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Table of Contents
Year : 2019  |  Volume : 56  |  Issue : 1  |  Page : 60-65

Malaria elimination: Using past and present experience to make malaria-free India by 2030

1 Malaria Elimination Demonstration Project, Foundation for Disease Elimination and Control of India, Mandla, India
2 Vector Borne Disease Control Programme, Directorate of Health Services, Bhopal, India
3 ICMR–National Institute of Research in Tribal Health, Indian Council of Medical Research, Jabalpur, Madhya Pradesh, India

Date of Submission26-Mar-2019
Date of Web Publication7-May-2019

Correspondence Address:
Dr Altaf A Lal
Malaria Elimination Demonstration Project, ICMR–National Institure for Research in Tribal Health, Jabalpur-482003, Madhya Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0972-9062.257777

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Malaria causes significant morbidity and mortality worldwide. Since 2005, malaria cases have been declining globally with many countries having eliminated malaria and several other countries heading towards malaria elimination. The World Health Organization’s Global Technical Strategy for malaria targets at least 90% reduction in case incidences and mortality rates, and elimination in 35 countries by 2030. India along with other Asia-Pacific countries has pledged to eliminate malaria by 2030. Sustainable vector control and case management interventions have played a pivotal role in malaria control leading to elimination. Malaria is complex in India due to the presence of multiple parasites and vectors species, asymptomatic cases, resistance against antimalarials and insecticides, social, demographic, cultural and behavioural beliefs. Therefore, maintaining zero indigenous malaria transmission and preventing malaria through importation of cases requires well-planned multi-pronged intervention strategies. This article provides insights into the past and present malaria control and elimination efforts that may be useful for the national programme for eliminating malaria from India by 2030.

Keywords: India; insecticide; interventions; malaria elimination

How to cite this article:
Lal AA, Rajvanshi H, Jayswar H, Das A, Bharti PK. Malaria elimination: Using past and present experience to make malaria-free India by 2030. J Vector Borne Dis 2019;56:60-5

How to cite this URL:
Lal AA, Rajvanshi H, Jayswar H, Das A, Bharti PK. Malaria elimination: Using past and present experience to make malaria-free India by 2030. J Vector Borne Dis [serial online] 2019 [cited 2023 Mar 27];56:60-5. Available from: http://www.jvbd.org//text.asp?2019/56/1/60/257777

  Introduction Top

Malaria remains as one of the most ancient and deadly diseases, but there is optimism that elimination of this disease is an achievable goal. India, along with 15 countries in the sub-Saharan Africa contributes to about 80% of the global malaria burden. Between 2000 and 2015, global case incidence[1] has fallen by 41% and mortality rates by 62%. The 2018 World Health Organization (WHO)[2] reports that malaria is endemic in 76 countries, an estimated 219 million cases and 435,000 related deaths occurred in the year 2017. The report also revealed that after an unprecedented period of success in global malaria control, progress has stalled.

The Global Technical Strategy (GTS) for malaria 2016–2030, developed to accelerate progress towards malaria elimination sets the target of reducing global malaria incidence and mortality rates by at least 90% by 2030. The other milestones include global reductions in disease burden to at least 40% by 2020 and 75% by 2025, and elimination in at least 10 and 20 countries by 2020 and 2025, respectively. The GTS for malaria elimination stresses on three pillars that a malaria elimination programme should focus on— (i) Ensure universal access to malaria prevention, diagnosis and treatment; (ii) Accelerate efforts towards elimination and attainment of malaria-free status; and (iii) Transform malaria surveillance into a core intervention. These three pillars are aided by two supporting elements–(a) Harnessing innovation and expanding research; and (b) Strengthening the enabling environment[1].

The Asia Pacific Malaria Leaders Alliance (APLMA), identifies six priority action items and lays down a path of guidance for the countries attempting malaria elimination[3]. In the IX East Asia Summit (EAS) the leaders agreed to the goals of an Asia Pacific free of malaria by 2030[4].

