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Table of Contents
REVIEW ARTICLE
Year : 2019  |  Volume : 56  |  Issue : 1  |  Page : 32-40

Malaria elimination in India—The way forward


1 ICMR–National Institute of Malaria Research, Field Unit, Bengaluru, India
2 Indian Council of Medical Research (ICMR), New Delhi, India

Date of Submission27-Mar-2019
Date of Web Publication7-May-2019

Correspondence Address:
Dr Susanta K Ghosh
ICMR–National Institute of Malaria Research, Field Unit, Poojanahalli, Bengaluru–562 110
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-9062.257771

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  Abstract 


The World Malaria Report 2018 published by the World Health Organization highlights that no significant progress in reducing global malaria cases was achieved for the period 2015–2017. India carries 4% of the global malaria burden and contributes 87% of the total malaria cases in South-East Asia. India is in malaria elimination mode, and set targets for malaria-free status by 2030. Diagnosis and treatment of asymptomatic falciparum malaria cases continues to be a challenge for health care providers. To overcome these hurdles innovative solutions along with the existing tools and strategies involving vector control, mass drug administration, disease surveillance hold the key to solve this gigantic health problem.

Keywords: Disease surveillance; drug resistance; malaria elimination; Plasmodium falciparum; Plasmodium vivax; vector control


How to cite this article:
Ghosh SK, Rahi M. Malaria elimination in India—The way forward. J Vector Borne Dis 2019;56:32-40

How to cite this URL:
Ghosh SK, Rahi M. Malaria elimination in India—The way forward. J Vector Borne Dis [serial online] 2019 [cited 2019 Aug 22];56:32-40. Available from: http://www.jvbd.org/text.asp?2019/56/1/32/257771




  Introduction Top


In the World Malaria Report 2018 produced by the World Health Organization (WHO), there were an estimated 219 million malaria cases and 435,000 related deaths in 2017. India currently accounts for 4% of the global malaria burden and contributes 87% of the total malaria cases in Southeast Asia[1]. A total of 0.84 million confirmed malaria cases and 194 related deaths were reported by the National Vector Borne Disease Control Programme (NVBDCP) in 2017[2]. Odisha, Chhattisgarh, Madhya Pradesh and Jharkhand states accounted for 74.1% of the total malaria cases reported in the country. The highest number of malaria cases (40%) was reported from the Odisha state[2].

In February 2016, the Government of India formally launched the National Framework for Malaria Elimination (NFME)[3], which outlines the strategies for elimination of malaria from India by 2030. It aims to interrupt indigenous transmission of malaria (zero indigenous case reporting) throughout the country, prevent reestablishment of transmission in areas where it has been eliminated, and maintain national malaria-free status by 2030 and beyond using the existing intervention tools and strategies. In 2017, India launched its five-year National Strategic Plan for Malaria Elimination[4]. This is a landmark plan to fight against malaria shifting the focus from “control” to “elimination”. The plan provides a roadmap to end malaria in 571 of country’s 678 districts by 2022. A detailed information on strategic action plan of malaria elimination with state level categorization has been described in a study by Narain et al[5]. An estimated cost of INR 20 billion will be required per year for implementation of malaria elimination in India[5]. Global Technical Strategy for Malaria Elimination framed by the World Health Organization (WHO) has recommended a 3-pillar system for elimination emphasizing universal access to malaria diagnosis and treatment, strengthen surveillance, and accelerate towards elimination[6].

Challenges in malaria elimination efforts

Diagnosis: Early diagnosis and effective treatment is one of the main pillars in malaria elimination. In India, malaria is a notifiable disease. This means any malaria case detected must be reported to the local health authority so that proper follow-up action can be undertaken. At present use of microscopy and/or immuno-chromatography-based rapid diagnostic tests (RDTs) used in the programme underestimates the prevalence of sub-microscopic and/or low-density infections (<100 parasites/μl)[7]. In most endemic areas, sub-microscopic and asymptomatic reservoirs of parasites have been shown to be efficient gametocyte producers[8], and thus, serving a potential source of continued transmission[9].

