|Year : 2019 | Volume
| Issue : 1 | Page : 53-55
Malaria elimination drive in Odisha: Hope for halting the transmission
Madan Mohan Pradhan1, PK Meherda2
1 State Vector Borne Disease Control Programme, Boudh, India
2 Department of Health & Family Welfare, Bhubaneswar, Odisha, India
|Date of Submission||26-Mar-2018|
|Date of Web Publication||7-May-2019|
Dr Madan Mohan Pradhan
Additional Director of Public Health (VBD), Boudh, Odisha
Source of Support: None, Conflict of Interest: None
Keywords: DAMaN; Odisha; malaria
|How to cite this article:|
Pradhan MM, Meherda P K. Malaria elimination drive in Odisha: Hope for halting the transmission. J Vector Borne Dis 2019;56:53-5
|How to cite this URL:|
Pradhan MM, Meherda P K. Malaria elimination drive in Odisha: Hope for halting the transmission. J Vector Borne Dis [serial online] 2019 [cited 2019 Jun 26];56:53-5. Available from: http://www.jvbd.org/text.asp?2019/56/1/53/257775
Odisha is a highly malaria endemic state in India with ~46 million population at risk of infection,,. The interplay of various factors like favourable climate, geo types, large forest coverage, difficulty in accessing remote and hilly villages and prevalence of efficient Anopheles mosquito vectors have resulted in persistent malaria transmission in different parts of the state.
Malaria burden and transmission vary from region-to-region in Odisha. The KBK (Koraput-Bolangir-Kalahandi) regions followed by the northern and western districts are under very high risk of malaria infection. In contrast, eight coastal districts have demonstrated very low incidence of malaria over the years except few pockets in these districts. The Plasmodium falciparum infection rate is very high, i.e. 93% in 2012 and 81% in 2018 in the high malaria endemic districts. It is well-known that falciparum malaria is dangerous and needs aggressive management as its severity causes mortality,.
In spite of various programmatic efforts that have been taken up in the state following national guidelines for prevention and control of malaria, there was no significant decline in the malaria incidences for decades. State continued to account for nearly 40% of the total malaria burden of India, until 2017. Though there was substantial control of malaria in other states including northeastern states with strategic inputs from Government of India, there was no success which could be demonstrated in Odisha,.
The inputs from the field level learnings and the findings from the operational research conducted by the National Vector Borne Disease Control Programme (NVBDCP) on “Comprehensive Case Management Programme-CCMP” gave insights that persistence of malaria transmission occurs in remote villages/hamlets where there is poor surveillance and the presence of asymptomatic malaria cases (no fever but they test positive for malaria). These asymptomatic cases act as silent reservoirs for malaria. The State Government envisaged to launch an innovative programme,, “Durgama Anchalare Malaria Nirakarana (DAMaN)” to combat the asymptomatic reservoirs. DAMaN was conceived in 2016 but it was operational in mid 2017 and was rolled out in congruence with the availability of the long-lasting insecticidal nets (LLINs).
The main rider in DAMaN is simultaneous killing of the malaria-parasites from the entire population of remote and inaccessible pockets through mass screening and treating all positive cases and reducing the infected anopheline mosquito vector population with effective and supervised vector control measures such as promoting use of LLIN and conducting indoor residual spray (IRS).
The state leadership of Odisha stepped up to meet the cost of DAMaN from the state budget. All remote, inaccessible, un-served and under-served areas were addressed by DAMaN to detect all malaria infections with or without fever by using bivalent rapid diagnostic test (RDT). All the efforts were taken to defeat malaria in the remote-forested, tribal, marginalized and malaria-endemic villages. DAMaN, thus, stood out as a flagship state programme that was devised with strategic intervention based on research evidence, programme experience and resourced through state’s own fund. It’s noteworthy that health is a state subject in India, and the responsibility of malaria elimination lies on the State Government. Thus, State Government could take independent-decision to solve its biggest public health problem, i.e. malaria in hard to reach areas by initiating its own public health interventions. DAMaN activities are conducted twice to thrice in a year. Dealing with asymptomatic malaria cases, i.e. malaria infection having no fever was a huge challenge as it is difficult to capture such cases under routine fever surveillance system.
In DAMaN camps, the focus has been on health awareness and community mobilization. It targeted the entire population of the village where the priority was given to under-five yr children, pregnant women and lactating mothers. Besides malaria screening and treatment, haemoglobin estimation, anthropometric measurements are done to assess the nutritional status and find out anaemic cases. The anaemic cases are given iron and folic acid (IFA) supplementation and the malnourished children were given nutritional support through Integrated Child Development Services (ICDS). DAMaN camps initially were conducted twice a year and now it is done thrice a year. The first phase is being done prior to monsoon during April–May, second phase camps during September–October and the third phase during January–February.
