For malaria elimination India needs a platform for data integration

India should invest in the expansion of genomic epidemiology for vector-borne diseases filariasis, malaria and visceral leishmaniasis that are targeted for elimination

Genomic epidemiology (GE) is an integration of genomics and epidemiology. The field has evolved significantly in the past decade, enhancing our understanding of genetic susceptibility, drug resistance, disease transmission patterns, outbreak surveillance, and vaccine development. It employs an arsenal of advanced tools such as whole-genome sequencing and single-nucleotide polymorphisms for analysis, tracing pathogen evolution, mapping genetic variations, and tracking drug resistance. The role of GE in infectious disease management extends beyond outbreak control to routine public health practices, precision medicine, and determining treatment policies. The expansion of GE can significantly bolster global health defenses by effectively enabling the detection and response to emerging health threats. However, challenges such as sampling bias, data quality, integration, standardization of computational pipelines, and need for trained personnel remain. To tackle these challenges, we must invest in building capacity, improving infrastructure, providing training, and fostering collaborations between scientists and public health officials. Concerted efforts must focus on overcoming existing hurdles and promoting seamless integration of basic research into public health frameworks to fully realize its potential. It is timely for India to rapidly expand its base in GE to gain valuable insights into genetic variations and disease susceptibilities. This will provide a fillip towards eliminating the three dominant vector-borne diseases in India: filariasis, malaria, and visceral leishmaniasis.

For Malaria Elimination, India Needs to Integrate Its Research and Control Arms

India has targeted malaria elimination by 2030. The national malaria control program has positioned its strategies in this direction. Substantial support in the form of dynamic research inputs leading to policy formulation and change is needed to steer the country towards malaria elimination. Indian Council of Medical Research (ICMR), India's nodal research body, has been generating evidence and helping to frame several policies ranging from malaria management to vector control operations. Since the country is preparing for malaria elimination, the connection between the programmatic needs and the research agenda needs further strengthening. Typically, the national malaria control program handles the implementation of programmatic activities, while the national research body, ICMR, conducts research studies to generate evidence. We propose a virtual integration of the activities conducted by these two entities to maximize the potential for translating research findings into programmatic policies. Joint monitoring of drug and insecticide resistance, codevelopment and utilization of more innovative surveillance systems, data-backed mitigation responses, and overcoming last-mile challenges are reasons for the virtual amalgamation of the two bodies. Timely translation of research outputs into policy, co-opting of workforce and material resources, joint capacity building, and synergistic advocacy are benefits of the proposed new alliance for more efficient operations. The close functioning will provide impetus to narrow down current gaps and disrupt traditional barriers, galvanizing the country toward malaria elimination.

Enhancing healthcare access and malaria management via mobile clinics and phone call services in Nuh district of Haryana, India

BACKGROUND OBJECTIVES

Malaria remains a complex challenge in India due to its diverse epidemiology, multi-ethnic population, and multiplicity of malaria vectors. While progress has been made in reducing malaria nationally, persistent pockets hinder elimination efforts. These challenges include hidden reservoirs, inadequate healthcare, suboptimal surveillance, non-compliance, and subclinical infections. Shortage of grassroot level and primary care health staff, transportation issues and general inaccessibility and unavailability of healthcare services are additional challenges.

METHODS

Mobile healthcare vans have been tried and found useful in enhancing healthcare availability in several health conditions in different settings. Nuh district in Haryana, India is a malaria endemic region; it is indeed one of the districts included by India's NITI Aayog in the Aspirational Districts Programme, a government initiative that focuses on rapidly transforming and developing the most underdeveloped districts in country. With an aim to improve the healthcare seeking behavior of malaria-endemic community of selected villages of Nuh district, we carried out a study using interventions in two villages of the district, that had mobile malaria clinics and toll-free telephone services in enhancing healthcare access.

RESULTS

We found that Sangel village had higher literacy rates (60.6%) as compared to 39.4% in Naushera. Similarly, the unemployment rate was higher for Naushera. It the mobile malaria clinic was deployed from December 2019 to July 2020 and a total of 269 phone calls were received from both the villages. A similar number of rapid tests and microscopy smears were examined and all were negative for malaria. The febrile patients were referred to the nearest healthcare facility.

INTERPRETATION CONCLUSION

The study shows that the community is open to using these healthcare interventions. These initiatives of mobile malaria clinics and toll-free telephone services can bridge healthcare gaps, especially in malaria-endemic regions, aligning with India's malaria elimination and equitable healthcare access goals.