A new real-time micro-PCR based hand held PDA (personal digital assistant) diagnostic device has been developed recently by group of Indian scientists, which has very high sensitivity and specificity. This is a point-of-care device that can detect as low as 1.3 parasites/μl, and the results can be transferred to the health authorities through internet facility enabling detection of sub-microscopic and asymptomatic cases with highest accuracy. One device can perform about 80 to 100 tests per day which is more than that of one microscopist can perform. Thus, such device can play an important role in malaria elimination programme[10].

Asymptomatic cases: Asymptomatic cases carrying falciparum parasites in most endemic areas are potential source of transmission even in non-endemic areas especially among migratory labour force. Artesunate has very little effect on the late stage of gametocytes. A single dose of primaquine (0.75 mg/kg) is administered along with ACT, but that has rarely been tested in controlled trials, whether this translates into preventing people transmitting malaria to mosquitoes[11]. Studies should be undertaken to address such an important issue which will surely accelerate elimination process by stalling residual malaria transmission.

Treatment: In the elimination phase, prompt and effective treatment is an important factor. Both the Plasmodium vivax and P. falciparum are prevalent in India; however, treatment regimen for each species is different.

Plasmodium vivax: Infection with P. vivax was considered to be benign, but now this poses a great threat to malaria elimination for protracted illness and reports of severe clinical presentations and deaths. India contributes 18% of the total vivax cases globally[12]. Almost half of malaria cases in India are caused due to vivax infection. It is good to note that vivax malaria is still responding to the 3-day course of chloroquine (25 mg/kg)[13], though there are reports of presence of polymorphism in chloroquine resistance genes pvcrt-0 and pvmdr-1 in south India[14].

Vivax malaria is frequently encountered with the nagging issue of relapse caused by the presence of ‘hypnozoites’ in the liver. Only primaquine, an 8-aminoquinoline antirelapse drug (0.25 mg/kg per day) over a period of 14 days, currently used in the programme, remains an operational issue. Two recent trials with a single dose of Tefenoquine (up to 600 mg) also an 8-aminoquinoline, effectively prevented relapses of P. vivax malaria. On the other hand, tolerance to glucoses-phosphate dehydrogenase (G6PD) deficient patients warrants careful administration owing to its slow elimination of approximate terminal half-life of 15 days, compared to primaquine (approximate half-life 5 hr)[15]. Hence, development of newer molecules targeting ‘hypnozoites’ in liver stage is an urgent need. Possibly, this would deem necessary in the post-elimination period when relapse may frustrate such efforts.

Plasmodium falciparum: Chloroquine is no more effective for falciparum treatment, and thus not recommended in the national programme. WHO recommends all confirmed falciparum cases including mixed infections to be treated with artemisinin-based combination therapy (ACT). Several fixed-dose ACTs are now available containing an artemisinin component and a partner drug which has a long half-life, such as mefloquine (ASMQ), lumefantrine, amodiaquine, piperaquine, and pyronaridine[16]. In India, NVBDCP provides artesunate-sulfadoxine-pyrimethamine combination except in northeastern states. In P. falciparum, polymorphisms in Kelch propeller protein gene-chromosome 13 (k13) have been associated with ACT resistance in Asia, and are linked to treatment failure. Almost 200 k13 non-synonymous mutations have been reported. Mutations at F446I, R539T, I543T, P574L and C580Y have the highest prevalence. In spite of the existence of highly diverse k13 mutant alleles in Africa, the association between these alleles and treatment failure has not been confirmed. Recent report on artemisinin-resistant P.falciparum in Eastern India is a cause of prime concern. Two mutations at G625R as a potential novel mutation along long with R539T have been identified[17]. However, in vivo therapeutic studies need to be carried out where molecular markers may play a pre-emptive role for predicted prevalence of resistance and predicted prevalence of failure calculating the genotype-resistance index (GRI) and genotype-failure index (GFI), where GRI-prevalence of molecular marker/prevalence of parasitological resistance, and GFI-prevalence of molecular marker/prevalence of therapeutic failure[13].

Malaria in pregnancy: Malaria infections in pregnant women are the real cause of concern to build confidence in the communities during the elimination process. In most malaria-endemic areas, WHO recommends the intermittent preventive treatment (IPT) with sulfadoxine-pyrimethamine (SP) in the second and third-trimester of pregnancy. However, owing to widespread resistance to SP, ACT is becoming the choice both for treatment and prevention of malaria in pregnancy even during first trimester[18].

