Connecting the dots to strengthen malaria elimination strategies in India: A Malaria Elimination Research Alliance - India initiative

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.

Recurrence in Plasmodium vivax malaria: a prospective cohort study with long follow-up from a coastal region in South-West India

Background:  India is endemic for Plasmodium vivax(Pv) malaria. Despite a decrease in incidence, its elimination is hampered by recurrences. This study aimed to characterize recurrences in Pv malaria and study its association with primaquine (PQ) usage.

Methods:  Symptomatic adult Pv patients were followed-up for up to 23 months for recurrences. The time to recurrence was compared by the PQ dosage they received using a log-rank test.

Results: Of the 294 malaria patients, 206 (70%) patients had Pv infection during the study period. A total of 20 (9.7%) recurrences were seen in 17 (8.2%) patients of Pv. The percentage of first-time recurrences were highest in the no PQ group (25%), followed by the weekly PQ group (20%), low dose daily PQ (8.2%) group, and high dose daily PQ group (3.1%).

Conclusions: Recurrence in Pv malaria is common, especially in those who receive an incorrect prescription of primaquine.