Mosquito-borne diseases in India over the past 50 years and their Global Public Health Implications: A Systematic Review

Mosquito-borne diseases (MBDs) pose a significant public health concern globally, and India, with its unique eco-sociodemographic characteristics, is particularly vulnerable to these diseases. This comprehensive review aims to provide an in-depth overview of MBDs in India, emphasizing their impact and potential implications for global health. The article explores distribution, epidemiology, control or elimination, and economic burden of the prevalent diseases such as malaria, dengue, chikungunya, Japanese encephalitis, and lymphatic filariasis, which collectively contribute to millions of cases annually. It sheds light on their profound effects on morbidity, mortality, and socioeconomic burdens and the potential for international transmission through travel and trade. The challenges and perspectives associated with controlling mosquito populations are highlighted, underscoring the importance of effective public health communication for prevention and early detection. The potential for these diseases to spread beyond national borders is recognized, necessitating a holistic approach to address the challenge. A comprehensive literature search was conducted, covering the past five decades (1972-2022), utilizing databases such as Web of Science, PubMed, and Google Scholar, in addition to in-person library consultations. The literature review analyzed 4,082 articles initially identified through various databases. After screening and eligibility assessment, 252 articles were included for analysis. The review focused on malaria, dengue, chikungunya, Japanese encephalitis, and lymphatic filariasis. The included studies focused on MBDs occurrence in India, while those conducted outside India, lacking statistical analysis, or published before 1970 were excluded. This review provides valuable insights into the status of MBDs in India and underscores the need for concerted efforts to combat these diseases on both national and global scales through consilience.

A Platform for Data-Centric, Continuous Epidemiological Analyses (EpiGraphHub): Descriptive Analysis

BACKGROUND

Guaranteeing durability, provenance, accessibility, and trust in open data sets can be challenging for researchers and organizations that rely on public repositories of data critical for epidemiology and other health analytics. The required data repositories are often difficult to locate and may require conversion to a standard data format. Data-hosting websites may also change or become unavailable without warning. A single change to the rules in one repository can hinder updating a public dashboard reliant on data pulled from external sources. These concerns are particularly challenging at the international level, because policies on systems aimed at harmonizing health and related data are typically dictated by national governments to serve their individual needs.

OBJECTIVE

In this paper, we introduce a comprehensive public health data platform, EpiGraphHub, that aims to provide a single interoperable repository for open health and related data.

METHODS

The platform, curated by the international research community, allows secure local integration of sensitive data while facilitating the development of data-driven applications and reports for decision-makers. Its main components include centrally managed databases with fine-grained access control to data, fully automated and documented data collection and transformation, and a powerful web-based data exploration and visualization tool.

RESULTS

EpiGraphHub is already being used for hosting a growing collection of open data sets and for automating epidemiological analyses based on them. The project has also released an open-source software library with the analytical methods used in the platform.

CONCLUSIONS

The platform is fully open source and open to external users. It is in active development with the goal of maximizing its value for large-scale public health studies.

Evaluation of the model malaria elimination strategy in Mandla district along with its neighbouring districts: a time series analysis from 2008 to 2020

BACKGROUND

Compared to 2017, India achieved a significant reduction in malaria cases in 2020. Madhya Pradesh (MP) is a tribal dominated state of India with history of high malaria burden in some districts. District Mandla of MP state showed a considerable decline in malaria cases between 2000 and 2013, except in 2007. Subsequently, a resurgence of malaria cases was observed during 2014 and 2015. The Malaria Elimination Demonstration Project (MEDP) was launched in 2017 in Mandla with the goal to achieve zero indigenous malaria cases. This project used: (1) active surveillance and case management using T4 (Track fever, Test fever, Treat patient, and Track patient); (2) vector control using indoor residual sprays and long-lasting insecticidal nets; (3) information education communication and behaviour change communication; and (4) regular monitoring and evaluation with an emphasis on operational and management accountability. This study has investigated malaria prevalence trends from 2008 to 2020, and has predicted trends for the next 5 years for Mandla and its bordering districts.

METHODS

The malaria prevalence data of the district Mandla for the period of January 2008 to August 2017 was obtained from District Malaria Office (DMO) Mandla and data for the period of September 2017 to December 2020 was taken from MEDP data repository. Further, the malaria prevalence data for the period of January 2008 to December 2020 was collected from DMOs of the neighbouring districts of Mandla. A univariate time series and forecast analysis was performed using seasonal autoregressive integrated moving average model.

