Demonstration of indigenous malaria elimination through Track-Test-Treat-Track (T4) strategy in a Malaria Elimination Demonstration Project in Mandla, Madhya Pradesh

Malaria elimination: situation analysis of cases in India, the state of Madhya Pradesh in central India, and district Mandla of Madhya Pradesh

India contributed approximately 66% of the malaria cases in the WHO South-East Asia region in 2022. In India, approximately 44% of cases have been reported to be disproportionately contributed by approximately 27 districts. A comparative analysis of reported malaria cases between January 2017 and December 2022 was performed in Mandla district, which is the site of a model malaria elimination demonstration project (MEDP) in Madhya Pradesh (MP), India. Compared to 2017, the decrease in malaria cases in Mandla from 2018 to 2022 was higher than MP and the rest of the country. The reduction of cases was significant in 2018, 2019, and 2021 (p < 0.01) (Mandla vs. MP) and was highly significant during 2018-2022 (p < 0.001) (Mandla vs. India). Robust surveillance and real-time data-based decisions accompanied by appropriate management, operational controls, and independent reviews, all designed for resource optimisation, were the reasons for eliminating indigenous malaria in Mandla district. The increase in infection rates during the months immediately following rains suggests that surveillance, vector control, and case management efforts should be specifically intensified for eliminating imported and indigenous cases in the near-elimination districts to work towards achieving the national elimination goal of 2030.

Mass Testing and Treatment to Accelerate Malaria Elimination: A Systematic Review and Meta-Analysis

In regions where malaria transmission persists, the implementation of approaches aimed at eliminating parasites from the population can effectively decrease both burden of disease and transmission of infection. Thus, mass strategies that target symptomatic and asymptomatic infections at the same time may help countries to reduce transmission. This systematic review assessed the potential benefits and harms of mass testing and treatment (MTaT) to reduce malaria transmission. Searches were conducted in March 2021 and updated in April 2022 and included cluster-randomized controlled trials (cRCTs) as well as nonrandomized studies (NRSs) using malaria infection incidence, clinical malaria incidence, or prevalence as outcomes. The risk of bias was assessed with Cochrane's risk of bias (RoB2) tool and Risk of Bias Tool in Nonrandomized Studies - of Interventions (ROBINS-I), and the certainty of evidence (CoE) was graded for each outcome. Of 4,462 citations identified, seven studies (four cRCTs and three NRSs) contributed outcome data. The analysis revealed that MTaT did not reduce the incidence (risk ratio [RR]: 0.95, 95% CI: 0.87-1.04; 1,181 participants; moderate CoE) or prevalence (RR: 0.83, 95% CI: 0.67-1.01; 7,522 participants; moderate CoE) of malaria infection but resulted in a small reduction in clinical malaria (RR: 0.82; 95% CI: 0.70-0.95; 334,944 participants; moderate CoE). Three studies contributing data on contextual factors concluded that MTaT is an acceptable, feasible, and cost-effective intervention. Mathematical modeling analyses (n = 10) suggested that MTaT effectiveness depends on the baseline transmission level, diagnostic test performance, number of rounds, and other co-interventions. Based on the limited evidence available, MTaT has little to no impact on reducing malaria transmission.

Time series analysis of malaria cases to assess the impact of various interventions over the last three decades and forecasting malaria in India towards the 2030 elimination goals

BACKGROUND

Despite the progress made in this decade towards malaria elimination, it remains a significant public health concern in India and many other countries in South Asia and Asia Pacific region. Understanding the historical trends of malaria incidence in relation to various commodity and policy interventions and identifying the factors associated with its occurrence can inform future intervention strategies for malaria elimination goals.

METHODS

This study analysed historical malaria cases in India from 1990 to 2022 to assess the annual trends and the impact of key anti-malarial interventions on malaria incidence. Factors associated with malaria incidence were identified using univariate and multivariate linear regression analyses. Generalized linear, smoothing, autoregressive integrated moving averages (ARIMA) and Holt's models were used to forecast malaria cases from 2023 to 2030.

RESULTS

The reported annual malaria cases in India during 1990-2000 were 2.38 million, which dropped to 0.73 million cases annually during 2011-2022. The overall reduction from 1990 (2,018,783) to 2022 (176,522) was 91%. The key interventions of the Enhanced Malaria Control Project (EMCP), Intensified Malaria Control Project (IMCP), use of bivalent rapid diagnostic tests (RDT-Pf/Pv), artemisinin-based combination therapy (ACT), and involvement of the Accredited Social Health Activists (ASHAs) as front-line workers were found to result in the decline of malaria significantly. The ARIMA and Holt's models projected a continued decline in cases with the potential for reaching zero indigenous cases by 2027-2028. Important factors influencing malaria incidence included tribal population density, literacy rate, health infrastructure, and forested and hard-to-reach areas.

CONCLUSIONS

Studies aimed at assessing the impact of major commodity and policy interventions on the incidence of disease and studies of disease forecasting will inform programmes and policymakers of steps needed during the last mile phase to achieve malaria elimination. It is proposed that these time series and disease forecasting studies should be performed periodically using granular (monthly) and meteorological data to validate predictions of prior studies and suggest any changes needed for elimination efforts at national and sub-national levels.

