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

Benefits of Lot Testing to Improve the Quality of Malaria Rapid Diagnostic Tests in India

Since 2010, malaria rapid diagnostic tests (RDTs) are widely used to detect malaria. The Indian Council of Medical Research-National Institute of Malaria Research performed lot testing (LT) according to WHO procedures since 2016. Lot testing is performed to evaluate the lot-to-lot variation in performance of malaria RDTs. Four sets of positive quality control (QC) panels for P. falciparum (Pf) and P. vivax (Pv) and 10 negative panels tested RDTs. RDTs were reported as pass, failed, or deferred on the basis of WHO criteria. In the past 5 years, 275 lots containing 15,488 RDT kits for malaria diagnosis were subjected to LT. The monovalent RDTs (n = 1,216), based on either Pf histidine rich protein 2 (HRP2) or Pan-Plasmodium lactate dehydrogenase (Pan-pLDH) antigens, showed 90.4% sensitivity and 100% specificity, whereas RDTs based on HRP2 + Pan-pLDH or HRP2 + pLDH (n = 13,924) had sensitivity 95.6% and specificity 99.5%, respectively. RDTs based on PfHRP2 + Pv-pLDH + Pan-pLDH (n = 348) had 100% sensitivity and specificity. In a comparison between HRP2 + pLDH or HRP2 + Pan-pLDH to HRP2 + pLDH + Pan-pLDH RDTs, it was found that the sensitivity of PfHRP2 with Pan-pLDH RDTs (n = 2,382) was only 83%. Of the 275 lots analyzed, 15 lots of PfHRP2 with Pan-pLDH were deferred. The QC panel for Pf revealed a faint Pan band in the tested lots, which is a cause for concern. The results of deferred lots were reported to concerned government agencies. Quality-compromised RDTs may lead to an incorrect diagnosis. It is critical to have a QC system in place for effective malaria management.

Seasonal Distribution and Trend Analysis of Urban Malaria Prevalence in a Malaria Clinic, South Delhi, India, between 2012 and 2019

It is important to study the recent malaria incidence trends in urban areas resulting from rapid urbanization that can lead to changes in environmental conditions for malaria. This retrospective study assessed trends in malaria patients, their distribution according to parasite species, patient demographics, and weather data for the past 8 years at a malaria clinic in the National Institute of Malaria Research, New Delhi, India. We overlaid the effects of environmental factors such as rainfall, relative humidity, and temperature on malaria incidence. The malaria data were digitized for a period spanning 2012 to 2019, during which 36,892 patients with fever attended the clinic. Of these, 865 (2.3%) were diagnosed with malaria microscopically. Plasmodium vivax was predominant (96.2%), and very few patients were of Plasmodium falciparum (3.5%) or mixed infections (0.3%). The patients with malaria were within a 10-km radius of the clinic. Males (70.9%) were more commonly affected than females (29.1%). Of the total malaria patients, a majority (∼78%) belonged to the > 15-year age group. A total of 593 malaria patients (68.6%) received primaquine. These patients were most commonly diagnosed in April through October. Furthermore, there was a lag of 1 month between the rainfall peak and the malaria case peak. The peak in malaria cases corresponded to a mean temperature of 25 to 30°C and a relative humidity of 60% to 80%. This analysis will be useful for policymakers in evaluating current interventions and in accelerating malaria control further in urban areas of India.

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.

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.

Polymerase Chain Reaction-Based Malaria Diagnosis Can Be Increasingly Adopted during Current Phase of Malaria Elimination in India

Despite commendable progress in control of malaria in India and other countries, there are hidden reservoirs of parasites in human hosts that continually feed malaria transmission. Submicroscopic infections are a significant proportion in low-endemic settings like India, and these infections possess transmission potential. Hence, these reservoirs of infection add to the existing roadblocks for malaria elimination. It is crucial that this submerged burden of malaria is detected and treated to curtail further transmission. The currently used diagnostic tools, including the so-called "gold standard" microscopy, are incapable of detecting these submicroscopic infections and thus are suboptimal. It is an opportune time to usher in more sensitive molecular tools like polymerase chain reaction (PCR) for routine diagnosis at all levels of healthcare as an additional diagnostic tool in routine settings. PCR assays have been developed into user-friendly formats for field diagnostics and are near-point-of-collection. Because of the COVID-19 pandemic in India, these are being used rampantly across the country. The facilities created for COVID-19 diagnosis can easily be co-opted and harnessed for malaria diagnosis to augment surveillance by the inclusion of molecular techniques like PCR in the routine national malaria control program.

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.