Vaccines: Efforts to make effective malaria vaccine are running for last three decades. Over 2000 vaccine candidates have been reported. Two vaccine candidates are undergoing trials. RTS,S/AS01 (trade name Mosquirix) is a recombinant protein-based promising malaria vaccine, containing sequences of the P. falciparum circumsporozoite protein fused to hepatitis B virus surface antigen and an immunogenic adjuvant AS01. It targets the pre-erythrocyte stage of P. falciparum parasites by inducing anti-circumsporozoite antibodies. A phase III randomized trial conducted in seven sub-Saharan African countries showed that three doses of RTS,S/AS01 (at month 0, 1 and 2) had a modest efficacy of 28.3% in children (aged 5–17 months) and 18.3% in infants (aged 6–12 weeks) against clinical malaria during 4 years follow-up. The efficacy further increased to 36.3% in children and 25.9% in infants with a booster dose at 20 months (after the initial dose)[19]. Another vaccine, PfSPZ, which is in an earlier stage of trials, has been found to offer complete protection to 55 percent in research volunteers for one year[20]. Though, considering the efficacy, vaccines may not be very useful in malaria elimination programmes. Possibly, these vaccines may be required to reduce mortality and morbidity in children in high malaria-endemic settings.

Mass drug administration: Mass drug administration (MDA) is an old strategy to delineate the residual malaria cases in most of the endemic areas. Its application in malaria elimination programme raises some doubts. Recent report from 16 villages (8 intervention and 8 control) spread across Cambodia, Laos, Myanmar and Vietnam in the Greater Mekong Delta sub-region indicates this strategy may be recommended in malaria elimination programme. By the third month of administrating the antimalaria drugs dihydroartemisinin-piperaquine and low-dose primaquine, the prevalence of P. falciparum had decreased by 92% in the MDA intervention villages. Over the subsequent nine months, P. falciparum infections returned but were well below baseline levels. The emergence and spread of multidrug-resistant P. falciparum in this sub-region continue to threaten global malaria elimination efforts. MDA—The presumptive antimalarial treatment of an entire population to clear the subclinical parasite reservoir is a potential strategy that can help accelerate malaria elimination[21].

Counterfeit drugs

Counterfeit and substandard drugs are associated with tens of thousands of deaths, mainly in young children in poor countries. It is responsible for an annual economic toll up to US$ 200 billion and contributes to the global threat of antimicrobial resistance. Recently, WHO has emerged as the global leader in the battle against poor quality drugs. Pharmaceutical companies have intensified their efforts in assuring the integrity of drug supply chains. Despite advances in drug quality surveillance and detection technology, more efforts are urgently required in research, policy, and field-monitoring to check the menace of counterfeit drugs[22]. Local drug and food control authorities must take strong measures to check circulation of spurious drugs. A study has found that 7% of anti-malarial drugs tested in India are of poor quality and many are fake. In Southeast Asia one in every 3 antimalarial drugs sold is also fake[23].

Surveillance: Surveillance is the backbone in malaria elimination, and in most of the states, this is not adequate, as the average annual blood examination rate (ABER) is below the threshold level of 10%. The NVBDCP through the respective state must address this issue by strengthening disease surveillance[2]. Several associated agencies are carrying out such activities but monitoring at the highest level will ensure improvement in case detection, line-listing of each case followed by treatment including follow-up. The People’s Republic of China adopted the ‘1-3-7’ strategy to detect and treat every single case of malaria during the elimination phase. Briefly, malaria elimination requires strong surveillance mechanism that can reliably and rapidly detect and respond to individual cases. This approach defines reporting of malaria cases within one day, their confirmation and investigation within three days including treatment, and the appropriate public health responses to prevent further transmission within seven days[24]. This simple approach is a valuable and simple set of targets that could be adopted by other countries for similar disease elimination programme. Currently, this strategy is followed in Karnataka that envisages rapid elimination process.

