Anti Malaria Month is observed every year in the month of June. Pratik Kumar, Country Director, Malaria No More India in an interaction with Viveka Roychowdhury talks about India’s malaria elimination journey and highlights that even while the World Malaria Report highlighted disparity in estimated and officially recorded numbers of malaria cases, it did note that India was one of the only high-burden to high-impact country’s to record a decline in malaria cases and deaths, albeit at a rate lower than that before the pandemic
The latest World Health Statistics report, with data to 2020, the first year of the COVID-19 pandemic, shows that service disruptions contributed to an increase in deaths from tuberculosis and malaria between 2019 and 2020. What is India’s disease burden from malaria?
This question demands a two-spoked response. While official reported figures stated that India recorded around 187,000 malaria cases in 2020, the World Health Organization, in its World Malaria Report 2021 estimated cases between 2.7 million and 5.9 million. This disparity in estimates and official numbers acts as a major barrier in India’s malaria elimination drive. Unless the country can accurately detect each case of malaria, eliminating the disease will not be possible. One of the primary reasons for such disparity remains the malaria cases diagnosed and treated in the private health sector. Several patients, by some reports more than 70 per cent, tend to seek treatment from private healthcare facilities both formal and informal. The lack of enforcement of malaria’s notifiable status, i.e., each diagnosed case needs to be notified in the official government data, and the absence of a centralised reporting system that can assimilate patient data from the public and private sector fuels this issue.
What have been the strategies deployed to get malaria prevention and control efforts back on track to their pre-pandemic levels? The theme of World Malaria Day 2022 (April 25) was “Harness innovation to reduce the malaria disease burden and save lives.” What are the technology innovations that can help India achieve the goal to be malaria-free by 2030?
No specific strategies were implemented to address the disruptions caused by the pandemic to India’s malaria elimination journey. While there are some critical gaps in our country’s elimination effort, the strategies that have been drafted and in use are still robust. Even while the World Malaria Report highlighted disparity in estimated and officially recorded numbers of malaria cases, it did note that India was one of the only high-burden to high-impact country’s to record a decline in malaria cases and deaths, albeit at a rate lower than that before the pandemic. The current National Strategic Plan for Malaria Elimination (2017-22) focused on the following strategies for combatting malaria:
Early case detection and prompt and complete treatment
Immediate identification of the incidence of malaria, and the administration of complete treatment as required by the type of malaria diagnosed (Pv, Pf, or Mixed)
Vector control measures
- Chemical control
- Use of indoor residual spraying in households, use of larvicides in potable water, aerosol sprays and malathion fogging)
- Biological control
- Use of biocides and larvivorous fish
- Personal protection measures for the community
- Use of mosquito repellents, screening households with mesh, use of insecticide treated bednets, and wearing clothes that cover maximum surface area of the body
Community participation
Sensitisation of the community members through Information-Education-Communication (IEC), Behaviour-Change-Communication (BCC), and Inter-Personal Communication (IPC) interventions
Environmental management and breeding source reduction
Filling of breeding sites, proper covering of stored water, and dissipation of water logging
Regular monitoring and evaluation of the programme
Maintenance of a digital Management Information System (MIS) and regular field visits to assess on-ground situation
There are some existing and emerging innovations and inventive solutions that can greatly benefit and expedite India’s fight against malaria. These include innovations in diagnostic tools such as the highly-sensitive rapid diagnostic test kits – such kits are able to detect even lower levels of parasite exposure, and identify asymptomatic cases of malaria as well; the newly approved malaria vaccine although this has only been approved for administration to children, the use of this vaccine in Indian contexts can be revolutionary; newer, and more advanced anti-malarial drugs that can reduce the treatment period and increase drug compliance; new generation of long-lasting insecticial nets called Pyrethroid-PBO nets that reduced the number of malaria infections in areas of high pyrethroid resistance as per some studies; and finally the integration of advanced data capturing and management tools that can increase real-time reporting and produce timely strategies.
How would you evaluate the success and gaps in India’s National Vector Borne Disease Control Programme? Has funding been adequate to tackle the disease?
While India has demonstrated tremendous progress in controlling the spread of malaria in recent years, the road to elimination is still a far way ahead, and one that is currently ridden with some key gaps and challenges:
Private sector reporting
WHO, in their World Malaria Report 2021, estimated cases between 2.7 and 5.9 million [1] for India in 2020, whereas the official data recorded only around 187,000 cases [2]. One of the primary reasons for such disparity remains the malaria burden diverted to the private health sector, as above 70 per cent of patients rely on this sector for seeking healthcare facilities. The disparity can also be seen as in 2016, the country reported 10.09 lac malaria cases while the sales of anti-malaria drugs were for courses 10 times that figure [3]. While malaria has been made notifiable in 31 states/union territories the enforcement of this for the private health sector largely remains a challenge.