Since 2000, eight countries have achieved malaria elimination and many more have significantly reduced the transmission levels. Paraguay has been certified as malaria-free, Algeria, Argentina and Uzbekistan have made formal requests for the certification, and in 2017–China and El Salvador reported zero indigenous cases. India observed 24% reduction in malaria cases from last year, reaffirming the faith in the validity and effectiveness of the existing tools and principles of malaria elimination[2]. Learnings from these experiences will be extremely helpful in achieving malaria elimination in India and other endemic countries.

The recent progress in malaria control began in the late 1990s with the support of global organizations that provided technical, operational, policy, advocacy, and financial support. The Roll Back Malaria (RBM) partnership; the global fund to fight AIDS, Tuberculosis, and Malaria (GFATM); the US President’s Malaria Initiative (PMI), Asia Pacific Malaria Elimination Network (APMEN); and Asia Pacific Leaders Malaria Alliance (APLMA), World Health Organization (WHO), African Leaders Malaria Alliance (ALMA), Malaria No More (MNM), and End Malaria Council (EMC) are some of the key organizations supporting malaria elimination at global, regional, and national levels. In India, M/s. Sun Pharmaceutical Industries Ltd., Mumbai established the Foundation for Disease Elimination and Control (FDEC) (not-for-profit entity) with a goal to work on malaria elimination in India.

WHO identified 21 countries in 2016 with the potential to eliminate malaria by 2020. Four of these countries (Algeria, China, El Salvador, and Paraguay) have eliminated and/or been certified malaria-free since that list was published. Of the remaining 17 with ongoing transmission, Belize, Bhutan, Costa Rica, Iran, Malaysia, Suriname, and Timor-Leste reported fewer than 100 cases in 2017 and are on track to eliminate by 2020. The other 10 countries have experienced difficulties that have slowed down the progress[2],[5].

Despite the progress achieved in control and elimination efforts since 2005, malaria remains endemic in all of the WHO regions. In 2016, India accounted for 6% of the global malaria burden and 90% of the malaria cases in the WHO South East Asia region[5]. Although, Plasmodium falciparum is the most prevalent malaria parasite globally (about 95% cases), P. vivax predominates in Asian region. In the year 2016, about 85% of estimated P. vivax cases were reported from five countries—namely India, Afghanistan, Ethiopia, Indonesia and Pakistan[5].

In India, approximately 539 million people reside in high transmission areas. Malaria is a major health problem in rural/tribal areas of the central eastern (9) and northeastern (7) states of India[6]. These are all tribal dominated states having large population of ethnic groups. Out of 609 districts, 124 districts with 30% or more tribal population comprising about 8% country’s population contributed to 46% of the total malaria cases, 70% of P. falciparum and 47% of malarial deaths in the country[6]. Thus, tribal areas are heartlands of malaria and there should be the focus on malaria elimination strategies-specific to these areas.

National policy strength

India has a long history of success and struggles with malaria control. Prior to the launch of the National Malaria Control Programme (NMCP) in 1953, 75 million cases and about 0.8 million deaths were reported annually for malaria[7]. The widespread use of DDT indoor residual spray (IRS) resulted in a sharp decline in malaria cases, and in 1958, the NMCP was converted to the National Malaria Eradication Programme (NMEP). The NMEP was initially a great success with the malaria incidence dropping to 0.1 million cases and no deaths were reported due to malaria in 1965. In 1971, the urban malaria scheme (UMS) was also launched to cover 131 cities and towns. These gains were short-lived, and in 1976, 6.4 million cases of malaria re-emerged[8]. The resurgence was attributed to complacency and various operational, administrative, and technical reasons. The emergence of drug resistance in the parasites and insecticide resistance in the vectors also contributed to the resurgence. In 1977, the modified plan of operation (MPO) was initiated with the objectives to reduce malaria morbidity and prevent deaths due to malaria. Under the MPO, in addition to early diagnosis and prompt treatment, IRS was recommended in areas with annual parasite incidence (API) ≥ 2. The malaria incidence[7] dropped to 1.66 million cases in 1987. The limited resources in many states, however, allowed spray coverage in areas with API > 5 only. In 1977, the eradication goal was officially shelved and the programme was changed to the National Anti-Malaria Programme (NAMP).