In 2017, the first phase DAMaN camps could not be conducted in pre-monsoon season as during that time the state received >11.13 million LLINs from The Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM). These LLINs were distributed with meticulous planning in a campaign mode and through strict monitoring system. The District Collectors led the distribution process, with the support from all related departments. Political leadership at local level were also involved. The entire LLIN distribution process was monitored and supervised by high level steering committees formed at the state, district and block levels.
During the first and second phase of the DAMaN camps, the entire population was screened for malaria, however, in the third phase only under 5-yr children, pregnant women and lactating mothers were targeted. Best efforts were put for ensuring the availability of other health services like addressing minor ailments, left out immunisation cases, supplementation of IFA, treatment for worms, detection of hypertension, etc. ICDS workers and the health department personnel provided required health care services at the camp sites. Staff of other government and non-government sectors, community based organisations and community volunteers participated in DAMaN camps to make it a true community activity. DAMaN screening camps were also supported by very good innovative community mobilization, information, education and communication (IEC) & behavioural change communication (BCC) activities like village contact drive, school sensitization and Malaria Shramdhan Shivir.
Around 1.6 million population residing in high malaria risk areas of 24 districts are covered under DAMaN. In most of the DAMaN villages, the asymptomatic malaria proportion was too high in the first round ranging from 8–80%. After two-to-three rounds of DAMaN activities, the symptomatic case load has dropped to a very low level, but proportion of asymptomatic malaria cases still remain higher in some areas which is expected to decline after few rounds of DAMaN.
Odisha’s astounding success in reducing malaria is, however, not only because of state’s own efforts but also support from Government of India and the Global Fund as well. During mid 2017, 11.13 million LLINs which were supplied through Government of India by the Global Fund were distributed within a record time of four months despite the gruelling hot summer during June to September. Thus, all high risk population (more than 20 million) could entirely be protected in 17 districts and partially in three districts. This is the largest ever LLIN distribution campaign that any state government could successfully complete in a short span. Along with LLIN distribution, intensified health awareness campaigns and community mobilisation activities were conducted for up-scaling the use of LLINs and enhancing health seeking behaviour for improving community acceptance towards IRS. Routine programmes like surveillance, case diagnosis and treatment through the large network of around 47,000 Accredited Social Health Activists (ASHAs) and health facilities from district to subcentre levels continued as earlier.
As high risk population of both in remote and plain areas could be protected by LLINs and asymptomatic reservoirs got cleared in remote villages, along with other routine multi prong approaches, malaria transmission could be halted within short span of time.
There was increasing trend of malaria in 2017 which was more than 2016 till June and the decline started after the intervention in June–July 2017. Subsequently, there was a sharp declining trend every month and in 2018 there was around 80% drop in malaria cases as compared to 2017 and around 90% as compared to 2016 [Figure 1]. The test positivity rate (TPR) also declined to 1.03 in 2018 from 6.23 in 2017 and mortality declined by 87%.
|Figure 1: Trend of malaria in Odisha state for the years 2016, 2017 and 2018. Malaria cases in the state started declining after July for each year. Substantial reduction is noticed in subsequent months of 2017, compared to the corresponding months of 2016. The declining trend continues in 2018 with reporting of 59% case reduction in December 2018 (Predicted). Case reduction values are shown in percent.|
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We have achieved the initial success with very high declining trend which is a historical record. But there is a long way to go and it is not the time to be complacent seeing the immediate results. Sustaining the gains is a challenge, for which we need to have continuous efforts with strategic approaches in different malaria settings. The LLINs need to be replenished by 2019–20. Furthermore, additional LLINs are needed to protect the left out high malaria risk populations at the earliest possible time.
Malaria is a local and focal disease. We shall be able to ensure malaria-free state mainly by micro stratification and strategic interventions. Community ownership is the major strength for which civil society organisations should come forward and be a partner for the common goal. TATA Trust, Malaria No More are now in partnership with Odisha Government and earlier CARITAS India also supported the initiative with support from Global fund. Research and academic organisations need to generate evidences to reorient the programme as there may be many unseen threats in the biological field including drug and insecticidal resistance. Through this approach of malaria elimination the communities literally own the programme. Once, they understand why and how to defeat malaria then they will be self-reliant to combat malaria in their own community. When malaria declines it is a well-known fact that many more morbidities due to other cofactors decreases. Due to this decline in malaria cases in Odisha, India’s macro picture changed significantly and it is now recognised as one of the few countries where malaria has declined appreciably. While India showed 24% decline during 2018, Odisha showed >80% decline in malaria cases.
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