FINDINGS

Malaria prevalence in Mandla showed a sharp decline [- 87% (95% CI - 90%, - 84%)] from 2017 to 2020. The malaria forecast for Mandla predicts zero cases in the next 5 years (2021-2025), provided current interventions are sustained. By contrast, the model has forecasted a risk of resurgence of malaria in other districts in MP (Balaghat, Dindori, Jabalpur, Seoni, and Kawardha) that were not the part of MEDP.

CONCLUSION

The interventions deployed as part of MEDP have resulted in a sustainable zero indigenous malaria cases in Mandla. Use of similar strategies in neighbouring and other malaria-endemic districts in India could achieve similar results. However, without adding extra cost to the existing intervention, sincere efforts are needed to sustain these interventions and their impact using accountability framework, data transparency, and programme ownership from state to district level.

Tracking district-level performance in the context of achieving zero indigenous case status by 2027

India has committed to zero indigenous malaria cases by 2027 and elimination by 2030. Of 28 states and 8 union territories of India, eleven states were targeted to reach the elimination phase by 2020. However, state-level epidemiology indicates that several states of India may not be on the optimum track, and few goals set in National Framework for Malaria Elimination (NFME) for 2020 remain to be addressed. Therefore, tracking the current progress of malaria elimination in India at the district level, and identifying districts that are off track is important in understanding possible shortfalls to malaria elimination. Annual malaria case data from 2017-20 of 686 districts of India were obtained from the National Center for Vector-Borne Diseases Control (NCVBDC) and analysed to evaluate the performance of districts to achieve zero case status by 2027. A district's performance was evaluated by calculating the annual percentage change in the total number of malaria cases for the years 2018, 2019 and 2020 considering the previous year as a base year. The mean, median and maximum of these annual changes were then used to project the number of malaria cases in 2027. Based on these, districts were classified into four groups: 1) districts that are expected to reach zero case status by 2027, 2) districts that would achieve zero case status between 2028 and 2030, 3) districts that would arrive at zero case status after 2030, and 4) districts where malaria cases are on the rise. Analysis suggest, a cohort of fifteen districts require urgent modification or improvement in their malaria control strategies by identifying foci of infection and customizing interventions. They may also require new interventional tools that are being developed recently so that malaria case reduction over the years may be increased.

Evaluating chemicals of emerging concern in the Ganga River at the two major cities Prayagraj and Varanasi through validated analytical approaches

Evaluating environmental water quality means to assess and protect the environment against unfriendly impacts from various organic impurities emerging from industrial emissions and those released during harvesting. Potential risks related with release of polycyclic aromatic hydrocarbons (PAHs), pesticides and pharmaceuticals (PhAcs), and personal care products (PCPs) into the environment have turned into an increasingly serious issue in ecological safety. Monitoring helps in control of chemicals and ecological status compliance to safeguard specific water uses, for example, drinking water abstraction. A longitudinal review was carried out for 55 different persistent organic pollutants (POPs) for the Ganga River which passes through the urban areas of Prayagraj and Varanasi, India, through validated analytical approaches and measurement uncertainty (MU) estimation to assess their potential use for routine analysis. Furthermore, environmental risk assessment (ERA) carried out in the present study has revealed risk quotient (RQ) higher than 1 in a portion of the aquatic bodies. Using a conservative RQ strategy, POPs were assessed for having extensive risks under acute and chronic exposure, proposing that there is currently critical ecological risk identified with these compounds present in the Ganga River. In general, these outcomes demonstrate a significant contribution for focusing on measures and feasible techniques to minimize the unfavorable effects of contaminants on the aquatic environment.

Digital dashboards with paradata can improve data quality where disease surveillance relies on real-time data collection

Dealing with the threats of vector-borne diseases necessitates robust disease surveillance systems. The gathered information from surveillance studies is used to evaluate the effectiveness of control measures. It also guides the allocation of resources within the healthcare system. The disease surveillance data also identify high-risk populations or geographic areas to target interventions. Because of the importance of surveillance in decision-making and its timely requirement, real-time data collection is vital. A few advantages of real-time data collection apps are building powerful digital forms, exporting data for quick analysis in various formats, and being open-source. These apps automate data collection and transfer to an online server even without an internet connection. While collecting disease surveillance data digitally one crucial aspect lacking is data quality. This paper aims to present the importance of dashboards that includes paradata in improving data quality using real-time data collection tools in disease surveillance. Various types of paradata such as timestamps, geo-referencing, audio recording and so on help enhance the quality of data and can help monitor and evaluate surveillance staff. The outcomes of the paradata analysis may lead to the retraining of the surveillance team and even re-planning of surveillance. Undoubtedly, real-time data collection is the way of the future in any field-based study, and studies should be planned in conjunction with paradata to ensure that high-quality data are recorded.