Science of malaria elimination: using knowledge of bottlenecks and enablers from the Malaria Elimination Demonstration Project in Central India for eliminating malaria in the Asia Pacific region

Malaria poses a major public health challenge in the Asia Pacific. Malaria Elimination Demonstration Project was conducted as a public-private partnership initiative in Mandla between State government, ICMR, and FDEC India. The project employed controls for efficient operational and management decisions. IEC campaigns found crucial in schools and communities. Capacity building of local workers emphasized for better diagnosis and treatment. SOCH mobile app launched for complete digitalization. Better supervision for Indoor Residual Sprays and optimized Long Lasting Insecticidal Nets distribution. Significant malaria cases reduction in Mandla. Insights from MEDP crucial for malaria elimination strategies in other endemic regions of the Asia Pacific.

Assessment of Plasmodium falciparum drug resistance associated molecular markers in Mandla, Madhya Pradesh, India

BACKGROUND

Resistance against artemisinin-based combination therapy is one of the challenges to malaria control and elimination globally. Mutations in different genes (Pfdhfr, Pfdhps, Pfk-13 and Pfmdr1) confer resistance to artesunate and sulfadoxine-pyrimethamine (AS + SP) were analysed from Mandla district, Madhya Pradesh, to assess the effectiveness of the current treatment regimen against uncomplicated Plasmodium falciparum.

METHODS

Dried blood spots were collected during the active fever survey and mass screening and treatment activities as part of the Malaria Elimination Demonstration Project (MEDP) from 2019 to 2020. Isolated DNA samples were used to amplify the Pfdhfr, Pfdhps, Pfk13 and Pfmdr1 genes using nested PCR and sequenced for mutation analysis using the Sanger sequencing method.

RESULTS

A total of 393 samples were subjected to PCR amplification, sequencing and sequence analysis; 199, 215, 235, and 141 samples were successfully sequenced for Pfdhfr, Pfdhps, Pfk13, Pfmdr1, respectively. Analysis revealed that the 53.3% double mutation (C59R, S108N) in Pfdhfr, 89.3% single mutation (G437A) in Pfdhps, 13.5% single mutants (N86Y), and 51.1% synonymous mutations in Pfmdr1 in the study area. Five different non-synonymous and two synonymous point mutations found in Pfk13, which were not associated to artemisinin resistance.

CONCLUSION

The study has found that mutations linked to SP resistance are increasing in frequency, which may reduce the effectiveness of this drug as a future partner in artemisinin-based combinations. No evidence of mutations linked to artemisinin resistance in Pfk13 was found, suggesting that parasites are sensitive to artemisinin derivatives in the study area. These findings are a baseline for routine molecular surveillance to proactively identify the emergence and spread of artemisinin-resistant parasites.

Testing and treatment for malaria elimination: a systematic review

BACKGROUND

Global interest in malaria elimination has prompted research on active test and treat (TaT) strategies.

METHODS

A systematic review and meta-analysis were conducted to assess the effectiveness of TaT strategies to reduce malaria transmission.

RESULTS

A total of 72 empirical research and 24 modelling studies were identified, mainly focused on proactive mass TaT (MTaT) and reactive case detection (RACD) in higher and lower transmission settings, respectively. Ten intervention studies compared MTaT to no MTaT and the evidence for impact on malaria incidence was weak. No intervention studies compared RACD to no RACD. Compared to passive case detection (PCD) alone, PCD + RACD using standard diagnostics increased infection detection 52.7% and 11.3% in low and very low transmission settings, respectively. Using molecular methods increased this detection of infections by 1.4- and 1.1-fold, respectively.

CONCLUSION

Results suggest MTaT is not effective for reducing transmission. By increasing case detection, surveillance data provided by RACD may indirectly reduce transmission by informing coordinated responses of intervention targeting.

Prevalence and proportion estimate of asymptomatic Plasmodium infection in Asia: a systematic review and meta-analysis

Asymptomatic Plasmodium infection raises a problem for the persistent transmission of malaria in low-endemic areas such as Asia. This systematic review was undertaken to estimate the prevalence and proportion of asymptomatic Plasmodium infection in Asia. The systematic review was registered at PROSPERO (ID: CRD42022373664). The research followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. A comprehensive search of five databases, Ovid, Scopus, MEDLINE, PubMed, and Embase, was conducted to identify studies of asymptomatic Plasmodium infection in Asian countries. The pooled prevalence of asymptomatic Plasmodium infection, the pooled proportion of asymptomatic Plasmodium infection among all parasitised individuals, and the associated 95% confidence intervals were estimated using a random-effects model. A total of 916 articles were retrieved, and 87 articles that met the criteria were included in the systematic review. The pooled prevalence of asymptomatic Plasmodium infection among enrolled participants in Southeast Asia, South Asia, and Western Asia was 5.8%, 9.4%, and 8.4%, respectively. The pooled proportion of asymptomatic Plasmodium infection among all parasitised individuals in Southeast Asia, South Asia, and Western Asia was 89.3%, 87.2%, and 64.8%, respectively. There was a low prevalence of asymptomatic Plasmodium infection, but there was a high proportion of asymptomatic Plasmodium infection per all parasitised individuals in different parts of Asia. These results may support and facilitate elimination and control programs for asymptomatic Plasmodium infection in Asia.

How can the complex epidemiology of malaria in India impact its elimination?

