Surveillance based estimation of burden of malaria in India, 2015-2016

Determinants of malaria prevention and control at household level in Assam: An analysis of data using composite index

Background

Malaria prevention and control is a major public health problem of tropical countries including India. Usage of insecticide-treated bed nets, and early treatment especially in high-risk areas are the crucial factors for the malaria prevention at household levels. This study aimed to determine the crucial factors associated with malaria prevention at households' level such as household's characteristics, education, knowledge and awareness, insecticide treated bed nets usage, early treatment etc.

Methods

Data of 1989 households was used from the cross-sectional survey of malaria-endemic areas of Assam. Principal component analysis and multinomial logistic regression model were used to compute the composite scores of malaria awareness and prevention practices, and to estimate the associated factors with malaria prevention practices, respectively.

Results

The average age of household respondents were 41.1 ± 12.0 years and among them 71% were males. Almost 47% respondents were illiterate, and 38.6% of the respondents were farmers and 35% were employed. Multinomial logistic regression analysis indicates that malaria prevention practices are associated with age, education, religion, type of house and occupation of household heads and their level of malaria awareness among them. The prevention practices were significantly five times associated [Adjusted Rates Ratio (ARR): 5.0, 95% CI: 2.7-9.4] with the high level of malaria awareness compared with the low level of awareness. Overall, the level of prevention awareness, education, occupation, and house type related to the standard of living was significantly associated with the malaria prevention practices.

Conclusion

Malaria awareness and education are the key factors of malaria prevention practices that need to be accelerated for effective control of malaria. Malaria education and increasing awareness of people have a high impact on malaria prevention practices and their control.

Vivax malaria: a possible stumbling block for malaria elimination in India

Plasmodium vivax is geographically the most widely dispersed human malaria parasite species. It has shown resilience and a great deal of adaptability. Genomic studies suggest that P. vivax originated from Asia or Africa and moved to the rest of the world. Although P. vivax is evolutionarily an older species than Plasmodium falciparum, its biology, transmission, pathology, and control still require better elucidation. P. vivax poses problems for malaria elimination because of the ability of a single primary infection to produce multiple relapses over months and years. P. vivax malaria elimination program needs early diagnosis, and prompt and complete radical treatment, which is challenging, to simultaneously exterminate the circulating parasites and dormant hypnozoites lodged in the hepatocytes of the host liver. As prompt surveillance and effective treatments are rolled out, preventing primaquine toxicity in the patients having glucose-6-phosphate dehydrogenase (G6PD) deficiency should be a priority for the vivax elimination program. This review sheds light on the burden of P. vivax, changing epidemiological patterns, the hurdles in elimination efforts, and the essential tools needed not just in India but globally. These tools encompass innovative treatments for eliminating dormant parasites, coping with evolving drug resistance, and the development of potential vaccines against the parasite.

Malaria in newborn: A missed entity for primary care physician

Neonatal malaria and congenital malaria, though thought to be a rare entity in non-endemic areas but incidences from epidemic countries are eye openers. It is still thought by primary care physicians that its existence among neonates is not common even in endemic areas due to a low index of suspicion. In order to attain the objective set out in the global technical strategy against malaria 2016-2030, it is important to have a gravity of this disease in all age groups, especially in children and neonates in which misconception of low burden of infection results in underestimation of its morbidity and mortality in these age groups. This disease is only the tip of the iceberg due to unidentified, underreported and neglected illness and being a pointer towards higher circulation among society and pregnant women. So this review article highlights pathophysiology, epidemiology, clinical features, complications, prognosis, treatment and prevention of malaria in newborns and intends to bring awareness among the caregivers to understand the need for attention towards this neglected disease of neonates so that they should be able to identify and manage the disease in this vulnerable age group.

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.

Let's Not Miss the Treatable Ones: Two Cases of Neonatal Sepsis Due to Malaria

Congenital malaria is the direct infection of an infant with a malarial parasite from the mother either during pregnancy or at birth. Neonatal malaria occurs due to an infective mosquito bite after birth. Neonatal and congenital malaria (NCM) can occasionally present with life-threatening neonatal sepsis and rarely with neonatal jaundice. These conditions are typically managed by general pediatricians, especially in remote areas without access to specialized care. A high clinical index of suspicion is required to diagnose neonatal and congenital malaria, given that their presentation can mimic other more common neonatal conditions. We present two neonates with malaria, highlighting the importance of considering this treatable entity in the differential.

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.

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.

Surveillance-based estimation of the malaria disease burden in a low endemic state of Punjab, India, targeted for malaria elimination

BACKGROUND

The state of Punjab in India qualifies for malaria elimination because the number of cases reported through routine surveillance is in decline. However, surveillance system prevalence mainly provides malaria trends. Therefore, a prospective epidemiological study was designed to estimate the malaria burden in the state.

METHODS

District-wise annual parasite incidence (API) was used for identification of three strata, representing high, moderate and low API zones. A total of 0.9 million people from nine districts was under malaria surveillance for 1 y. The weighted estimates of API for the three regions was calculated and combined to give an estimate of API for the total population of the state.

RESULTS

Based upon the primary data generated, malaria cases from high, moderate and low malaria-endemic areas were estimated to be 3727, 904 and 106, respectively. Further, the total number of malaria cases in the state was estimated to be 4737 (95% CI 4006 to 5469) cases per annum.

CONCLUSION

Actual burden of malaria in the state of Punjab, India, is about seven to eight times higher than that reported by routine surveillance activities. However, the state still qualifies for malaria elimination but needs vigorous efforts to strengthen the active surveillance and reporting system along with implementation of effective control strategies to achieve malaria elimination.

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.