Insecticide resistance status of malaria vectors in the malaria endemic states of India: implications and way forward for malaria elimination

Background

In 2012, the World Health Organization (WHO) released the Global Plan for Insecticide Resistance Management in malaria vectors to stress the need to address insecticide resistance. In a prospective multi-centric study commissioned by the Indian Council of Medical Research (ICMR), we assessed the insecticide susceptibility status of the primary malaria vectors in India from 2017 through 2019.

Methods

The insecticide susceptibility status of the prevalent primary malaria vectors - An. culicifacies, An. fluviatilis, An. stephensi, An. minimus and An. baimaii and secondary malaria vectors - An. aconitus, An. annularis and An. philippinensis/nivepes from 328 villages in 79 districts of 15 states of India were assessed following the WHO method mainly to insecticides used in vector control, organochlorine (DDT), organophosphate (malathion), and other pyrethroids (alpha-cypermethrin, cyfluthrin, lambda-cyhalothrin and permethrin). The study sites were selected as suggested by the National Vector Borne Disease Control Programme.

Results

The primary malaria vector An. culicifacies showed resistance to DDT (50/50 districts including two districts of Northeastern India), malathion (27/44 districts), and deltamethrin (17/44 districts). This species was resistant to DDT alone in 19 districts, double resistant to DDT-malathion in 16 districts, double resistant to DDT-deltamethrin in 6 districts, and triple resistant to DDT-malathion-deltamethrin in 9 districts. An. minimus and An. baimaii were susceptible in Northeastern India while An. fluviatilis and the secondary malaria vector An. annularis was resistant to DDT in Jharkhand.

Conclusion

In this study we report that among the primary vectors An. culicifacies is predominantly resistant to multiple insecticides. Our data suggest that periodic monitoring of insecticide susceptibility is vital. The national malaria program can take proactive steps for insecticide resistance management to continue its push toward malaria elimination in India.

India may need an additional metric to assess the endemicity of malaria in low surveillance districts

India's National Framework for malaria elimination is essentially dependent on Annual Parasite Incidence (API). API is the primary criterion for classifying states and districts into different categories: intensified control, pre-elimination, elimination, prevention and re-establishment of malaria. However, API's validity is critically dependent on multiple factors, one such important factor is Annual Blood Examination Rate (ABER) and is often considered as indicator of operational efficiency. Therefore, the present study aimed to determine whether the API is a sufficiently good malaria index to assess malaria endemicity in India. An in-depth analysis of malaria data (2017-19) was done to determine the appropriateness of API as a sole indicator of malaria endemicity. We stratified the Indian districts into three strata based on Annual Blood Examination Rate (ABER): <5, 5.0-5.0, >15, further APIs was compared with Slide Positivity Rates (SPRs) using sign rank test, independently in each stratum. API and SPR were found comparable (p-value 0.323) in stratum 2 only. However, in the case of lower ABER (<5%, strata 1), the API was significantly lower than the SPR, and higher ABER (>15%), the API was found substantially higher than the SPR. Thus, ABER tunes the validity of API and should avoid to use as a single indicator of malaria endemicity. API is an appropriate measure of malaria endemicity in high and moderate transmission areas where surveillance is good (ABER≥5%). However, it is vitally dependent upon surveillance rate and other factors such as population size, the selection of individuals for malaria testing. Therefore, where surveillance is poor (<5%), we propose that API should be complemented with SPR and the number of cases. It will significantly aid the design and deployment of interventions in India.

India could harness public-private partnerships to achieve malaria elimination

Public-private partnerships (PPP) have been beneficial in different sectors like infrastructure development and service sector across the world, including in India. Such partnerships in the healthcare sector have also been successful in providing access to affordable medical attention to all sections of society. These partnerships between public and private entities have proven to be beneficial in controlling malaria in high burden districts of India and taking these areas to the brink of elimination, thus setting examples to follow. The two successful ones are the Comprehensive Case Management Project (CCMP) in Odisha which is now adopted by the state, and the Malaria Elimination Demonstration Project (MEDP) which has nearly eliminated malaria from the highly endemic district of Mandla in Madhya Pradesh. Here we propose that non-government and semi-government actors may be given vital roles in the malaria elimination efforts till 2030 and beyond. These partners will add value to the national programme and may have the potential to develop and test different models of malaria elimination in real-life settings that the government programme can absorb sustainably.

An investigation of the efficacy of different statistical models in malaria forecasting in the semi-arid regions of Gujarat, India

BACKGROUND & OBJECTIVES

Robust forecasting of malaria cases is desirable as we are approaching towards malaria elimination in India. Methods enabling robust forecasting and timely case detection in unstable transmission areas are the need of the hour.