Malaria is a human health hazard in the tropical and subtropical zones of the globe and is poised to be eliminated by the year 2030. Despite a decrease in incidence in the past two decades, many endemic countries, including India, report cases regularly. The epidemiology of malaria in India is unique owing to several features of the Plasmodium parasites, Anopheles vectors, ecoepidemiological situations conducive to disease transmission, and susceptible humans living in rural and forested areas. Limitations in public health reach, and poor health-seeking behaviour of vulnerable populations living in hard-to-reach areas, add to the problem. We bring all of these factors together in a comprehensive framework and opine that, in spite of complexities, targeted elimination of malaria in India is achievable with planned programmatic approaches.

A comparative assessment of the community frontline health workers for their knowledge and practices of malaria diagnosis and treatment in three contiguous districts Mandla, Balaghat, and Dindori of Madhya Pradesh, India

BACKGROUND

Global malaria cases rose by 14 million, and deaths by 69,000, in 2020. In India, a 46% decline has been reported between 2020 and 2019. In 2017, the Malaria Elimination Demonstration Project conducted a needs-assessment of the Accredited Social Health Activists (ASHAs) of Mandla district. This survey revealed the inadequate level of knowledge in malaria diagnosis and treatment. Subsequently, a training programme was launched for enhancing malaria-related knowledge of ASHAs. The present study was conducted in 2021 to evaluate the impact of training on malaria-related knowledge and practices of ASHAs in Mandla. This assessment was also done in two adjoining districts: Balaghat and Dindori.

METHODS

A cross-sectional survey using a structured questionnaire was administered to ASHAs to measure their knowledge and practices related to malaria etiology, prevention, diagnosis, and treatment. A comparison of information collected from these three districts was performed using simple descriptive statistics, comparison of means and multivariate logistic regression analysis.

RESULTS

Significant improvement was noted amongst ASHAs of district Mandla between 2017 (baseline) and 2021 (endline) in knowledge related to malaria transmission, preventive measures, adherence to the national drug policy, diagnosis using rapid diagnostic tests, and identification of age group-specific, colour-coded artemisinin combination therapy blister packs (p < 0.05). The multivariate logistic regression analysis revealed that odds of Mandla baseline was 0.39, 0.48, 0.34, and 0.07 times lower for malaria-related knowledge on disease etiology, prevention, diagnosis, and treatment, respectively (p < 0.001). Further, participants in districts Balaghat and Dindori showed significantly lower odds for knowledge (p < 0.001) and treatment practices (p < 0.01) compared to Mandla endline. Education, attended training, having a malaria learner's guide, and minimum 10 years' work experience were potential predictors for good treatment practices.

CONCLUSION

The findings of the study unequivocally establishes significant improvement in overall malaria-related knowledge and practices of ASHAs in Mandla as a result of periodic training and capacity building efforts. The study suggests that learnings from Mandla district could be helpful in improving level of knowledge and practices among frontline health workers.

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.

Mass screening and treatment (MSaT) for identifying and treating asymptomatic cases of malaria-malaria elimination demonstration project (MEDP), Mandla, Madhya Pradesh

BACKGROUND

Mass screening and treatment (MSaT) aims at reducing the spread of malaria in communities by identifying and treating infected persons regardless of the symptoms. This study was conducted to identify and treat asymptomatic cases using MSaT approaches in the community.

METHODS

Three rounds of MSaT using cluster combination approaches were carried out during September 2018 to December 2019 to identify and treat asymptomatic malaria cases in the community. All individuals who were present in the household were screened using RDT irrespective of malaria related symptoms. Simultaneously thick and thin blood smear and blood spot were collected for further analysis using microscopy and diagnostic PCR done in a subset of the samples.

RESULTS

Logistic regression analysis revealed that asymptomatic malaria cases significantly less among the older age groups compared with < 5 years children (OR ranged between 0.52 and 0.61; p < 0.05), lowest in cluster 4 (OR = 0.01; p < 0.0001); during third round of MSaT survey (OR = 0.11; p < 0.0001) and significantly higher in moderate to high endemic areas (OR = 88.30; p < 0.0001).

CONCLUSION

Over the three rounds of MSaT, the number of asymptomatic cases were significantly less in the older age groups, and during third round. Similarly, the asymptomatic cases were significantly less in the low endemic area with API < 1 (cluster four). Therefore, the malaria elimination programme may consider the MSaT strategy to identify asymptomatic cases that would be otherwise missed by routine fever based surveillance. This MSaT strategy would help accomplish the malaria elimination goal in an expedited manner.

A qualitative study on community perceptions on quality of healthcare services they received in the Malaria Elimination Demonstration Project in district Mandla, India

BACKGROUND

The utilization and impact of the healthcare services depend on the perceived quality, appropriateness, ease of availability, and cost of the services. This study aimed to understand the community's perception of the quality of healthcare services delivered as part of the Malaria Elimination Demonstration Project (MEDP), Mandla, Madhya Pradesh, India.

METHODS

The study used qualitative techniques to analyze the community perceptions that emerged from the participants' narratives during the Focus Group Discussions (FGDs) and in-depth Interviews with Key Informants (IKIs) on the promptness and quality of healthcare service delivery, the behaviour of MEDP staff, Information, Education and Communication, and Behavioural Change Communication activities, coordination with community members and other health personnel, and capacity building of healthcare workers and the community.