By 1996, there was another malaria upsurge with reported 3.03 million cases and 2803 deaths. In 2002, the NMCP became a part of the National Vector Borne Disease Control Programme (NVBDCP). Responsibility for malaria control was divided between the central and the state governments of India. Technical and operational guidance was provided by the NVBDCP and the on-ground services and oversight were provided by the State Vector Borne Disease Control Division. The key elements of India’s malaria control strategy include early case detection and complete treatment (EDCT), based on parasitological diagnosis of all suspected cases and complete treatment of all confirmed cases identified through active and passive case surveillance; along with vector control measures, information education and communication (IEC) strategies, and surveillance[7].

The NVBDCP’s commitment to end malaria aligns with rest of the world and responds to the commitment for malaria elimination by 2030. The National Strategic Plan for Malaria Control in India 2012–2017 was followed by the development of the National Framework for Malaria Elimination in India 2016–2030. The plan details every technical and operational element required for the nation to achieve malaria elimination[7],[9] by 2030.

Learning from neighbours

In the year 2016, Sri Lanka was declared WHO certified malaria-free country. The success story echoed the need for public-private partnerships to accelerate malaria elimination efforts[10]. The Anti Malaria Campaign (AMC) of Sri Lanka intensified malaria surveillance jointly with a private sector partner, Tropical and Environmental Diseases and Health Associates Private Limited (TEDHA) with a view to achieve malaria elimination targets by 2014. Within five years of operation, the TEDHA successfully completed its operations and delivered the desired results. Special focus was on sharing of information between TEDHA and AMC. Intensification of surveillance, capacity building, training and supervision along with entomological investigations were the key factors to achieve a malariafree country status[10]

Another neighbouring country of India that has made strides towards malaria elimination is China. In the year 2017, zero indigenous cases were reported in the nation[2]. Started in 2010, this effort is an inspiring example of a country-led and country-owned endeavour. China will be certified malaria-free, if no indigenous case is reported in the year 2019. The country championed the 1-3-7 elimination approach and identified a proactive surveillance system, intensification of government leadership, capacity building, maintenance of fund support, multisectorial coordination, and community mobilization as key areas to prevent re-introduction of the disease in the country[11].

Studies of malaria elimination in India

Studies have been undertaken in malaria endemic tribal areas in India by the Indian Council of Medical Research–National Institute of Malaria Research (ICMR–NIMR) and ICMR–National Institute of Research in Tribal Health (ICMR–NIRTH) in collaboration with the state programme to demonstrate malaria control in malaria endemic region and subsequently provide proof of principle that malaria elimination is an achievable goal. Some examples of studies done by ICMR–NIRTH, ICMR–NIMR, and others are provided below:

The Betul study: In Betul, a tribal district (population 1.4 million, 45% ethnic tribe), the reported annual incidence of malaria[12] had increased gradually from 1.4 in 1995 to 11.37 per 1000 population in the year 2000. In 2000, Betul accounted for 10% of all the malaria cases in Madhya Pradesh with the persistence of endemic foci coupled with the influx of migrants working on the developmental project[13]. The two powerful tools, i.e. IRS with DDT and chemotherapy with chloroquine upon which the programme relied, were no longer effective[8] due to resistance[14],[15], indicating the need for change in control strategies and better intervention tools. The ICMR-NIRTH investigated the malaria situation and recommended specialized intervention approaches, i.e. enhanced surveillance activities for early detection and prompt treatment (EDPT) using Fansidar (sulphadoxine-pyrimethamine), and intensified antivector intervention using two rounds of IRS with pyrethroid. In remote and inaccessible areas rapid diagnostic tests (RDTs) were used for on the spot diagnosis and treatment[16]. Larvivorous fishes (Gambusia spp.) were also introduced into large and small ponds that were identified as breeding places of vectors, and maintained in stock ponds in each Primary Health Centre (PHC)[17]. As a result of this intensified intervention, malaria cases were controlled from 51% positivity rate in 2000 to < 1% in 2003 and only single indigenous case was found[13] in 2005. Although, the interventions were due to vector control and case management, it was not possible to quantify which tool was responsible for the observed impact[13].