METHODS

Forecasting efficacy of the eight most prominent statistical models that are based on three statistical methods: Generalized linear model (Model A and Model B), Smoothing method (Model C), and SARIMA (Model D to model H) were compared using last twelve years (2008-19) monthly malaria data of two districts (Kheda and Anand) of Gujarat state of India.

RESULTS

The SARIMA Model F was found the most appropriate when forecasted for 2017 and 2018 using model-building data sets 1 and 2, respectively, for both the districts: Kheda and Anand. Model H followed by model C were the two models found appropriate in terms of point estimates for 2019. Still, we regretted these two because confidence intervals from these models are wider that they do not have any forecasting utility. Model F is the third one in terms of point prediction but gives a relatively better confidence interval. Therefore, model F was considered the most appropriate for the year 2019 for both districts.

INTERPRETATION & CONCLUSION

Model F was found relatively more appropriate than others and can be used to forecast malaria cases in both districts.

National Institute of Malaria Research-Malaria Dashboard (NIMR-MDB): A digital platform for analysis and visualization of epidemiological data

Background

A digital dashboard can be an invaluable resource for the research community and can help analyze and visualize data as per the inputs provided by the user. In India, large data sets on malaria are available though presently no digital dashboard is being used to monitor and analyze the malaria data.

Methods

We have developed a dashboard (National Institute of Malaria Research-Malaria Dashboard (NIMR-MDB)) in R software using 19 different packages within which shiny and ggplot2 are used more intensively. NIMR-MDB can be used offline by running the app on any R software installed computer. Furthermore, NIMR-MDB can be accessed across different computers within an organization using a local server, or it may be made publicly available by publishing it online with secured access. There are two options for publishing the shiny dashboard online 1) via a personal Linux server for hosting this application or 2) by hosting the application on a certified online platform such as 'shinyapps.io' at a reasonable cost without setting up a server.

Findings

The NIMR-MDB is a versatile interface that allows prompt and interactive analyses of malaria epidemiological data. The primary interface of NIMR-MDB is like a web page with 14 tabs (or pages) where each Tab corresponds to a particular set of analysis. Users may move from one Tab to another via icons. Each Tab allows flexibility in correlating various epidemiological parameters like SPR, API, AFI, ABER, RT, malaria cases, deaths, BSC and BSE. The malaria epidemiological data can be analyzed in the required granularity (national level, state level or district level), and its enhanced visualization allows for facile usage and extensive analysis.

Interpretation

This NIMR-MDB developed here will play an important role in the analysis of epidemiological data and in strategizing malaria control in India. Researchers and policymakers may use it as a prototype for developing other dashboards for various diseases globally.

Funding

There is no specific grant received from any funding agency for this work yet.

Malaria control initiatives that have the potential to be gamechangers in India's quest for malaria elimination

Malaria continues to have devastating effect on people's lives especially in developing countries. India is slated for malaria elimination by 2030. Though India has sustained a decline in malaria burden at the national level the epidemiological picture remains heterogenous. India's road to malaria elimination plan is riddled with many roadblocks. Major challenges include insufficient surveillance, slow and aggregated data reporting especially in exigent situations like cross-border areas and vulnerable high-risk groups. More than half of total malaria cases were due to Plasmodium vivax (P. vivax) in India as reported by national malaria control programme in 2019. This translates into substantial burden of P. vivax malaria in absolute numbers. P. vivax malaria, which is difficult to resolve as compared to other species, poses a threat to India's elimination plans by virtue of its tendency to develop hypnozoites, due to poor compliance to primaquine (PQ), due to host factors like G 6 PD deficiency and other genes that affect PQ metabolism. Also, India's malaria endemic areas largely coincide geographically with tribal regions which are poor in healthcare infrastructure. The tribal population disproportionately bears a huge burden of malaria. They also harbour more G6PD deficient individuals than non-tribal regions. Therefore, in addition to inadequate diagnostic facilities (for both malaria and G6PD testing) these remote rural and tribal communities suffer from lack of timely treatment, incomplete radical treatment due to poor compliance and thus repeated episodes of P. vivax due to relapses and/or reinfections. Another challenge is that the the current diagnostic tools in the national programme in India and other countries are mostly available only via the programme and are able to detect patent infections on the whole. These therefore miss low-density infections which are another major limitation for their use in malaria endemic countries. Drug and insecticide resistance need to be constantly monitored as they have direct impact on the efficacy of the current tools. Need for better vector control products for the diverse entomological requirements is also felt. India is the second most populous country in the world with majority of its population at risk of malaria. Despite many agencies (government and non-government) working in the field of malaria, there needs to be more synergy at the local or central level for malaria control. Here, we have proposed solutions for specific facets of the malaria programme. Surveillance, data visualization and analysis can all be supported through over the counter availability of rapid diagnostics, adoption of molecular tools like PCR (requiring additional infrastructure and expertise), mobile applications for data capture and use of malaria data dashboard. Management could be augmented by inclusion of tafenoquine for treatment of P. vivax malaria with a companion point-of care diagnostic which has been developed to assess G6PD enzyme activity. A switchover to artemether-lumefantrine for the entire country can also be considered. Vector control can be strengthened by commercial availability of insecticidal bednets and exploration of novel vector control tools like ivermectin. Lastly, enhancing synergy amongst various stakeholders would also catalyze the malaria elimination plans.