Urban malaria challenge: Urban malaria elimination is a great challenge because of several issues. Urban Malaria Scheme was launched in 1971 in 131 cities and towns especially to address urban malaria problem. All urban areas are governed by the respective Directorate of Municipal Administration under the Ministry of Urban Development. In most urban settings malaria transmission is directly related to building constructions that support breeding of the malaria vector Anopheles stephensi (Diptera: Culicidae). Moreover, huge human migration takes place in this sector. In urban areas, Department of Labour, Slum Development Board, Local Town Planning Department additionally play major roles in handling malaria and other vector-borne diseases[25].

Malaria interventions

Insecticide-based control: In India, An. culicifacies, An. stephensi, An. fluviatilis, An. minimus, An. dirus, and An. sundaicus are six primary, and An. varuna, An. annularis, An. Philippinensis, and An. jeyporiensis are four secondary vectors of malaria[26]. So far malaria control primarily rely upon insecticides in forms of indoor residual spraying (IRS) and insecticide-treated nets (ITNs & LLINs). Presently, insecticides belonging to different groups, namely organochlorine (DDT), organophosphate (Malathion), and synthetic pyrethroids (OP) are all used in public health. All the ITNs are primarily impregnated with OP compounds. Reports on insecticide resistance are well-documented. Resistance to OP compounds is a cause of concern. OP compounds with piperonyl-butoxide (PBO) can avert the resistance problem to some extent by synergism. PBO acts synergistically with OP compound preventing its detoxification in the mosquito. Programme may consider deploying other core-interventions as an approach to prevent, manage and mitigate insecticide resistance. The ITN and IRS products selected for co-deployment must not contain the same insecticide class(es)[27].

Fish-based larval control: Fish-based malaria control is a well-known strategy and practically this is one of the earliest method of vector management. Approximately, 315 larvivorous fish species belonging to 32 genera under seven families are used for mosquito control, and the family Cyprinodontidae contribute the highest number of genera (15) and species (300)[28]. Other known genera used for mosquito control belong to the genera Aphanius, Valencia, Aplocheilus, Oryzias, Epiplatys, Aphyosemion, Roloffia, Nothobranchius, Pachypanchax, Rivulus, Fundulus, and Cynolebias[29]. In the beginning of the 20th century, live bearing Poeciliid fish Gambusia affinis (Western mosquito fish), G. holbrooki (eastern mosquito fish) native to the southeastern USA and Mexico were widely introduced in several countries globally for mosquito control. There are no reported adverse effects of larvivorous fish on local native fish populations or other species[29]. Gambusia was brought to India in 1928 by Dr BA Rao from Italy and released in Lalbag tank in Bengaluru City. The other species Poecilia reticulata was brought to India in 1908. These fish are well-tolerated in polluted water bodies and suited good for drains, wells, and cesspools[28]. WHO has reviewed and given guidelines for release of these fish for malaria control[30]. In Karnataka, fish-based malaria control is main vector control strategy in sericulture areas, and subsequently implemented in the entire state based on successful outcomes for effective vector control[28].

Community engagement: The main stakeholders of any disease control programme are the local communities. However, community engagement is an integral part for successful implementation of diseases elimination. There are several mechanisms of community engagement, namely conducting health education through folk theatre, print media, electronic media, focus group discussion, person-to-person communication especially doctors-to-patients, etc[31]. In modern digital India era, authentic text messages can be easily shared through social media, like Twitter, WhatsApp, Facebook, etc. The local health authority should telecast such activities in the local cable channels in remote and outreach areas. This can have a huge impact on the disease control management.

In the democratic governance system, local self-government takes decisions at local level. Involvement and empowering of Panchayat Raj Institution should be an integral part in malaria elimination programme. Knowledge of vector control programme among the elected members is not adequate resulting improper implementation of such public health programme. Regular workshops at block-level with the elected members involving the local health authorities could yield desired results[32].

Newer innovations

Surveillance: In this digital and fast dissemination era, new innovations in disease surveillance employing smart phones for diagnosis, case management, treatment follow-up of each case is possible, and can be applied in malaria elimination programme[33]. The recently developed hand held micro-PCR device can perform such function[10]. Vector surveillance and intervention using GPS and Remote Sensed data can be performed effectively for spatial and temporal information[34]. Locally developed hand held Tablet computers are used for malaria surveillance and control in Mangaluru city. About 35 such devices have been provided to the local health staff for recording each malaria case and mosquito breeding habitats. Action taken for drug delivery to each patient including follow-up of radical treatment and source reduction of breeding habitats are monitored through these devices[35].