The Dindori study: Dindori is a tribal district (50% ethnic tribe) in Madhya Pradesh, which is highly malarious and contributed for 12% malaria in the state while its population is only 1% of the state population[18]. Three Community Health Centres (CHCs) of Dindori district, i.e. Bajag, Karanjiya and Samnapur are collectively known as Baigachak because the inhabitants of the area are predominantly Baiga categorized as particularly vulnerable tribal group (PVTG). In Baigachak, the persistence of endemic foci was on increase which gave rise to an epidemic of P. falciparum in spite of the use of artemisinin-based combination therapy (ACT)[19] and IRS, indicating the need for change in control strategies and better intervention tools. An intervention strategy that involved training workshops for health professionals from grass route level malaria workers to Medical Officers for surveillance, RDT testing and administration of ACT was put in place. The IRS with α-cypermethrin 5%, long-lasting insecticidal treated bed net (LLIN), RDT and ACT along with IEC/behaviour change communication (BCC) were used as intervention tools. Health education was implemented using intensive need based innovative strategy of IEC involving local schoolgoing children and unemployed youths by using culture-based communication tools to educate the people on preventive aspects of malaria and proper utilization of the biomedical intervention[20]. As a results of this intensified intervention malaria cases were reduced from 27% positivity rate in 2009 to <3% in 2013 and maintained till 2015.

The malaria elimination demonstration project: The malaria elimination demonstration project (MEDP) in Mandla, Madhya Pradesh was started as a first-of-its-kind public-private-partnership (PPP) between the ICMR, Government of Madhya Pradesh, and the FDEC-India.

The goal of MEDP was to demonstrate successful elimination of malaria from 1233 villages of Mandla district and use the lessons learnt for eliminating malaria from rest of Madhya Pradesh and the country. Mandla district was chosen because it provided various complexities of demographics (forest malaria, hard to reach malaria-infected communities, rural malaria, urban malaria and tribal malaria) and epidemiology (both species of malaria parasites). The MEDP employs field-and time-tested approaches of IEC, capacity building, rapid testing of infected individuals followed by prompt treatment.

The project used track, test, treat and track (T4) strategy for rapid identification of malaria cases followed up with prompt treatment. The project also monitored and provided support to IRS and LLINs use to ensure the optimum utilization of these measures. Capacity building and training based on needs assessment of existing health staff along with IEC/BCC in the district was another major part of the operational strategy.

Using this approach, in 15 months a reduction in malaria cases was observed at district level by over 80% and by ~90% in blocks with high transmission. The important take away from this study is that operational, financial and technical controls are the key to success of malaria elimination programme. Inter-sectoral coordination is being given utmost importance. All the district authorities, national authorities, technical and policy leaders are briefed on a regular basis and there is regular data sharing mechanisms in place for betterment of the project. The IEC materials were prepared with participation of field staff, which is used to inform members of the community at village, haat-bazar and schools. A mobile surveillance tool by the name of SOCH — Solution for community health worker has also been developed. This application will enable digitization of all paper-based reporting systems and also enable more efficient real-time information sharing. The IEC material and software have been offered to the state ‘free of cost’ for customization and usage for their programmes. The key components of the project includes: (i) Use of a dedicated, trained and fully equipped staff at subcentre level to perform active surveillance and case management; (ii) Strong monitoring, supervision and learning for all components of the project, viz. surveillance and case management, capacity building, IEC/BCC, IRS, LLINs, data quality; (iii) Development of original IEC/BCC material and strategies based on feedback from the community and keeping it free to use for all stakeholders and partners; (iv) Needs-assessment followed by training and monitoring including pre-and post-assessment for project staff, accredited social health activists (ASHAs), auxiliary nurse-midwifes (ANMs); (v) Development of a comprehensive mobile application surveillance, workforce and supply chain management tools to optimize monitoring, reporting, administrative, stock and data quality indicators; (vi) Conduct of mass screenings before beginning of transmission seasons in high-API blocks; (vii) Entomological and parasite surveillance in the district; and (viii) Real-time and effective sharing of information with all the stakeholders for swift action and response.