Funding

The authors have received no funding for this paper.

Moderate Rainfall and High Humidity During the Monsoon Season, Negligence in Using Malaria Protection Methods and High Proportion of Mild Symptomatic Patients Were the Driving Forces for Upsurge of Malaria Cases in 2018 Among Tea Tribe Populations in Endemic Dolonibasti Health Sub-center, Udalguri District, Assam State, North-East India

Malaria elimination is a global priority, which India has also adopted as a target. Despite the malaria control efforts like long-lasting insecticidal nets distribution, rounds of indoor residual spray, the introduction of bi-valent rapid diagnostic tests and artemisinin combination therapy, malaria remained consistent in Dolonibasti sub-center of Orang block primary health center (BPHC) under the district Udalguri, Assam state followed by abrupt rise in cases in 2018. Therefore, we aimed to investigate the factors driving the malaria transmission in the outbreak area of Dolonibasti sub-center. Malaria epidemiological data (2008–2018) of Udalguri district and Orang BPHC was collected. The annual (2011-2018) and monthly (2013–2018) malaria and meteorological data of Dolonibasti sub-center was collected. An entomological survey, Knowledge, Attitude and Practices study among malaria cases (n = 120) from Dolonibasti was conducted. In 2018, 26.1 % (2136/ 8188) of the population of Dolonibasti were found to be malaria positive, of which 55% were adults (n = 1176). Majority of cases were from tea tribe populations (90%), either asymptomatic or with fever only, 67.5 % (81/120) had experienced malaria infection during past years. The outbreak was characterized by a strong increase in cases in June 2018, high proportion of slide falciparum rate of 26.1% (other years average, 15.8%) and high proportion of P. falciparum of 81.2 % (other years average, 84.3%). Anopheles minimus s.l. was the major vector with 28.6% positivity and high larval density in paddy fields/ drainage area. Annual relative humidity was associated with rise in malaria cases, annual parasite incidence (r_s = 0.69, 90%CI; p = 0.06) and slide positivity rate (r_s = 0.83, 95%CI; p = 0.01). Older people were less educated (r_s = −0.66; p < 0.001), had lesser knowledge about malaria cause (r_s = −0.42; χ²=21.80; p < 0.001) and prevention (r_s = −0.18; p = 0.04). Malaria control practices were followed by those having knowledge about cause of malaria (r_s = 0.36; χ² = 13.50; p < 0.001) and prevention (r_s = 0.40; χ² = 17.71; p < 0.001). Altogether, 84.6% (44/52) of the respondents did not use protective measures. We described a sudden increase in malaria incidence in a rural, predominantly tea tribe population group with high illiteracy rate and ignorance on protective measures against malaria. More efforts that are concerted needed to educate the community about malaria control practices.

What India can learn from globally successful malaria elimination programmes

India is targeting malaria elimination by 2030. Understanding and adopting the strategies employed by countries that have successfully eliminated malaria can serve as a crucial thrust in this direction for a geographically diverse country like India. This analysis is based on extensive literature search on malaria elimination policies, strategies and programmes adopted by nine countries (China, El Salvador, Algeria, Argentina, Uzbekistan, Paraguay, Sri Lanka, Maldives and Armenia) which have attained malaria-free status over the past decade. The key points which India can learn from their journey are mandatory time-bound response in the form of case reporting and management, rapid vector control response, continuous epidemiological and entomological surveillance, elevated community participation, more training and capacity building, private sector involvement, use of quality diagnostics, cross-border collaborations, inclusion of prevention of re-establishment programmes into the elimination plans, higher investment in research, and uninterrupted funds for successful implementation of malaria elimination programmes. These learnings would help India and other South Asian countries steer their programmes by devising tailor-made strategies for their own regions.

