Minority Health
burden of these diseases among migrant labor population
in Kerala as they can act as reservoirs leading to transmis-
sion to the native population and ultimately establishing
an endemic focus in the state. Hence this study was con-
ducted to assess the prevalence of NTDs (leishmaniasis and
lymphatic filariasis) and malaria among a migrant labor
settlement in Kochi Corporation of Ernakulam district in
Kerala and also to study the associated risk factors for these
diseases which will help in formulating policies to prevent
transmission and morbidity and mortality associated with
these diseases.
Methods
A cross sectional study was conducted among migrant labor-
ers in a labor settlement in Kochi from Feb–June 2016.
Kochi is a corporation in Ernakulam district of Kerala State
in India. Kochi is witnessing a rapid growth in information
technology, health services and tourism sector which leading
to manifold increase in construction activities resulting in
influx of migrants from northern states of India. The severe
shortage of laborers from the native population has offered
myriad of employment opportunities to these migrants and
has led to the establishment of several migrant settlements
in Kochi. The migrant settlement chosen for this study
contained laborers who were employed in various sectors
like construction, waste management, gardening, clean-
ing. The study population included laborers from north-
ern states of India like West Bengal, Bihar, Assam, Uttar
Pradesh, Jharkhand and Odisha. A pilot study was done
among 30 workers in the settlement which showed 2 posi-
tive for malaria (6.6%). With 95% confidence and absolute
precision of 3%, a sample size of 276 was calculated. There
were 350 people in the settlement. The present study being
a pilot project, it was considered appropriate to include all
the workers of the settlement in the study. Laborers who did
not give consent and those who spoke regional languages for
which translators were not available were excluded from the
study. Accordingly, data was collected from 309 individu-
als. A pre-tested questionnaire containing questions on socio
demographic variables, questions related to the different
diseases under study and associated morbidities was used.
After getting informed consent from the participants, trained
investigators with the assistance of translators administered
the questionnaire to each participant following which 5 ml of
blood was collected from each participant by a phlebotomist.
Detection of the antigens in the blood samples was done
in the microbiology lab of the institution. Antigens testing of
the samples were done using RDT. Malaria testing was done
using SD BIOLINE Malaria Ag P.f/Pan test which is a rapid,
qualitative and differential test for the detection of histidine-
rich protein II (HRP-II) antigen of Plasmodium falciparum
Journal of Immigrant and Minority Health
and common Plasmodium lactate dehydrogenase (pLDH) of
Plasmodium species in human whole blood. Filarial testing
was done with the BinaxNOW Filariasis card test (Alere,
Scarborough) for Wuchereria bancrofti antigen and visceral
leishmaniasis was detected using Kala-azar Detect (InBios
International, Inc.) which detects a kinesin-related recom-
binant protein of 39 amino acid repeats.
Prior to use the RDTs were brought to room temperature
and labelled with a sample code. Each sample was tested
once for each of the three diseases according to the man-
ufacturers’ instructions. Briefly, 50 µl of whole blood or
serum was added to the sample pad, allowing any antigen
present in the sample to bind to the colloidal gold-labelled
antibody on the strip. Results of test and control lines were
recorded as positive or negative only if control lines were
present. In the absence of the control line, the test result was
recorded as invalid. Reading and interpretation of the results
followed the manufacturer’s instructions. Results were read
and recorded on a standardized form by a technician at the
minimum reading time and within the maximum time rec-
ommended by the manufacturer.
Data collected from 309 individuals and were entered into
Excel sheet and analyzed using SPSS 17 version. Qualita-
