Written by Prof N K Ganguly
While the world deliberates the best way out of the present pandemic, this is also an opportune time to further conversations on another deadly vector-borne disease: malaria. The World Malaria Report 2021 states that, globally, there were an estimated 241 million cases in 2020, increasing from 227 million in 2019. Malaria deaths increased by 12 per cent globally in 2020, in comparison to 2019, to an estimated 6,27,000. For India, the numbers are grim. In 2020, the South-East Asia Region (SEAR) had 5 million estimated cases. Three countries accounted for 99.7 per cent of the estimated cases in the region, with India being the largest contributor (82.5 per cent). India also accounted for 82 per cent of all malaria deaths in the SEAR.
Evidently, we need to further refine our health interventions to defeat malaria. At the East Asia Summit in 2015, Prime Minister Narendra Modi committed India to eliminating malaria by 2030. Following the PM’s call to action, the National Framework for Malaria Elimination (NFME) was launched in 2016 and the National Strategic Plan for Malaria Elimination was launched as well (2017-22). The results were almost immediate—India reduced its malaria cases by nearly 69 per cent, according to government data. India was also the only high-endemic nation to see a decrease of 17.6 per cent in 2019 compared to 2018. Further, compared to the same time last year, the overall number of malaria cases recorded in 2020 was 1,57,284 (as compared to the number of cases in 2019 being 2,86,091), which is a year-on-year decrease of approximately 45 per cent. However, the pandemic disrupted health programmes across the country and the reduction in malaria cases in 2020 is potentially correlated with the under-reporting of cases in this period.
Several interventions are identified to prevent and control malaria. For instance, insecticide-treated bed nets (ITNs) and long-lasting insecticidal nets (LLINs) are two effective ways to prevent malaria. However, the distribution of ITNs has been a challenge. We delivered just 50 per cent of the nets planned for distribution in 2020. Drug resistance, too, is a challenge: the development of antimalarial drug resistance and insecticide resistance has been noticed in some parts of the country, as has been the development of malaria multi-drug resistance including ACT resistance in neighbouring countries.It will be useful to re-evaluate some other key diagnostic interventions to see how efficacious they are and the potential for further scale-ups in India as necessary. To this end, mention must be made of rapid diagnostic tests (RDTs), which assist in the diagnosis of malaria by detecting evidence of malaria parasites (antigens) in human blood. As per the latest World Malaria Report, India reported 20 million RDT distributions in 2020. There is also the ICT Malaria Combo Cassette Test, which has been seen as a useful support tool to diagnose malaria in resource-poor health care settings, where quality microscopy diagnosis is either not present or not guaranteed.
Within the larger narrative of malaria in India, there are some dimensions which need focus. Malaria in pregnancy (MiP) is a major complication for the mother, the foetus, and the newborn. Efforts should be made to ensure more scholarship of MiP cases in India, and mitigation mechanisms should be developed accordingly. Some studies have indicated a high overall burden already, in the range of 10 per cent to 30 per cent and this needs increased attention. We need to be cognisant of certain high transmission areas as well when countering malaria such as tribal zones. India’s National Framework for Malaria Elimination (2016-2030) does have a targeted Tribal Malaria Action Plan (TMAP) that strives for malaria prevention and control activities in tribal and ethnic population groups spread across different states and Union Territories. We must ensure such initiatives reach fruition. Hilly, forested, desert, and conflict-prone geographies also need a customised action plan and policies need to be refined keeping these considerations in mind.
Future elimination roadmaps will need to factor in contemporary challenges. Climate change and rapid urbanisation are high risk-factors for malaria. As temperatures rise globally, mosquitoes will spread to higher altitudes increasing disease spread. In fact, the Intergovernmental Panel on Climate Change (IPCC), in its 6th assessment report, indicated a distribution shift in diseases like malaria to higher altitudes including potential outbreaks in the Himalayan region .
Even though the landscape appears challenging, there already exists the right political will and the policy armature needed to effect change. We just need to address some fundamentals of public health better: levelling ditches, designing better manholes and developing biopesticides can help to prevent malaria. Furthermore, as the monsoon approaches, we need targeted screening camps in high-burden states/districts, periodic sanitation exercises, vector control, and regular fogging. We must certainly ensure the procurement and distribution of LLINs across susceptible geographies. The role of the community becomes critical here. Just as India leveraged the strength of community action to defeat polio, it can deploy a similar strategy for malaria too. At the last mile, community leaders and influential voices can ensure better disease awareness and the enforcement of preventive measures like LLINs and sanitation drives.
Grassroots action is critical to combat a disease like malaria. Such endeavours in addition to holistic policy interventions and effective delivery of services would be vital in helping us achieve our goal of a malaria-free India by 2030.
Professor N K Ganguly is former director general, ICMR