Hidden malaria burden
A gap that leads to discrepancy in case reporting is the burden of hidden/asymptomatic malaria. Malaria manifests itself in several forms and often goes unreported due to misattribution. From malaria-induced anemia to malaria-induced postpartum hemorrhage, cases of malaria deaths are often not recorded due to attribution to other causes. Since in these cases, malaria is not manifested through fever, people living with the asymptomatic malaria do not seek malaria testing and thus lead to the gap in malaria case identification that is crucial to the end disease elimination goal of India.
Problem of drug resistance
Lack of technology to reliably diagnose Plasmodium vivax malaria, the limited ability of antimalarials for radical cure, growing concern over increasing drug resistance-favoring polymorphism, and increasing insecticide resistance threatens to thwart success against malaria in the near future.
Lack of newer diagnostics and tools
The current effort towards malaria elimination lacks integration of new and emerging technologies in diagnostics and tools, such as Highly-sensitive Rapid Diagnostic Kit (HsRDT), Piperonyl-butoxide bed nets, advanced anti-malarial drugs, et al. Regulatory bottlenecks in the system contribute to longer uptake timelines for the integration of such innovations.
Outmoded decision support system
The current data management system in place suffers from the challenge of real-time data reporting. The process of capturing data is almost entirely based on a pen-and-paper mechanism, and the lack of digital integration and effective data visualisation leads to delays in real-time reporting and prompt decision making
Low health system priority
The health system in our country relies on the Accredited Social Health Activist (ASHA) for the delivery of health services at the last mile. The ASHA workers are responsible for carrying our several health programs in the field and are incentivised for successfully conducting their work in the field. The incentives allocated for conducting a malaria test and ensuring treatment of patients diagnosed with malaria are Rs 15 and Rs 75 respectively. This amount is dwarfed when compared with incentives allocated for other health responsibilities, thus reducing the priority of malaria in the existing health system.
Regarding the funding that has been allocated to eliminate malaria from India, if we consider control efforts, adequate funding has been sanctioned. However, as we move towards elimination, a larger, strategic, and targeted budgetary allocation will be required. Something that needs to be estimated.
Odisha had the largest malaria burden among India’s states but is now a symbol of a significant turnaround. What is the status today? What are the lessons which can be/are being applied to other high malaria-burden states?
- Historically, Odisha has been of one India’s highest burden states. However, in the last 4 years, the state has demonstrated tremendous progress in reducing the burden of malaria cases and deaths and has recorded an approximately 90 per cent decline. Some key lessons that can be adopted from Odisha’s malaria elimination effort include:
- Their persistent and unwavering efforts towards distribution of long-lasting insecticidal nets in high endemic districts.
- Their reliance on and encouragement of intersectoral action to combat malaria in the state – engaging diverse yet overlapping institutions to partake in the fight against malaria
- Their flagship DAMaN program that entails mass screening in places that record an outbreak. This helps test, track, and treat all malaria cases in the region and break the transmission of the disease
- Their annual Malaria-Dengue-Diarrhea campaign that specifically conducts interventions to address malaria and increase community awareness around the disease
Malaria No More India has been a proud partner in this tremendous journey of Odisha in combatting malaria. We have programmatic interventions in 2 of the highest endemic districts in the state – Koraput and Malkangiri – and our collective efforts with the government in these districts have enabled accurate disease data to be recorded from these surveillance dark regions, regions that are characterised by neglected and underrepresented tribal populations, an insurgent backdrop, and hilly, forested, and inaccessible topography.
Malaria, like TB is generally perceived as a disease mainly impacting rural and poor populations. How can we correct this misconception as urban areas, with congested and unhygienic environs, are also malaria hotspots?
Yes, malaria is perceived as a poor person’s disease – since there is also truth to this statement. The disease tends to have a larger impact in rural and poor communities. However, the disease does still manifest in urban pockets and as we are approaching elimination, uprooting each and every case will be imperative. Changing this skewed perspective of malaria as an only rural disease will be essential in this process. We can achieve this through a large-scale health communication campaign around malaria, inspiring collective action through a concerted community movement. Achieving complete elimination of the disease requires all sections of our society to come together in the fight and achieve the reality of a Malaria Mukt Bharat.
What has been the impact of Malaria No More’s five-year strategy starting 2018, to support India’s goal to be malaria-free by 2030? What are the contours of the next five-year plan?