Active Engagement of Private Healthcare Providers Is Needed to Propel Malaria Elimination in India

Malaria is a major public health concern in India. Despite a remarkable decline in overall malaria cases and deaths over the past several years, the caseload is still substantial. India's commitment towards malaria elimination by 2030 requires several additional measures for its achievement. The country's malaria data are collated from the public health sector only by the aggregated paper-based surveillance system, which is considered weak because it captures only a minuscule percentage (8% as per the World Malaria Report 2017). The absence of private-sector data is a serious caveat in India's malaria epidemiological scenario. The private healthcare sector (trained and untrained) is a major provider to communities in malaria-endemic areas. It is increasingly recognized that the involvement of the private healthcare sector is crucial for understanding the complete epidemiological picture and targeting elimination strategies accordingly as is being done for tuberculosis in India. Active involvement and alignment of the private sector to the government program of the private sector can be fostered by assessing the presence of the private healthcare sector via landscaping exercise, establishing linkages between the two sectors, incentivization, and encouraging reporting via user-friendly online and offline systems. There are challenges and barriers to the successful adoption of the private healthcare providers in the fold of the national malaria control program; at the same time, it is a critical step that will propel malaria elimination plans of India.

Four decades of epidemiological data reveal trajectories towards malaria elimination in Kheda district (Gujarat), western part of India

BACKGROUND

Malaria is a main public health problem in India and was so particularly in the state of Gujarat in the western part of the country. This study assesses the effects of various interventions on malaria cases using data from the last 33 years (1987-2019).

METHODS

Here we have analysed 33 years of malaria epidemiological data from a malaria clinic in Kheda district in Gujarat. The data were digitised yearly and monthly, age-wise and gender-wise, and descriptive analysis was performed to assess the effects of several interventions on malaria burden.

RESULTS

During 1987-2019, our clinic diagnosed 5466 Plasmodium vivax and 4732 P. falciparum malaria cases. Overall, there was a declining trend in malaria cases except for the years 1991, 1994, 2004 and 2005. The year 2004 especially witnessed an epidemic in Kheda as well as throughout Gujarat. Malaria infections were most common (40%) among the 21-40 years age group. Fever was the most common symptom in all age groups.

INTERPRETATION

Introduction of revised drug policy and improved surveillance technique (rapid diagnosis kits) have strengthened the diagnosis and treatment of malaria in the district. Use of pyrethroid in indoor residual insecticide spray has also strengthened vector control. Among the various interventions used, long-lasting insecticide nets and introduction of artemisinin-based combination therapy have played significant roles in controlling malaria cases. A more drastic decline in P. falciparum cases versus P. vivax is evident, but the latter persists in high proportions and therefore new tools for malaria control will be needed for elimination.

Validation of a Mobile Health Technology Platform (FeverTracker) for Malaria Surveillance in India: Development and Usability Study

Background

A surveillance system is the foundation for disease prevention and control. Malaria surveillance is crucial for tracking regional and temporal patterns in disease incidence, assisting in recorded details, timely reporting, and frequency of analysis.

Objective

In this study, we aim to develop an integrated surveillance graphical app called FeverTracker, which has been designed to assist the community and health care workers in digital surveillance and thereby contribute toward malaria control and elimination.

Methods

FeverTracker uses a geographic information system and is linked to a web app with automated data digitization, SMS text messaging, and advisory instructions, thereby allowing immediate notification of individual cases to district and state health authorities in real time.

Results

The use of FeverTracker for malaria surveillance is evident, given the archaic paper-based surveillance tools used currently. The use of the app in 19 tribal villages of the Dhalai district in Tripura, India, assisted in the surveillance of 1880 suspected malaria patients and confirmed malaria infection in 93.4% (114/122; Plasmodium falciparum), 4.9% (6/122; P vivax), and 1.6% (2/122; P falciparum/P vivax mixed infection) of cases. Digital tools such as FeverTracker will be critical in integrating disease surveillance, and they offer instant data digitization for downstream processing.

Conclusions

The use of this technology in health care and research will strengthen the ongoing efforts to eliminate malaria. Moreover, FeverTracker provides a modifiable template for deployment in other disease systems.