In each state, Regional Remote Sensing and Application Centres (under Indian Space Research Organization) records primary data of each village. Line listing of each malaria case and vector breeding sources can be included for effective implementation of elimination programme. The local health authority should take joint initiative to make such programme successful.

Vector surveillance: Routine vector surveillance is carried out for determining biodiversity of local mosquitoes. Host preferences of vectors are determined collecting mosquitoes landing on human and animal baits. This method of collection may be replaced using mosquito trapping devices. Behaviour of vector(s), feeding preferences (exo-or endophilic) can also be determined by this device. There are many such devices available which can be used in mosquito control operation[36].

Gene editing: The discovery of the clustered regularly interspaced short palindromic repeats (CRISPR)/CRISPR associated protein 9 (Cas9) system opened new vistas for gene editing. The use of CRISPR/Cas9 in mosquitoes follows from an idea, conceived in 2003, that naturally occurring genes producing homing endonuclease enzymes that target and cut specific deoxyribonucleic acid (DNA) sequences could be used to create gene drive. Here, the progenies thus generated follow gene drive inheritance against the natural Mendelian inheritance[37]. This has provided a widely accessible and potential molecular tool for creating driving transgenes. Currently, scientists are working on An. gambiae s.l., the most versatile malaria vector in Africa[37]. Application of this technology to control vectors, especially mosquitoes that carry malaria, dengue, chikungunya, etc has been recommended in India[38]. A careful consideration is strongly advocated while selecting the target genes. No ‘selfish genes’ should be selected where the target species is aimed at elimination rather than eliminating the diseases carried by them. Because eliminating of any species will severely affect the ‘Conservation of biodiversity’ concept. This tool would be very useful in eliminating invasive and endemic species which are responsible for damaging local biodiversity.

Malaria elimination initiatives

Several initiatives have been undertaken to target the goal of malaria elimination. Some prominent alliances and partnerships are mentioned here.

ICMR initiative MERA India: Indian Council of Medical Research (ICMR), through its institutes and several non-ICMR institutes, is supporting Government of India (GoI) and making efforts in demonstrating the best strategies which could be implemented in the field towards elimination of malaria. The institutes have taken up multi-centric concerted research studies with a specific mandate and objectives, wherein standard protocols are developed, which all sites will follow and generate uniform data.

However, there is very little cross-communication, harmonization and shared learning’s amongst the research communities. This often results in unnecessary duplication of efforts, and at times leads to contradictory results due to inappropriate approaches. Moreover, the findings of scattered and isolated research, which may have programmatic importance, are not communicated effectively to the national programme, thus, losing any translational values.

In this regard, ICMR has taken an initiative of creating a common platform and a shared research agenda and resources through establishment of the Malaria Elimination Research Alliance (MERA) India. The purpose of MERA India is to identify, articulate, prioritize and respond to the research needs of the country to eliminate malaria from India by 2030. MERA India is expected to reinforce improved scientific approaches for cutting-edge research building on experience and expertise, pool different types of expertise and experience, create interactive opportunities within and across research organizations; support and facilitate existing and emerging research organizations in identifying[39].

The President’s Malaria Initiative (PMI): PMI is a United States of America Government initiative with a mission to “reduce malaria-related mortality by 50 percent across 15 high-burden countries in sub-Saharan Africa”. The initiative was originally launched by the U.S. President George W. Bush in 2005, and has been continued by successive Presidents. PMI has expanded to 24 malaria-endemic countries in sub-Saharan Africa and 3 additional countries in the Greater Mekong Sub region of Southeast Asia. PMI works closely with national malaria programme and global partners including the World Health Organization, Roll Back Malaria, and Global Fund. Global malaria efforts, led largely part by PMI, have cut malaria mortality by over 60%, saved nearly 7 million lives, and prevented more than 1 billion malaria cases between 2000 and 2015. PMI currently supports malaria prevention and control for over 500 million people at-risk in Africa. The funding of this initiative in 2017 was US$ 723 million[40].