RESULTS

36 FGDs and 63 IKIs with 419 respondents were conducted in nine blocks of district Mandla. Overall, 97% to 100% of beneficiaries associated MEDP with regularity and prompt service delivery, availability of diagnostics and drugs, friendly behaviour, good coordination, and community mobilization to enhance treatment-seeking behaviour.

CONCLUSIONS

The study's findings highlighted the importance of building and maintaining the community's participation and promoting the demand for optimal utilization of healthcare services inside the village to promptly achieve the malaria elimination goal.

Significance of nested PCR testing for the detection of low-density malaria infection amongst febrile patients from the Malaria Elimination Demonstration Project in Mandla, Madhya Pradesh, India

Background

Low-density malaria infections (LDMI) are defined as infections that are missed by the rapid diagnostic test (RDT) and/or microscopy which can lead to continued transmission and poses a challenge in malaria elimination efforts. This study was conducted to investigate the prevalence of LDMI in febrile cases using species-specific nested Polymerase Chain Reaction (PCR) tests in the Malaria Elimination Demonstration Project, where routine diagnosis was conducted using RDT.

Methods

Every 10th fever case from a cross-sectional community based fever surveillance was tested with RDT, microscopy and nested PCR. Parasite DNA was isolated from the filter paper using Chelex based method. Molecular diagnosis by nested PCR was performed targeting 18SrRNA gene for Plasmodium species.

Results

The prevalence of malaria was 2.50% (436/17405) diagnosed by PCR, 1.13% (196/17405) by RDT, and 0.68% (118/ 17,405) by microscopy. Amongst 17,405 febrile samples, the prevalence of LDMI was 1.51% (263/17405) (95% CI 1.33–1.70), which were missed by conventional methods. Logistic regression analysis revealed that illness during summer season [OR = 1.90 (p < 0.05)] and cases screened within three days of febrile illness [OR = 5.27 (p < 0.001)] were the statistically significant predictors of LDMI.

Conclusion

The prevalence of malaria among febrile cases using PCR was 2.50% (436/17405) as compared to 1.13% (196/17405) by RDT. Higher number of the LDMI cases were found in subjects with ≤ 3 days mean duration of reported fever, which was statistically significant (p < 0.001). This observation suggests that an early detection of malaria with a more sensitive diagnostic method or repeat testing of the all negative cases may be useful for curtailing malaria transmission. Therefore, malaria elimination programme would benefit from using more sensitive and specific diagnostic methods, such as PCR.

Implementation and acceptance of government-sponsored malaria control interventions in Meghalaya, India

Background

India has made considerable progress in malaria reduction over the past two decades, with government-sponsored indoor residual spraying (IRS) and insecticide-treated bed net (ITN) or long-lasting insecticidal nets (LLIN) distribution being the main vector-related prevention efforts. Few investigations have used non-participant observational methods to assess malaria control measures while they were being implemented, nor documented people’s perceptions and acceptance of IRS or LLINs in India, and none have done so in the northeast region. This study evaluated household (HH)-level operation of IRS and distribution of LLINs by India’s National Vector Borne Disease Control Programme (NVBDCP) in 50 villages of Meghalaya state, and documented their acceptance and use.

Methods

Study field teams accompanied the government health system teams during August-October, 2019 and 2020 to observe deployment of LLINs, and record HH-level data on LLIN numbers and use. In addition, NVBDCP spray teams were followed during 2019–2021 to observe IRS preparation and administration. HH members were interviewed to better understand reasons for acceptance or refusal of spraying.

Results

A total of 8386 LLINs were distributed to 2727 HHs in 24 villages from five Primary Health Centres, representing 99.5% of planned coverage. Interviews with 80 HH residents indicated that they appreciated the LLIN dissemination programme, and generally made regular and appropriate use of LLINs, except during overnight travel or when working in agricultural fields. However, HH-level IRS application, which was observed at 632 HHs, did not always follow standard insecticide preparation and safety protocols. Of 1,079 occupied HHs visited by the spray team, 632 (58.6%) refused to allow any spraying. Only 198 (18.4%) HHs agreed to be sprayed, comprising 152 (14.1%) that were only partly sprayed, and 46 (4.3%) that were fully sprayed. Reasons for refusal included: inadequate time to rearrange HH items, young children were present, annoying smell, staining of walls, and threat to bee-keeping or Eri silk moth cultivation.

Conclusions

These findings are among the first in India that independently evaluate people's perceptions and acceptance of ongoing government-sponsored IRS and LLIN programmes for malaria prevention. They represent important insights for achieving India's goal of malaria elimination by 2030.

Impact of the malaria comprehensive case management programme in Odisha, India

Background

The Comprehensive Case Management Project (CCMP), was a collaborative implementation research initiative to strengthen malaria early detection and complete treatment in Odisha State, India.

Methods

A two-arm quasi-experimental design was deployed across four districts in Odisha, representing a range of malaria endemicity: Bolangir (low), Dhenkanal (moderate), Angul (high), and Kandhamal (hyper). In each district, a control block received routine malaria control measures, whereas a CCMP block received a range of interventions to intensify surveillance, diagnosis, and case management. Impact was evaluated by difference-in-difference (DID) analysis and interrupted time-series (ITS) analysis of monthly blood examination rate (MBER) and monthly parasite index (MPI) over three phases: phase 1 pre-CCMP (2009–2012) phase 2 CCMP intervention (2013–2015), and phase 3 post-CCMP (2016–2017).