Malaria Epidemiology Along the Indian Districts Bordering Bhutan and Implications for Malaria Elimination in the Region

It is important for malaria-endemic countries to address malaria control across international borders, and in particular to prioritize appropriate rapid diagnosis, treatment and surveillance. Bhutan and India aim to achieve malaria elimination by 2023 and 2030 respectively. Malaria elimination along the Indo-Bhutan border is of common concern. We delineated malaria epidemiology along the border to provide a blueprint for focusing malaria control efforts in key foci within this region. Epidemiological data from 2015 to 2019 were analyzed, as the most drastic reductions in malaria burden across most parts of India were witnessed in this time frame. Several areas of concern include low surveillance in most border districts, favorable climatic conditions for perennial malaria transmission, and movement of potential parasite carriers because of the porous borders. India and Bhutan need to control the importation/exportation of malaria cases. We highlight the foci of concern for which implementing tailor-made malaria control strategies may benefit both countries.

Coverage enhancement and community empowerment via commercial availability of the long-lasting nets for malaria in India

Achieving malaria elimination goal in India will require supplemental measures to plug in the gaps in implementation of malaria control programmes. Use of long-lasting insecticide nets is one of the two core interventions for vector control in malaria. The most common distribution channel is free delivery via national malaria control programme of various countries and in India, this is the only channel to provide nets to the masses. Understandably, there are gaps in the optimum coverage of at-risk population due to multiple reasons ranging from population growth to time lag in replacements, emergency conditions like floods and logistical impediments among others. At this juncture, it is crucial for India to explore complementary routes to expand access for nets by its people and one is making them available in private sector at an affordable price. The commercial availability of nets offers several advantages like filling in coverage gaps, overcoming additional requirements by families and financial resources being freed up for poor households. However, there are barriers to the successful operationalization of net commercialization like affordability issues, economic viability for manufacturers, regulatory issues etc. All the so-called barriers can be addressed in a concerted and pragmatic way to make access and availability of nets in private market a reality as that is a need of the hour, if India wants to achieve malaria elimination goal by 2030.

Free Market Availability of Rapid Diagnostics Will Empower Communities To Control Malaria in India

Globally, malaria incidence has declined but further reductions in malaria are not evident in many countries. In addition to the public health approaches for tackling malaria, involvement of the private sector is vital because the private sector plays a central role in healthcare delivery to the masses. In India, malaria management is primarily provided through government programs, nonetheless, significant numbers of fever patients continue to seek healthcare in the private sector. The private sector in India is comprised of formal healthcare (qualified and approved), informal healthcare (unqualified, untrained), including traditional healers. Commercial channels for the procurement of quality-assured malaria diagnostics like rapid diagnostic tests via pharmacies or other approved outlets would empower Indian populations to self-detect malaria without delay. Easier access would minimize the diagnostic time gap, reduce costs to the patient, prevent inappropriate malaria treatment, and foster timely treatment of both malaria and non-malaria infections. Commercially available rapid diagnostic tests in the hands of the people could be an important tool in our fight against malaria.

Forest malaria: the prevailing obstacle for malaria control and elimination in India

Despite the decrease in malaria mortality and morbidity, it remains a significant public health problem in India. India is targeting malaria elimination from the country by 2030. Different areas in India are in different phases of malaria elimination. The emerging resistance in vectors as well parasite have added necessity to accelerate the malaria elimination programme. Forested areas remain the foci for malaria transmission due to favourable human and environmental factors. Here, we analysed the longitudinal data from 2000 to 2019 to see the trends in forest malaria in India. Population living in forested areas are major malaria contributors. From 2000 to 2019, ~32% of malaria cases and 42% of malaria related deaths were reported from forested districts which represent only ~6.6% of the total Indian population. Increasing insecticide resistance, a high percentage of submicroscopic infections and challenging to test and treat communities are the crucial components of the prevailing obstacles of forested malaria. To achieve the elimination goal, efforts should be intensified with more resources diverted to the forested areas. Malaria control in forested areas will bring fruitful results for malaria control in India.

Malaria elimination in India requires additional surveillance mechanisms

Malaria surveillance is weak in high malaria burden countries. Surveillance is considered as one of the core interventions for malaria elimination. Impressive reductions in malaria-associated morbidity and mortality have been achieved across the globe, but sustained efforts need to be bolstered up to achieve malaria elimination in endemic countries like India. Poor surveillance data become a hindrance in assessing the progress achieved towards malaria elimination and in channelizing focused interventions to the hotspots. A major obstacle in strengthening India's reporting systems is that the surveillance data are captured in a fragmented manner by multiple players, in silos, and is distributed across geographic regions. In addition, the data are not reported in near real-time. Furthermore, multiplicity of malaria data resources limits interoperability between them. Here, we deliberate on the acute need of updating India's surveillance systems from the use of aggregated data to near real-time case-based surveillance. This will help in identifying the drivers of malaria transmission in any locale and therefore will facilitate formulation of appropriate interventional responses rapidly.