tive variables were expressed as percentages and quantitative
variables were expressed as mean with standard deviation.
Associations were checked using Chi square test. Variables
with p value < 0.2 were selected for multivariate logistic
regression. Accordingly, educational status, sector of work
and mosquito net usage in native place were analysed for
malaria and age category, educational status was analysed
for Filariasis. Study commenced after getting clearance from
the institutional ethical committee. Those found positive
were treated according to the best practice followed by the
institution.
Results
A cross sectional study was conducted to assess the preva-
lence of NTDs (leishmaniasis and lymphatic filariasis) and
malaria among migrant labor settlement in Kochi, Ernaku-
lam district and also to study the associated risk factors of
these diseases among the migrant workers. Regarding socio
demographic factors of the migrant laborers, the mean age
of participants was 27.72 (± 11.98) years. All were males.
The mean time of employment in the current settlement was
8.27 (± 12.65) months. The socio demographic profile of the
study population is presented in Table 1.
Of the 309 individuals tested, none of the individu-
als were positive for VL. Twelve persons (3.8%; 95% CI
1.63–5.97) were positive for malaria (P. falciparum) and
11 persons (3.6%; 95% CI 1.48–5.72) were positive for
filariasis.
Regarding history of Malaria, 24.6% (76/309) reported a
previous episode of malaria and 94.7% (72/76) among them
took treatment. History of malaria among the family mem-
bers was reported by 21.7% (67/309). Considering filariasis,
3.2% (10/309) reported filariasis in a family member. Mass
drug administration (MDA) against filariasis using alben-
dazole and diethylcarbamazine was taken by 3.9% (12/309)
while 42.1% (130/309) did not know about MDA. Visceral
leishmaniasis was not reported among family members of
any participants in the study.
All the 12 cases (100%) of Malaria were natives of
the state of Orissa. Among the 11 filaria cases, majority
(64%) were natives of Orissa while others belonged to Uttar
Pradesh (18%), Bihar (9%) and West Bengal (9%).
Level of education, type of native house, presence of
domestic animals, use of mosquito nets and habit of sleeping
outside was not found to be statistically significant for the
prevalence of malaria and filariasis (Table 2). On multivari-
ate logistic regression, educational status, sector of work and
mosquito net usage in native place were analysed for malaria
and age category, educational status were analysed for Fila-
riasis. No independent predictors for malaria or filariasis
were noted by multivariate logistic regression (Table 3).
Discussion
This cross sectional study conducted to assess the prevalence
of NTDs (leishmaniasis and lymphatic filariasis) and malaria
showed 3.8% of migrants to be positive for malaria, 3.6% to
be positive for filariasis and none positive for leishmania-
sis. Level of education, type of native house, presence of
domestic animals, use of mosquito nets and habit of sleeping
outside was not found to be statistically significant for the
prevalence of malaria and filariasis.
As per WHO guidelines-2011, the districts having
observed minimum five rounds of MDA with more than 65%
coverage against total population at risk are to be subjected
to transmission assessment survey (TAS) to take a decision
for MDA stoppage [6]. Till May 2015, 49 districts have been
successfully cleared through TAS out of which four are in
Kerala and Ernakulam district is one among them. When
results of TAS are leading to stoppage of MDA in Ernaku-
lam, it is highly essential to look into the burden of filariasis
among migrant population. Continuation of MDA among
migrants even if it is being stopped among the native popula-
tion has to be considered.
In this study, 3.8% (95% CI 1.63–5.97) were positive for
malaria and all were P. falciparum cases. All the positive
cases reported were from the state of Orissa. Although the
state of Orissa constitutes only 4% of the total population
of India it contributes the highest number of malaria cases
(22%); 43% of total P. falciparum cases and about 50% of
13
 Journal of Immigrant and Minority Health