Results

During CCMP implementation, adjusting for control blocks, DID and ITS analysis indicated a 25% increase in MBER and a 96% increase in MPI, followed by a –47% decline in MPI post-CCMP, though MBER was maintained. Level changes in MPI between phases 1 and 2 were most marked in Dhenkanal and Angul with increases of 976% and 287%, respectively, but declines in Bolangir (−57%) and Kandhamal (−22%). Between phase 2 and phase 3, despite the MBER remaining relatively constant, substantial decreases in MPI were observed in Dhenkanal (−78%), and Angul (−59%), with a more modest decline in Bolangir (−13%), and an increase in Kandhamal (14%).

Conclusions

Overall, CCMP improved malaria early detection and treatment through the enhancement of the existing network of malaria services which positively impacted case incidence in three districts. In Kandhamal, which is hyperendemic, the impact was not evident. However, in Dhenkanal and Angul, areas of moderate-to-high malaria endemicity, CCMP interventions precipitated a dramatic increase in case detection and a subsequent decline in malaria incidence, particularly in previously difficult-to-reach communities.

Monitoring of the Village Malaria Workers to conduct activities of Malaria Elimination Demonstration Project in Mandla, Madhya Pradesh

Background

The capacity of the field staff to conduct activities related to disease surveillance, case management, and vector control has been one of the key components for successfully achieving malaria elimination. India has committed to eliminate malaria by 2030, and it has placed significance on monitoring and evaluation at the district level as one of the key strategies in its national framework. To support and guide the country’s malaria elimination objectives, the Malaria Elimination Demonstration Project was conducted in the tribal district of Mandla, Madhya Pradesh. Robust monitoring of human resources received special attention to help the national programme formulate a strategy to plug the gaps in its supply chain and monitoring and evaluation systems.

Methods

A monitoring tool was developed to test the capabilities of field workers to conduct activities related to malaria elimination work. Between November 2018 to February 2021, twenty-five Malaria Field Coordinators (MFCs) of the project utilized this tool everyday during the supervisory visits for their respective Village Malaria Workers (VMWs). The data was analysed and the scores were tested for variations against different blocks, educational status, duration of monitoring, and post-training scores.

Results

During the study period, the VMWs were monitored a total of 8974 times using the monitoring tool. Each VMW was supervised an average of 1.8 times each month. The critical monitoring indicators scored well in all seven quarters of the study as monitored by the MFCs. Monitoring by MFCs remained stable at 97.3% in all quarters. Contrary to expectations, the study observed longer diagnosis to treatment initiation time in urban areas of the district.

Conclusion

This study demonstrated the significance of a robust monitoring tool as an instrument to determine the capacity of the field workers in conducting surveillance, case management, and vector control related work for the malaria elimination programme. Similar tools can be replicated not only for malaria elimination, but other public health interventions as well.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12936-021-04040-2.

Learnings from two independent malaria elimination demonstration projects in India

PROBLEM

India and sub-Saharan Africa contributes about 85% of the global malaria burden, and India is committed to eliminating malaria by 2030.

APPROACH

Two novel initiatives-the Malaria Elimination Demonstration Project (MEDP) in Madhya Pradesh and Durgama Anchalare Malaria Nirakaran (DAMaN) in Odisha-were initiated independently to demonstrate that indigenous malaria can be eliminated in a short period of time.

LOCAL SETTING

These initiatives focused on rural, tribal areas where there is a high malaria burden and complex epidemiology.

RELEVANT CHANGES

The case management and vector control strategies used in these programmes were based on the national guidelines, with context-specific changes and introduction of accountability at management, operational, technical and financial levels. The MEDP achieved a 91% reduction in malaria cases and recorded zero transmission for 6 consecutive and a total of 9 mo. The DAMaN project brought about an 88% reduction in malaria cases.

LESSONS LEARNED

Malaria elimination will require robust surveillance and case management, monitoring of vector control interventions, community-centric information education communication and behaviour change communication initiatives and management controls, as well as regular internal and external reviews.

Assessing community knowledge, attitude and practices to strengthen communication strategy for Malaria Elimination Demonstration Project in Mandla

BACKGROUND

Changes in social, belief, and behavioural practices are essential for the success of any public health delivery programme. In the planning stages of the Malaria Elimination Demonstration Project (MEDP), priority was given to communication with a goal to develop capacity of health workers and to improve the knowledge, attitude and practices (KAP) of the people of Mandla. This paper describes the level of community knowledge on malaria, including its prevention, diagnosis, treatment-seeking behaviour, and the level of satisfaction with the services provided by the project.

METHODS

A cross sectional survey was undertaken in 1233 villages of Mandla to study the KAP and self-assessed improvement in knowledge and satisfaction level of the community. The goal of the study was to understand whether there is need for strengthening communication strategy of MEDP for better impact. The survey was conducted amongst the head/eligible members of the 733 households located in the nine blocks of the district using clustered random sampling.

RESULTS

Though four-fifths of the respondents were able to correlate the transmission of malaria with mosquitoes, misconceptions existed among them. The types of malaria were not known to everyone. Only 39% were aware of the Indoor Residual Spray (IRS) and 41% understood the value of Long-Lasting Insecticidal Nets (LLIN). Around 71% of subjects surveyed were aware of the proper diagnostic tests for malaria. A total of 87% of the respondents knew about the MEDP staff working in their respective villages.