E-2020 countries: Several countries are moving towards malaria elimination. Maldives in 2015 followed by Kyrgyzstan and Sri Lanka were certified by WHO as malaria free in 2016, and 44 countries reported fewer than 10,000 malaria cases. In 2016, WHO identified 21 countries having the potential to eliminate malaria by the year 2020 – known as “E-2020 countries”. Some of these countries remain on track to achieve their elimination goals. In 2017, China has reported zero malaria case, while increased number of cases has been reported from South Africa[1]. A lesson from this initiative and corrective measures should be taken for the reasons of failures in achieving the elimination goal.

E-8 Countries-Contribution towards zero elimination of malaria in Southern Africa: The malaria programme in Namibia has expanded to include community-based testing, treating and tracing (TTT). Partners supporting the National Vector-borne Disease Control Programme (NVDCP) and Development Aid from People to People Namibia (DAPP Namibia) have been implementing malaria awareness campaigns using community volunteers to educate communities on malaria preventative measures and assisting in the distribution of long-lasting insecticidal nets–LLINs (bed nets) and now this strategy has broadened to TTT.

DAPP Namibia is part of a consortium consisting of five organizations; Ajuda de Desenvolvimento de Povo para Povo Angola (ADPP Angola), The MENTOR Initiative, CICA with JC Flowers Foundation operating in Angola and DAPP Namibia and AAP (Anglican Aids Programme) operating at Angola-Namibia boarders implementing E8 Malaria project targeting cross border mobile populations to eliminate malaria transmission among the countries. Surveillance in the malaria programme traces positive malaria cases and tests and treats everyone within a 100 m radius of the affected patient.

DAPP Namibia ultimate goal is to continue to be a part of the implementing organizations assisting the 8 SADC countries (Angola, Botswana, Mozambique, Namibia, South Africa, Swaziland, Zambia and Zimbabwe) governments to eliminate malaria in the continent[41].

High burden to high impact: Ten countries in sub-Saharan Africa (Burkina Faso, Cameroon, Democratic Republic of the Congo, Ghana, Mali, Mozambique, Niger, Nigeria, Uganda and United Republic of Tanzania) and India account for approximately 70% of global malaria cases and deaths. Four key components are: (a) Political will to reduce malaria deaths; (b) Strategic information to drive impact; (c) Better guidance, policies and strategies; and (d) A coordinated national malaria response. Strengthened political commitment, financing and programmatic action are urgently needed to get malaria responses back on track, especially in countries that carry the heaviest burden of disease[42].

The Asia Pacific Malaria Elimination Network (APMEN): APMEN is a network of countries and stakeholders in the Asia Pacific region that are committed to working towards malaria elimination. The Network acts as a platform to allow collaboration and exchange between regional malaria control programme and a range of international elimination partners from the academic, nongovernmental and private sectors, as well as the WHO.

APMEN was established in 2009 to bring attention and support to the under-appreciated and little-known work of malaria elimination in Asia Pacific, with a particular focus on addressing the unique challenges of Plasmodium vivax malaria. APMEN now consists of 18 Country Partners: Bangladesh, Bhutan, Cambodia, China, the Democratic People’s Republic of Korea, India, Indonesia, Lao People’s Democratic Republic, Malaysia, Nepal, Papua New Guinea, the Philippines, the Republic of Korea, the Solomon Islands, Sri Lanka, Thailand, Vanuatu and Vietnam.

APMEN also works in close partnership with the Asia Pacific Leaders Malaria Alliance (APLMA), to enhance and streamline the Asia Pacific’s regional response to malaria. The APLMA-APMEN partnership aims to strengthen elimination efforts through combining the political advocacy through shared experiences and coordinated action towards common goal of defeating malaria[43].


  Discussion Top


India is the second largest populous country in the world, and its 94% population is at risk of malaria. Decision to undertake malaria elimination is a huge challenge and needs proper planning, local leadership, political commitment and accountability. India is a vast country with different geo-ecological settings representing local malaria paradigms. Each paradigm is governed by local malaria vector(s). Mosquitoes are very sensitive to climatic factors. Hence, studies on vector(s) biology, behaviour, site of contracting the infection, etc. are utmost necessary to implement effective control of vectors.