Table 1  Sociodemographic Characteristic Frequency Percentage (%)

profile of the study population
Marital status
 Married 124 40.1
Native place
 Orissa 188 60.8
 West Bengal 70 22.7
 Madhya Pradesh 23 7.4
 Others 28 9.1
Place of residence
 Rural 301 97.4
Educational status
 Illiterate 117 37.9
 Literate 192 62.1
Current sector of work
 Construction 121 39.2
 Waste management 60 19.4
 Cleaning 42 13.6
 Gardening 13 4.2
 Others 73 23.6
Type of house at native place
 Kutcha 217 70.2
 Pucca 87 28.2
 Mixed 5 1.6
Presence of domestic animals in native place 155 50.2
Mosquito net usage in native place 155 50.2
Mosquito net usage in current place of residence 139 45
Habit of sleeping outside in native place 76 24.6
Habit of sleeping outside in current place of residence 14 4.5
Insecticide spraying around native place of residence 105 34
Insecticide spraying around current place of residence 151 48.9

all reported deaths due to malaria in the country. P. falcipa-
rum accounts for 80–90% of the malarial cases in the tribal
areas of the state [15]. The integrated disease surveillance
project reports accessed from the Directorate of Health Ser-
vices, Government of Kerala shows that there were 1751 and
1549 cases of malaria with six and four deaths in 2014 and
2015 respectively. The data for 2016 till 1st October shows
a total of 1053 malaria cases of which 95% (1002/1053)
were imported [16]. These reports indicate that the migrant
laborers act as a new reservoir for malaria thereby leading
to indigenous transmission in Kerala. The living conditions
of these migrant laborers are very bad with poor personal
hygiene, poor sanitation and overcrowding making it con-
ducive for vector breeding and consequent transmission of
malaria and other vector borne diseases.
None of the participants in this study were positive for
leishmaniasis. Cutaneous leishmaniasis has been reported
from Kerala and till recently, assumed to be an imported dis-
ease [17]. However, a recent study investigating cutaneous
leishmaniasis in a tribal population reported 12 cases with
no history of travel to endemic states or contact with people
from endemic areas, therefore establishing indigenous foci
in Kerala [18]. The temporal distribution of sand flies in
relation to environmental factors was studied in the Kani
tribe settlements located on the southernmost part of the
Western Ghats, Kerala, India, between June 2012 and May
2013 [19]. No sand fly species other than P. argentipes was
obtained from cattle sheds. Although, sand fly populations
were prevalent throughout the year, their abundance fluctu-
ated with seasonal changes. Visceral leishmaniasis has never
been reported in indigenous population. With the presence
of the vector and migrants arriving from areas where the
disease is endemic, the chance of visceral leishmaniasis
becoming endemic is very likely.
Level of education, type of native house, presence of
domestic animals, use of mosquito nets and habit of sleeping
outside was not found to be statistically significant for the
prevalence of malaria and filariasis according to this study.
A study done in Calcutta showed that having a household
member with malaria, illiteracy, low household income

13
Journal of Immigrant and Minority Health

Table 2  Association of socio demographic factors with the diseases

Factor Malaria p value Filaria p value
n (%) n (%)
Positive 12 (3.8) Negative 297 (96.2) Positive 11 (3.6) Negative 298 (96.4)

Age
 ≤ 23 8 (4.8) 159 (95.2) 0.549 3 (1.8) 164 (98.2) 0.067
 > 23 4 (2.8) 138 (97.2) 8 (5.6) 134 (94.4)
Education
 Illiterate 7 (5.9) 110 (94.1) 0.136 7 (6) 110 (94) 0.073
 Literate 5 (2.6) 187 (97.4) 4 (2) 188 (98)
Type of house
 Kutcha 10 (4.6) 207 (95.4) 0.58 8 (3.6) 209 (96.3) 0.91
 Pucca 2 (2.3) 85 (97.7) 3 (3.4) 84 (96.6)
 Mixed 0 5 (100) 0 5 (100)
Domestic animal
 Present 7 (4.5) 148 (95.5) 0.564 7 (4.5) 148 (95.5) 0.363
 Absent 5 (3.2) 149 (96.8) 4 (2.6) 150 (97.4)
Mosquito net usage
 Present 4 (2.6) 151 (97.4) 0.234 6 (3.9) 149 (96.1) 0.767
 Absent 8 (5.2) 146 (94.8) 5 (3.2) 149 (96.8)
Habit of sleeping outside
 Yes 3 (3.9) 73 (96.1) 0.974 4 (5.3) 72 (94.7) 0.356
 No 9 (3.9) 224 (96.1) 7 (3) 226 (97)
Sector of work
 Construction 1 (0.8) 120 (99.2) 0.052 5 (4.1) 116 (95.9) 0.692
 Waste management 4 (6.7) 56 (93.3) 1 (1.7) 59 (98.3)
 Cleaning 1 (7.7) 12 (92.3) 0 13 (100)
 Gardening 2 (15.4) 11 (84.6) 0 13 (100)
 Others 4 (3.9) 98 (96.1) 5 (4.9) 97 (95.1)