CONCLUSION

The study reported gaps in knowledge on malaria at community level. The self-assessment of the community revealed that the communication strategy established by MEDP in Mandla district has been useful to them as they are becoming better informed about the prevention and treatment aspects of disease. The lessons learned as revealed in the KAP survey will improve malaria elimination outcomes in a timely manner.

Improvement of Indoor Residual Spraying and Long-Lasting Insecticidal Net services through structured monitoring and supervision as part of the Malaria Elimination Demonstration Project in Mandla, Madhya Pradesh

Background

The Government of Madhya Pradesh employed Indoor Residual Spraying (IRS) with alpha-cypermethrin synthetic pyrethroids in sub-centres with Annual Parasite Incidence (API) from 2 to 4.99. In sub-centres with API more than 5, Long-Lasting Insecticidal Nets (LLINs) were distributed. At the request of the State Government, the Malaria Elimination Demonstration Project (MEDP) staff observed and provided support to both IRS and LLINs campaigns. In the year 2017, the study team monitored only the IRS campaigns, however, in the year 2018, the supportive supervision was provided to the IRS campaign teams along with post-distribution monitoring of the LLINs.

Methods

The study was carried out during IRS spraying using a pre-tested, closed-ended monitoring checklist which consisted of two parts- observations of spraying team and observation of sprayed houses. For LLINs, a sample of the households that received the bed nets was taken for the study. For IRS, the spraying teams were monitored for quality and technique for a total of 159 times in 2017 and 183 times in the year 2018, respectively. For post spraying observations, a total of 1261 and 1791 households were observed in the years 2017 and 2018, respectively. The use of LLINs was observed in 5 % of the households in 2018 and 2020, which is about 2,000 houses in each survey where each house received about 2.5 LLINs per household. The results of surveys were compared to assess impact of supportive supervision and monitoring.

Results

Significant improvement was noted after supportive supervision in year 2018 in various aspects of spraying. Preparedness of spraying, such as advance information to villagers, presence of equipment and records improved by up to 70 %. The methodology of spraying preparation improved from 50 to 90 %, spraying technique improved from 54 to 80 %, and proper use equipment during spraying improved from 51 to 92 %. After eight months post distribution of the LLINs in 2019, improvement was seen in regular usage of LLINs by 28 %. It was found that on-spot demonstrations during distribution and carrying of LLINs when sleeping outside homes increased by 56 %. Results of IEC campaigns revealed the reduction in adverse effects by 64 % and increase in awareness by 97 %.

Conclusions

Effective supervision improved the quality of IRS and usage of LLINs in the study area. Based on these results, continued training and monitoring of staff that is deployed to spraying houses and distribute bed nets was suggested. The study also revealed that proper IEC/BCC drives help increase community acceptance of vector control measures and their rational usage.

A comprehensive mobile application tool for disease surveillance, workforce management and supply chain management for Malaria Elimination Demonstration Project

BACKGROUND

Health care technologies are now offering accountability, quality, robustness, and accuracy in disease surveillance and health care delivery programmes. With the advent of mobile hand-held devices, these technologies have become more accessible and adaptable for use by field staff working in remote areas. The Malaria Elimination Demonstration Project started collection of data and conduct of routine operations using paper-based reporting systems. Observing the need for a robust and quality digital mobile application, a comprehensive mobile application tool was developed that allowed the project to conduct disease surveillance, workforce management and supply chain management.

METHODS

In June 2017, the project conceptualized a comprehensive mobile application tool in the local language (Hindi) for disease surveillance, human resources management, and supply chain management. The tool is also available in English. Solution for Community Health-workers (SOCH) mobile app is an android native application developed using android SDK and web-based tool using MVC.net framework. Construction of the application started in November 2017 and rolled out its pilot in April 2018, followed by pan-district roll out in July 2018. The application uses self-validation tools to ensure high level of data quality and integrity.

RESULTS

The software is available in android based hand-held devices and web-screens with built-in data analytical capabilities. Using SOCH, the project has now successfully digitized its routine surveillance, attendance, tour plans, supply chain management components. The project has documented a reduction in 91% indigenous cases in the district, 60% improvement in stock accountability, and 99.6% accuracy in data collected through the mobile application.

CONCLUSION

SOCH is an excellent and user-friendly tool, which can be customized for any public health management programme. The system ensures accountability and data robustness, which is needed for malaria elimination efforts throughout the country. The mobile application can be adapted for English or any other Indian or international language for use for malaria or any other disease surveillance and control programme. Another expansion feature of this mobile application is incorporation of indicators for Indoor Residual Spraying (IRS), Long-Lasting Insecticidal Nets (LLINs), and minor engineering by the residents of community under surveillance. The authors believe that it would be highly desirable and appropriate for an international organization, such as the World Health Organization (WHO), to conduct an independent comparison of all available mobile e-surveillance tools, so that a high-performing and globally suitable system can be selected for use in malaria elimination programmes. The Foundation of Disease Elimination and Controlof India has decided to make the SOCH mobile application available to anyone who would like to use it for disease surveillance and health care programmes.