The results of this project clearly showed that elimination can be accomplished with proper management, financial and operational controls, robust surveillance, efficient case management and vector control strategies. Going forward, the MEDP will provide targeted training of existing health staff based on needs assessment, maintain the robust surveillance, track the imported cases, conduct mass surveillance and treatment programmes, and focus on management and operational controls to achieve malaria elimination in Mandla. In a collaborative manner, the project will also develop model for malaria elimination in India with the existing health staff, develop costing and investment case study for malaria elimination leading to eradication in collaboration with key national stakeholders, and conduct molecular epidemiologic studies to monitor population-level changes, including studies of drug and insecticide resistance.

The Odisha experiences: The Odisha has registered a decrease of 50% in disease burden and more than two third reduction in fatalities[2]. This has been made possible with the introduction of comprehensive case management programme (CCMP), a study undertaken by ICMR–NIMR. Intensive intervention activities targeted at improved access to malaria diagnosis and treatment, produced a substantial increase in blood examination and case notification, especially in inaccessible, hard-to-reach pockets. The CCMP provides insights into how to achieve universal coverage of malaria services through a routine, state-run programme[21].

The CCMP used the following key-strategies: (i) Strengthening of supply chain management system at village-level including maintenance of buffer stock; and (ii) Establishment of additional microscopy centres at PHCs. These centres also provided supportive supervision to the ASHAs; (iii) Appointment of block level managers (BLMs) to improve monitoring and supervision along with data quality; (iv) Digitization of data into the DHIS2— an electronic health management information system. Assigning unique identification numbers (UIDs) to patient data for effective tracking; (v) Engagement and training to additional local volunteer providers (ASHA-plus), they were compensated on same lines as the ASHAs; and (vi) intensified training including job-aids, refresher courses and supportive supervision.

  Conclusion Top

Malaria elimination in India is possible by 2030. The experiences of Odisha malaria elimination and the MEDP in Madhya Pradesh need to be utilized for national malaria elimination programme. The elimination efforts would require goal-oriented, evidence-based, and context specific operational strategies and approaches at the local, state and national levels. The social beliefs, local perceptions, cultural and other associated priorities of the communities need to be understood and utilized in elimination programmes. The staff doing surveillance and administering diagnostic tests and treatments need to be trained, and their work should be monitored by independent external agencies and stakeholders on a regular basis to ensure operational efficiencies. Identification of human resources and funding gaps together with robust surveillance and availability of RDTs and ACTs at field level are essential for malaria elimination within the stipulated time. The hotspot-targeted interventions should also take place at defined transmission levels, which may include mass surveillance and mass treatment. The key component to success would be management and operational controls, so that the resources and efforts committed to malaria elimination pays off and provide returns on investment from public health perspectives as well as funding perspectives. If the lessons learnt from elimination efforts are properly utilized, malaria can be eliminated before 2030, but if the efforts don’t incorporate the lessons learnt, India may miss the 2030 elimination target.

Conflict of interest: None.

  References Top

Global technical strategy for malaria 2016–2030. Geneva: World Health Organization 2015; p. 32.  Back to cited text no. 1
World Malaria Report 2018. Geneva: World Health Organization 2018; p. 210. Available from: https://www.who.int/malaria/publications/world-malaria-report-2018/report/en/ (Accessed on Decmber 5, 2018).  Back to cited text no. 2
Asia Pacific Leaders Malaria Alliance: Malaria elimination roadmap 2017. Available from: https://www.aplma.org/upload/ resource/files/APLMA_Roadmap_2017.pdf ; p. 36 (Accesed on January 24, 2019).  Back to cited text no. 3
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