Every year 25 April is commemorated as World Malaria Day to raise awareness and highlight the need for continued investment and sustained political commitment to malaria prevention and control. It is a preventable and treatable disease yet it is responsible for the death of over 5,00,000 people around the globe. According to World Malaria Report 2019 by World Health Organization (WHO), India represents 3 percent of the global malaria burden. However, despite being the highest malaria burden country in the South-East Asia region, the country has shown a reduction of 49 percent in reported malaria cases and 50.5 percent in deaths as compared with 2017. The global health agency has also maintained that India has made “remarkable progress” in recent years in reducing malaria incidence.
However, despite the continued efforts its a long way to go. After the ongoing coronavirus pandemic hit the world, and the countries put all their attention on their fight against COVID-19, the efforts toward the treatment of non-COVID ailments like Malaria staggered.
According to the World Malaria Report 2021, there was an estimated 241 million malaria cases and 627 000 malaria deaths worldwide in 2020 and it is about 14 million more cases in 2020 compared to 2019, and 69,000 more deaths. The WHO report also revealed that 15 countries with a high prevalence of malaria reported reductions in malaria testing of more than 20 percent in April-June 2020 compared to the same period in 2019. The report also revealed that India accounted for 83 percent of estimated cases and about 82 percent of all malaria deaths in the WHO South-East Asia Region.
What is Malaria?
Malaria is an acute disease caused by Plasmodium parasites, which are spread to people through the bites of infected female Anopheles mosquitoes. According to WHO, there are five parasite species that cause malaria in humans, and two of these species – P. falciparum and P. vivax – pose the greatest threat. P. falciparum is the deadliest malaria parasite and the most prevalent on the African continent. P. vivax is the dominant malaria parasite in most countries outside of sub-Saharan Africa. Usually, after 10-15 days of the infective bite, symptoms like fever, headache, and chills appear. If left untreated, P. falciparum malaria can progress to severe illness and death within a period of 24 hours.
According to the WHO, nearly half of the world’s population was at risk of malaria in 2020. The global health agency also maintained that certain population groups like infants, children under 5 years of age, pregnant women, and patients with HIV/AIDS, as well as people with low immunity are at a considerably higher risk of contracting malaria and developing severe disease.
India and Malaria
Malaria is a serious public health concern in several parts of the country. According to National Centre for Vector-Borne Diseases Control (NCVBD), about 95 percent of the population in the country resides in malaria-endemic areas and 80 percent of malaria reported in the country is confined to areas consisting of 20 percent of the population residing in tribal, hilly, difficult and inaccessible areas. Due to the framed guidelines and policies, various indicators have been developed at the national level for monitoring the various implemented programmes and a uniform system has been set up for collection, compilation and onward submissions of data.
Meanwhile, surveillance of malaria is being carried out by PHCs, Malaria Clinics, CHCs and other secondary and tertiary level health institutions that patients visit for treatment. Additionally, ASHA workers are also involved in the programme to provide diagnostic and treatment services at the village level as a part of the introduction of measures like Rapid Diagnostic Tests and the use of Artemisinin Combination Therapy (ACT) for the treatment of Pf cases. Although India still contributes a lot to the global malaria cases, the country has also witnessed a decline in the numbers too in the recent years.
“We should not only look at India’s absolute number of Malaria cases. We should also look at the fact that India managed to reduce malaria cases by more than 80 percent between 2017 and 2018 and emerged as a global example in this area. Eradicating malaria requires a lot of buy-in from the common man. Government measures will fall flat if people leave stagnant water in their homes. This is where the importance of public health messaging comes in,” Sudipta Sengupta, CEO, The Healthy Indian Project (THIP), India’s health literacy platform and one of India’s only IFCN certified fact-checkers in the Health domain told Financial Express.com.
Sengupta also said that they have seen an increased awareness drives around malaria by the various state government in recent days and the same should continue.
The fact that malaria is not just a simple fever and a doctor consultation is required at the earliest possible will also be able to prevent deaths that happen due to delayed treatments in this case, Sengupta said.
India’s Steps towards Malaria Control-Have they worked?
According to NCVBD, the malaria caseload, though steady at around 2 million cases annually in the late nineties, has shown a declining trend since 2002. Meanwhile, the Annual Parasite Incidence (API) has consistently declined from 2.12 per thousand in 2001 to 0.25 per thousand in 2019.
In 2016, India has also introduced its first National Framework for Malaria Elimination (2016-2030). The Central government has also increased funding by more than 25 percent for the National Vector Borne Disease Control Programme and increased support as a donor to the Global Fund to Fight AIDS, Tuberculosis, and Malaria.