A model for malaria elimination based on learnings from the Malaria Elimination Demonstration Project, Mandla district, Madhya Pradesh

Background

Malaria Elimination Demonstration Project (MEDP) was started as a Public-Private-Partnership between the Indian Council of Medical Research through National Institute of Research in Tribal Health, Govt. of Madhya Pradesh and Foundation of Disease Elimination and Control of India, which is a Corporate Social Responsibility (CSR) initiative of the Sun Pharmaceutical Industries Limited. The project’s goal was to demonstrate that malaria can be eliminated from a high malaria endemic district along with prevention of re-establishment of malaria and to develop a model for malaria elimination using the lessons learned and knowledge acquired from the demonstration project.

Methods

The project employed tested protocols of robust surveillance, case management, vector control, and capacity building through continuous evaluation and training.  The model was developed using the learnings from the operational plan, surveillance and case management, monitoring and feedback, entomological investigations and vector control, IEC and capacity building, supply chain management, mobile application (SOCH), and independent reviews of MEDP.

Results

The MEDP has been operational since April 2017 with field operations from August 2017, and has observed: (1) reduction in indigenous cases of malaria by about 91 %; (2) need for training and capacity building of field staff for diagnosis and treatment of malaria; (3) need for improvement insecticide spraying and for distribution and usage of bed-nets; (4) need for robust surveillance system that captures and documents information on febrile cases, RDT positive individuals, and treatments provided; (5) need for effective supervision of field staff based on advance tour plan; (6) accountability and controls from the highest level to field workers; and (7) need for context-specific IEC.

Conclusions

Malaria elimination is a high-priority public health goal of the Indian Government with a committed deadline of 2030. In order to achieve this goal, built-in systems of accountability, ownership, effective management, operational, technical, and financial controls will be crucial components for malaria elimination in India. This manuscript presents a model for malaria elimination with district as an operational unit, which may be considered for malaria elimination in India and other countries with similar geography, topography, climate, endemicity, health infrastructure, and socio-economic characteristics.

Significance of training, monitoring and assessment of malaria workers in achieving malaria elimination goal of Malaria Elimination Demonstration Project

Background

The Malaria Elimination Demonstration Project (MEDP) maintained a workforce of 235 Village Malaria Workers (VMWs) and 25 Malaria Field Coordinators (MFCs) to conduct disease surveillance, case management, IEC/BCC activities, capacity building, and monitoring of vector control activities in 1233 villages of Mandla, a high malaria endemic district of Madhya Pradesh in central India.

Methods

The induction training was conducted for 3 days on malaria diagnosis, treatment, prevention, and ethics. All trainings were assessed using a pre and post-training assessment questionnaire, with 70% marks as qualifying threshold. The questionnaire was divided into three thematic areas viz. general knowledge related to malaria (KAP), diagnosis and treatment (DXRX), and vector control (PVC).

Results

In 2017, the project trained 330 candidates, followed by 243 and 247 candidates in 2018 and 2019, respectively. 94.3% candidates passed after a single training session. Almost all (95%) candidates showed improvement in knowledge after the training with 4% showing no effect and 1% showing deterioration. Progressive improvement in scores of 2017 cohort was seen along with significant improvement in performance of candidates in 2019 after the introduction of systematic monitoring and ‘shadowing’ training exercises.

Conclusion

The project has successfully demonstrated the value of recruitment of workers from the study area, outcome of training, and performance evaluation of field staff in malaria elimination programme. This careful strategy of recruitment and training resulted in a work-force that was capable of independently conducting surveillance, case management, vector control, and Information Education Communication/Behaviour Change Communication (IEC/BCC). The learnings of this study, including the training modules and monitoring processes, can be used to train the health delivery staff for achieving national goal for malaria elimination by 2030. Similar training and monitoring programmes could also be used for other public health delivery programmes.

Socio-economic determinants of malaria in tribal dominated Mandla district enrolled in Malaria Elimination Demonstration Project in Madhya Pradesh

Background

Malaria is known as a disease of poverty because of its dominance in poverty-stricken areas. Madhya Pradesh state in central India is one of the most vulnerable states for malaria morbidity and mortality. Socio-economic, environmental and demographic factors present challenges in malaria control and elimination. As part of the Malaria Elimination Demonstration Project in the tribal district of Mandla in Madhya Pradesh, this study was undertaken to assess the role of different social-economic factors contributing to malaria incidence.

Methods

The study was conducted in the 1233 villages of district Mandla, where 87% population resides in rural areas. The data was collected using the android based mobile application—SOCH for a period of 2 years (September 2017 to August 2019). A wealth index was computed along with analysis of the socio-economic characteristics of houses with malaria cases. Variables with significant variation in malaria cases were used in logistic regression.

Results

More than 70% of houses in Mandla are Kuccha (made of thatched roof or mud), 20% do not have any toilet facilities, and only 11% had an annual income of more than 50,000 INR, which converts to about $700 per year. Households with younger heads, male heads, more number of family members were more likely to have malaria cases. Kuccha construction, improper water supply, low household income houses were also more likely to have a malaria case and the odds doubled in houses with no toilet facilities.

Conclusion

Based on the results of the study, it has been found that there is an association between the odds of having malaria cases and different household variables such as age, gender, number of members, number of rooms, caste, type of house, toilet facilities, water supply, cattle sheds, agricultural land, income, and vector control interventions. Therefore, a better understanding of the association of various risk factors that influence the incidence of malaria is required to design and/or deploy effective policies and strategies for malaria elimination. The results of this study suggest that appropriate economic and environmental interventions even in low-income and poverty-stricken tribal areas could have huge impact on the success of the national malaria elimination goals.