Table 3  Logistic regression of sociodemographic factors associated done among population residing permanently in endemic
with prevalence of malaria and filariasis areas. A study from Kuwait on filarial antigenaemia among
Variable Adjusted odds 95% CI migrant workers found that the overall prevalence was
18.3% with more than 90% of the study subjects from filaria
Malaria
endemic areas of Bihar, Andhra Pradesh, Uttar Pradesh and
 Educational status 0.211 0.145–1.534
Tamil Nadu in India [23]. A similar study in the Indian expa-
 Sector of work 0.119 0.853–3.997
triate population in Saudi Arabia reported a lower preva-
 Mosquito net usage 0.308 0.554–6.506
lence of 10.6% due to inclusion of groups of individuals
Filariasis
from the Indian state of Kerala, where filarial infection is
 Age category 2.814 0.720–11.002
very low [24]. A similar prevalence of 10% filarial infection
 Educational status 0.391 0.110–1.390
was also reported in migrants from Myanmar in Thailand
[25]. This is the first study from India which has tried to
determine the burden of transmissible vector borne diseases
and living in a structure not built of bricks were associated among migrant laborers from an endemic area living in a
with an increased risk for malaria [20]. A study in Andhra non-endemic area.
Pradesh revealed that socioeconomic variables like educa- The state of Kerala in south India is an exception when
tional status, house structure and participation in mass drug compared to the other states within the Indian subcontinent.
administration program were found to be highly associated The health indicators, life expectancy and literacy are close
with the occurrence of filarial disease [21]. A study in Bihar to those of developed countries [26, 27]. Kerala’s human
points out that Visceral leishmaniasis is linked to poor hous- development index as reported in a 2011 census was 0.920,
ing and unhealthy habitats [22]. All the above studies were which is higher than that of most developed countries [28].

13

In the National Family Health Survey conducted in 2014-
15 the infant mortality rate (IMR) per 1000 live births was
down to six, equalling the IMR rate of the United States
[29]. It also has the distinction of being the cleanest and
healthiest state. The re-emergence of these vector borne
diseases in Kerala due to influx of migrant population from
endemic areas has the potential to reverse all these gains
by increasing the morbidity and mortality among the native
population.
A few limitations were noted in our study. This study has
been conducted in a single migrant settlement. Generaliza-
tion of the study results to the whole migrant population
requires further studies. Sample size was small as it was
estimated with a lesser precision due to logistic reasons.
The samples were screened using RDT which could have
missed few cases due to their poor sensitivity when com-
pared to ELISA based testing kits. Screening the samples
using a molecular test could have identified asymptomatic
carriers with very low parasitic load. However being an ini-
tial attempt to delineate the NTD issue among migrants the
present study is relevant.
Conclusions
The study showed 3.8% of migrants positive for malaria,
3.6% positive for filariasis and none positive for leishma-
niasis. Though the prevalence percentage seems to be small,
with an annual arrival rate of 235,000 migrants to Kerala and
2.5 million migrant laborers working in Kerala, it translates
to nearly 100,000 cases. Migrant laborers from endemic
areas have the potential to thwart the achievements of the
control/elimination programs in the state of Kerala which
is abundant with vectors vital for transmission of these dis-
eases. Kerala government’s objective to achieve elimination
of filariasis is facing a daunting challenge and implementing
MDA among migrants needs to be actively considered. Level
of education, type of native house, presence of domestic
animals, use of mosquito nets and habit of sleeping outside
was not found to be statistically significant for the prevalence
of malaria and filariasis. Only active surveillance among
the migrant workers and their subsequent treatment coupled
with clean environment will help in averting a possible out-
break. The findings of the present study will help formulate
policies to implement measures to prevent transmission and
re-emergence of these vector borne diseases. The public
health care system along with the ministry of labour should
address this important emerging issue.
Acknowledgements  We thank D M Vasudevan of Amrita Institute of
Medical Sciences for the research Grant. We thank Amritesh, Paul T
Francis, Sreejith S Nair and Rakesh P S of the Department of Commu-
nity Medicine for their cooperation. Sumi and Libin from Department
13
Journal of Immigrant and Minority Health
of Public Health are acknowledged for the logistic support, Sumi and
Shanti from Department of microbiology for their technical assistance.
Funding  Intramural funding from Amrita Institute of Medical Sci-
ences, Amrita Vishwa Vidyapeetham University (Grant No. 32456),
Ponekkara, Kochi, Kerala, India, Pin: 682041.
Compliance with Ethical Standards 
Conflict of interest  The authors have no conflicts of interest to declare.
Ethics Approval  The study received ethical approval Amrita Institute
of Medical Sciences and Research Center Ethics Committee.
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