“If India is to successfully eliminate malaria by 2030, existing efforts and strategies have to be supported by advancements in science, technology, and innovation. It is great to see that WHO also recognizes this sentiment, evident from their theme for this year’s World Malaria Day – Harnessing Innovations to reduce malaria burden and save lives. Innovations such as Highly-sensitive Rapid Diagnostic Testing Kits (HsRDT), Pyrethroid-Piperonyl-butoxide bed nets, the recently approved vaccine, advancements in anti-malarial drugs, and advanced data management systems are options that we must explore as we approach malaria elimination,” Pratik Kumar, Country Director, Malaria No More India told Financial Express.com.
Kumar also said that along with innovation, there is also a need to emphasise an inter-sectoral and inter-industry approach to address malaria – involving collaborative efforts of diverse stakeholders such as the government, private sector, research bodies, bilateral organizations, and civil societies.
According to a report in BMJ Global Health journal, despite significant progress in malaria control by India, it is still a public health problem in several parts of the country with 95 percent of the Indian population living in malaria-endemic areas. The report also revealed that there are several challenges to India’s ambition of eradicating Malaria by 2030 and Forest malaria is one of them.
“The recent declines in malaria are due to new malaria policies that are, Artemisinin Combination Therapy (ACT), use of rapid diagnostics, and long-lasting insecticide nets (LLIN). However, the reduction that has been observed in malaria cases and deaths in India is heterogeneous. Indeed, elimination can be facilitated by targeting all malaria foci with malaria transmission,” the report suggested.
To make things worse, the two major Plasmodium species responsible for malaria in India, Plasmodium falciparum (Pf) and Plasmodium vivax (Pv), are unevenly distributed in India.
At present, India’s malaria surveillance reporting system has a number of limitations like inadequate linkage with the private health sector, failure to detect outbreaks and hotspots in time, lack of surveillance of mobile and tribals populations, insufficient interstate monitoring and surveillance within the country and lack of true estimates of the at-risk population and more so in forested areas, according to health experts.
“There are issues like drug resistance, especially in regions with intense malaria load, incidence gap which is due to insufficient surveillance, examination and underreporting of malaria cases primarily due to misdiagnosis, the small size of the population in intense malaria zones act as asymptomatic carriers of plasmodial infection. There is an urgent need for estimating the true burden of malaria,” Dr. Saniya Wasim Shaikh, Tropical Diseases Specialist, Masina Hospital, Mumbai told Financial Express.com.
Some also suggest that India needs to switch to digital, near real-time surveillance via mobile apps and engage with options for timely data transfer and analysis using digital dashboards and data-backed action, especially for the forested areas.
What are the major obstacles on the way to eradicate Malaria?
According to public health experts, India’s diverse geo-ecological landscape is one of the reasons for the spread of vector-borne diseases like Malaria.
“India has hills, plains, coast and deserts areas with different environmental conditions, facilitating the spread and transmission of vector-borne diseases. Malaria Imposes a socio-economic burden on humanity in general and India in particular. India is a Multi-ethnicity wide variety of vectors transmitted different malaria species in rural, urban, and especially hilly and forest areas leading to multi-organ failure posing an uphill task for the Public health system in India,” Dr Kanav Khera, M-Pharm, MBA, Ph.D., Associate Professor, Department Pharmacy Practice/Pharmacology, Lovely Professional University told Financial Express.com.
Dr. Khera also said that India’s fight against malaria is tough to sustain because of its inadequate surveillance, inaccessible swathes of land, insecticide and drug resistance, poor drug adherence, and poor rural health infrastructure.
“India has implemented National Vector Borne Disease Control Program (NVBDCP) which aims at controlling and eradicating certain vector borne diseases. The key factors of malaria control strategy of NVBDCP include early detection and complete treatment, integrated vector control which includes insecticide-treated nets indoor residual spraying (IRS), antilarval measures and minor environmental engineering measures, epidemic preparedness and early response and supportive interventions like behavior change communications and monitoring and evaluation. Nearly all the methods employed by NVBDCP are showing great outcomes. However, public awareness and extensive engineering changes like prevention of stagnation of water at construction sites, etc could prove to be of immense help,” Dr. Shaikh said.
What are the major scientific advancements for Malaria?
Recently, various scientific and technological advancements to control the vector-borne disease has been made as the malaria strain mutates from time to time in different regions.
“In this regard, WHO has recommended widespread use of the RTS, S/AS01 malaria vaccine to be used for the prevention of deadly Plasmodium Falciparum malaria which is widely prevalent among children living in regions with moderate to high transmission. Secondly, WHO has issued new guidance for research on genetically modified mosquitoes to fight malaria and other vector-borne diseases but with a caution “to the issues related to ethics, safety, affordability and effectiveness,” Dr. Khera said.