A study of malaria vector surveillance as part of the Malaria Elimination Demonstration Project in Mandla, Madhya Pradesh

BACKGROUND

Understanding of malaria vector density, distribution, insecticide resistance, vector incrimination, infection status, and identification of sibling species are some of the essential components of vector control measures for achieving malaria elimination goals.

METHODS

As part of the malaria elimination demonstration project, entomological surveillance was carried out from October 2017 to October 2019 by collecting indoor resting mosquitoes using hand catch method. Susceptibility test was done for determining the insecticide resistance status of vector mosquito Anopheles culicifacies using standard protocols by the World Health Organization. The cone bioassay method was used for determining the efficacy and quality of insecticide sprayed. Mosquitoes collected from different ecotypes were identified and processed for parasite identification, vector incrimination and sibling species determination.

RESULTS

The two known malaria vector species (Anopheles culicifacies and Anopheles fluviatilis) were found in the study area, which have been previously reported in this and adjoining areas of the State of Madhya Pradesh. The prevalence of An. culicifacies was significantly higher in all study villages with peak in July while lowest number was recorded in May. Proportion of vector density was observed to be low in foothill terrains. The other anopheline species viz, Anopheles subpictus, Anopheles annularis, Anopheles vagus, Anopheles splendidus, Anopheles pallidus, Anopheles nigerrimus and Anopheles barbirostris were also recorded in the study area, although their prevalence was significantly less compared to the An. culicifacies. In 2017, An. culicifacies was found to be resistant to dichloro-diphenyl-trichloroethane (DDT) and malathion, with possible resistance to alphacypermethrin and susceptible to deltamethrin. However, in 2019, the species was found to be resistant to alphacypermethrin, DDT, malathion, with possible resistance to deltamethrin. The bioassays revealed 82 to > 98% corrected % mortality of An. culicifacies on day-one post-spraying and 35 to 62% on follow-up day-30. Anopheles culicifacies sibling species C was most prevalent (38.5%) followed by A/D and E while B was least pre-dominant (11.9%). Anopheles fluviatilis sibling species T was most prevalent (74.6%) followed by U (25.4%) while species S was not recorded. One An.culicifacies (sibling species C) was found positive for Plasmodium falciparum by PCR tests in the mosquitoes sampled from the test areas.

CONCLUSION

Based on the nine entomologic investigations conducted between 2017-2019, it was concluded that An. culicifacies was present throughout the year while An. fluviatilis had seasonal presence in the study areas. Anopheles culicifacies was resistant to alphacypermethrin and emerging resistance to deltamethrin was observed in this area. Anopheles culicifacies was confirmed as the malaria vector. This type of information on indigenous malaria vectors and insecticide resistance is important in implementation of vector control through indoor residual spraying (IRS) and use of insecticide-impregnated bed nets for achieving the malaria elimination goals.

Digital Health Care Services to Control and Eliminate Malaria in India

In the rural and tribal areas of India, poor healthcare services for malaria are posing a great challenge to malaria control and elimination. Digitisation in malaria healthcare services, including surveillance, diagnosis, and treatment, may be helpful in malaria control and, subsequently, may move towards the elimination goal of India by 2030.

Study design and operational framework for a community-based Malaria Elimination Demonstration Project (MEDP) in 1233 villages of district Mandla, Madhya Pradesh

Background

In the past decade substantial reduction in malaria morbidity and mortality has been observed through well-implemented case management and vector control strategies. India has also achieved a significant reduction in malaria burden in 2018 and has committed to eliminate malaria by 2030. The Mandla Malaria Elimination Demonstration Project (MEDP) was started in 2017 in 1233 villages of District Mandla to demonstrate malaria elimination in a tribal district with hard-to-reach areas was possible using active and passive surveillance, case management, vector control, and targeted information, education and communication campaigns. An operational plan was developed to strengthen the existing surveillance and malaria elimination systems, through fortnightly active case detection to ensure that all cases including those that are introduced into the communities are rapidly identified and treated promptly. The plan also focused on the reduction of human-mosquito contact through the use of Long-Lasting Insecticial Nets (LLINs) and Indoor Residual Spray (IRS). The operational plan was modified in view of the present COVID-19 pandemic by creating systems of assistance for the local administration for COVID-related work while ensuring the operational integrity of malaria elimination efforts.

Results

The use of MEDP study design and operational plan, with its built-in management control systems, has yielded significant (91%) reduction of indigenous cases of malaria during the period from June 2017 to May 2020. The malaria positivity rate was 0.33% in 2017–18, 0.13% in 2018–19, and 0.06% in 2019–20. Mass screening revealed 0.18% malaria positivity in September–October 2018, followed by 0.06% in June 2019, and 0.03% in December 2019, and these were mostly asymptomatic cases in the community. The project has been able to sustain the gains of the past three years during the ongoing COVID-19 pandemic.

Conclusion

This paper provides the study design and the operational plan for malaria elimination in a high-burden district of Central India, which presented difficulties of hard to reach areas, forest malaria, and complex epidemiology of urban and rural malaria. The lessons learned could be used for malaria elimination efforts in rest of the country and other parts of South Asia with comparable demography and epidemiology.