Two human malaria parasites, P. vivax and P. falciparum are predominant in the country. In most of hilly and tribal high burden areas P. falciparum is predominantly present with limited P. malariae cases. The fifth new human malaria parasite P. knowlesi has been reported in Malaysia and adjoining Southeast Asian countries. It is not reported from India to date. However, in Andaman and Nicobar Islands, cases with P. knowlesi- specific gene sequences have been reported[44]. In a recent report, the possible role of An. sundaicus as vector of human P. knowlesi has been indicated. This needs to be confirmed. Two reasons do not support this finding are: (a) The P. knowlesi burden in these Islands is not enough to have incessant transmission in humans; and (b) An. leucospyrus group mosquitoes are the natural vectors of P. knowlesi in the non-human primates[45]. In these areas, only long-tailed macaques, Macaca fascicularis umbrosa, the only non-human primate is found in Andaman and Nicobar Islands[44]. A recent study in these Islands did not find P. knowlesi infection in this macaque[46]. These authors first time reported the presence of P. falciparum malaria parasites in two predominant non-human Indian primate species Macaca mulatta and M. radiata. This finding does not rule out the zoonotic source of P. falciparum infection, like P. knowlesi in human. This zoonotic source of human malaria parasites is surely not a good news when India is committed to eliminating malaria by 2030.

A Socio-Economic-Political-Cultural (SEPC) analysis will fasten the malaria elimination initiative. Social acceptance and political commitment on such programme will accelerate the elimination process. Proper financial provisions must be ensured so that there should not be any hurdle during the implementation phase. Additional support from philanthropic organizations, corporate houses, as part of the Corporate Social Responsibility would be an added advantage. There are many social misbelieves prevailing in many sectors of society. Gender inequality was also observed when a study was undertaken in South India under Roll Back Malaria initiative under WHO[47].

Mass dissemination campaign on the line of polio and tuberculosis should be implemented. Some prominent and socially accepted national and local celebrities conveying the specific messages should be given priority. Malaria elimination cell should be established in each State Health Headquarter followed by district administration for effective implementation of the programme. A national toll-free number dedicated for malaria elimination programme should work for 24 × 7. Routine inter-state border meetings between neighbouring states would maintain a regular check in the border areas. Involvement of school children, school teachers, like-minded NGOs, etc. will help accelerate the elimination process. Several competitions focusing various parameters of elimination may be organized to disseminate the elimination messages. All the State and District Programme Officers in the state should be retained at least for five years so that any administrative fallout may be avoided. Many states are now strengthening the entomological components by engaging local Entomologists. They can play a great role in the malaria elimination programme. Continued training programme needs to be organized for all the staff engaged in this endeavour.


  Conclusion Top


Elimination of any disease should be implemented on war footing. India should be declared as a malaria-war-zone, and everyone should participate in fighting against malaria. Now, the responsibility of programme implementation solely lies on the respective state governments. Each state should draw their plans according to the elimination category assigned by the NFME. For example, Karnataka falls under category-2 for largely malaria problem in two urban cities Mangaluru and Udupi which contributes about 72% of malaria in the state. In other words, if malaria control is to be achieved in these two cities, Karnataka will achieve malaria elimination much earlier. Vector surveillance will play an important role to sustain the malaria elimination process. The invasion of An. stephensi in Sri Lanka in the postelimination era is a warning signal[48]. This may become an Achilles’ heels.

In 2017, India reported a 24% decrease in malaria cases compared with 2016. Odisha reported an 80% decline in malaria cases and related deaths. This is a huge success in the history of malaria elimination. In 2016, the Odisha state government implemented a programme called Durgama Anchalare Malaria Nirakaran (malaria elimination in inaccessible areas), in short DAMaN. The programme was implemented in eight most high-burden districts. The strategy involved mass screening for malaria, where positive cases were treated under intensified supervision. Mosquito control measures were adopted and regular health education and behaviour change activities were held throughout the year. Indoor insecticide spraying, reduction of mosquito breeding habitats and free distribution of LLINs were some of the measures initiated[1]. The recent report is a precautionary note that sufficient LLINs and RDTs are not available in many areas of Odisha. Regular and timely supply of logistics along with trained health personnel is utmost necessary to make malaria elimination a reality[49].

In India, this is the beginning of malaria elimination, and everyone must join hands to achieve the goal of ‘Malaria-free India’.



 
  References Top

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