Last month, WHO published an updated position paper on the RTS, S/AS01 (RTS, S) malaria vaccine that includes the October 2021 recommendation calling for the wider use of the vaccine among children living in areas of moderate-to-high P. falciparum malaria transmission.
“Science and technology have helped to understand parasite biology through genetic crosses, in-vitro parasite culture, development of monoclonal antibody technology and gene cloning along with the development of a vaccine has been a substantial breakthrough,” Dr. Shaikh said.
Can Genetically-modified mosquitoes control Malaria in India?
Last week, UK-based biotech firm Oxitech announced that its open-air experiment with genetically-modified mosquitoes in the United States has shown promising results in suppressing the wild population of virus-carrying mosquitoes. The aim of the experiment was to reduce the population of wild Aedes aegypti mosquitoes that is a vector for viruses such as chikungunya, dengue, zika, and yellow fever. To achieve that goal, the scientists engineered a gene that will kill the female offspring.
In another experiment in Indonesia, the modified mosquitoes reduce dengue cases by 77 percent in the country. “In India, Oxitech in collaboration with Indian company Gangabishan Bhikulal Investment and Trading Limited (GBIT), started an outdoor caged trial in 2017 suppressing the local Aedes Aegypti mosquito population by introducing genetically modified mosquitoes. Since the field trial of genetically modified mosquitoes raises a number of ethical, legal, and social issues impacting public health and environmental risk,” Dr. Khera said.
Dr. Khera also informed that people are, in general, reluctant to approve such trials and it requires the balancing of benefit and risk, collaborating with the local community, avoiding exploitation, and obtaining individual and community consent for research.
What needs to be done to eradicate Malaria?
Despite significant progress to control and eliminate by 2030 there is still a lot that needs to be done. As the vector-borne disease affects the poor in the poorest area with people having limited access to facilities and effective treatment, empowering communities to be part of prevention and control efforts is key to ensuring access to health services for all vulnerable populations, according to experts.
“Strengthening the health system through digital surveillance, timely monitoring, analysis of data, and quick database coordination, integration and action is the need of the hour. Systematic regional cooperation to control cross-border malaria transmission, investigation, and incorporation of the impact of climate change into future modeling in malaria disease control programs is a must. Continued emphasis on innovation in delivery to prevent, find, test, and treat every malaria case is important to ensure that no fever remains undiagnosed,” Dr. Khera said.
He also said that India should try to create its own indigenous genetically engineered mosquitoes program.
“Collaboration with WHO and other countries for Vaccination research in Vector-borne diseases will be helpful. Some of the tools, techniques, and strategies used in the global fight against Covid-19 can be replicated in our fight against malaria and vice-versa,” he added.
According to Dr. Khera, rather than having a segregated approach, India can consider a united integrated approach to control all vector-borne diseases to diminish the burden on the health system and it will be cost-effective too.
“The goals of National Framework for Malaria Elimination are–Eliminate malaria (indigenous cases) throughout the entire country by 2030 and maintain malaria-free status in areas where malaria transmission has been interrupted and prevent re-introduction of malaria. Elimination of malaria is a pioneering step that calls for extensive commitment and requires upgrading the surveillance system, well organised Programming, and including the lowest of healthcare levels. These along with adequate monetary investment and human resources shall help achieve the goal by the targetted year,” Dr. Shaikh said.
The Government of India had developed a robust framework to eliminate Malaria by 2030. Preventing any vector-borne disease including malaria, necessitates the adoption of a multi-sectorial approach. The government had also instituted a policy that discontinued the presumptive treatment for malaria.
The policy mandates that all suspected malaria patients undergo blood tests in a quality-controlled lab and results be delivered within 24 hours. Rapid diagnostic kits are used in areas where access to the lab is an impediment. Accurate diagnosis is the first and the most critical step in the control of any disease. The pandemic has been an example of this.
“Right from correct diagnosis including reporting of all cases and appropriate treatment to large-scale surveillance, Malaria can be controlled and eliminated only if all districts with high transmission rate has access to all the required tools to combat this deadly disease. Malaria elimination and prevention need a sense of urgency and the highest level of commitment from all stakeholders,” Anand K, CEO, SRL Diagnostics told Financial Express.com.
In 2016, Sri Lanka was declared malaria-free by WHO and according to experts, this can be a model for India.
“Public health strategies develop in Sri Lanka for malaria eradication program and healthy practices can be replicated. Despite the lack of health care workers in a war zone, disruption of vector control efforts, and gaps in medical supply chains, it has been a success story. The wholehearted support of the government of Sri Lanka and its society, excellent cooperation and coordination of Center and State governments, and engagement of NGOs and other stakeholders not only eliminated the menace of malaria but also helped to ensure that it did not relapse again,” Dr. Khera said.