Malaria No More has been working in India since 2016. We actively support the ambitious vision of our government to eliminate malaria from India by 2030. Key areas of work for MNM India include:
- Policy and advocacy: Center and State
- Focus on Behavior Change Communication (BCC) and media-Centre, State, District, and Below
- Inter-sectoral and Inter-industry coordination
- Introduction of innovative approaches and technological advancements in the fight against malaria
- Strengthening and enhancing government capacity-Centre, State, and District
Our key programs include,
Technical support-National
Leveraging technical capacity, MNM India has offered technical support to the National Program for Malaria Elimination-The National Centre for Vector-Borne Diseases Control (NCVBDC), erstwhile National Vector-Borne Disease Control Program (NVBDCP). One such support has been by way of a national Social Behavior Change Communication (SBCC) Strategy that was submitted to the program in 2020. The strategy enlisted a comprehensive approach for effecting change in behaviors of diverse audiences and encourage uptake of desired behaviors. The various audience segments comprised individuals at the community level; opinion/thought leaders such as religious leaders, programme managers, et al; and health workforce such as ASHAs, ANMs, AWWs, et al, at the last mile. Currently, we are collaborating with the NCVBDC to support across three verticals – communication, advocacy, and innovation. This will pertain support with creation of IEC/BCC communication collaterals, advocacy around key themes and topics that need to be addressed urgently, and encouragement around uptake of existing and forthcoming innovations to strengthen the ongoing fight against malaria.
National advocacy – National
MNM India has been facilitating discussions through an ongoing Malaria Advocacy Campaign ‘India’s March Towards Malaria Elimination by 2030: Challenges, Opportunities, and The Way Forward’, which was launched on the occasion of the World Mosquito Day on 20th August 2021. Through this campaign, MNM hopes to profile the agenda for the endgame strategic action plan 2022-2027, which will be crucial towards achieving zero indigenous transmission of Malaria cases in India by 2027. Till now, the advocacy campaign has covered themes, such as ‘Estimating the True Disease Burden of Malaria in India’, ‘The Role of Surveillance in Achieving India’s Malaria Elimination Goals’, ‘Integrated Vector Management: The Need for a Robust System to Achieve Malaria Elimination in India’, and ‘The integration of Science, Technology, and Innovation in India’s Malaria Elimination Journey.
National digital SBCC campaign – Bite Ko Mat Lo Lite
To raise awareness about the impact that mosquito-borne diseases have on India’s health and economy and educate and engage Indians with the information they need to protect themselves, their families, and their communities from these diseases, Malaria No More India, with partners, established the country’s first national behavior change communication (BCC) campaign – ‘Bite Ko Mat Lo Lite’. WPP Ogilvy led the brand creation for BKMLL and a robust network of media partners such as Facebook, The Times Group, Star Disney, Sony, and Google, ensured a reach of over 300 million Indians through scaled social media, print, radio, and television platforms, in the first year of the campaign.
Programmatic intervention in Odisha
Odisha has historically been one of India’s highest malaria burden states. In the last four years, the state has made tremendous progress by reducing its malaria burden by more than 90 per cent. Malaria No More India has been a proud partner of the Government of Odisha in this incredible journey. Through our collective efforts, we directly impact more than 16,000 marginalised beneficiaries and indirectly impact more than 2 million beneficiaries living in malaria hotspots by providing precision programming and micro-targeting of interventions through innovations in strategy, digital health, technology, and communication.
Since our inception, MNM India’s program in Odisha has focused on three pillars of concerted action to help the state build systemic resilience against malaria
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- Overarching surge capacity building at State
- On-ground innovations to impact the last mile
- Multi-level inter-sectoral coordination for concerted action towards malaria elimination
Innovation
Malaria No More has developed a first-of-its-kind malaria prediction and planning toolkit (MPPT) was developed. The MPPT uses artificial intelligence to integrate sophisticated weather data and hyperlocal epidemiological and programmatic information and provides real-time decision support at all levels of the healthcare system. The toolkit was designed to enable the efficient use of resources to improve health outcomes on a more routine basis. In identifying malaria hotspots and predicting outbreaks, the toolkit will allow health leaders to optimally time and target behavioral interventions, pre-position supplies, and deploy frontline health workers to avoid extreme weather, among other possibilities. The model has been built and trained in very high malaria-endemic areas of Odisha, India.
For our next five years, we envision to build on our current progress through the coming years and help actualise India’s goal of declaring itself malaria free!
References:
[1] World Malaria Report 2021, WHO
[2] Official figures shared on the NCVBDC website
[3] Calculation of these figures has been done using annual sales data of IQVAI