India’s Malaria Elimination Target May Be Tough To Meet, Say Experts

India’s new Strategic Plan for Malaria Elimination, which aims to eliminate malaria in a decade, focuses on controlling mosquito breeding and spread of infection using early diagnosis and treatment. The scheme also incorporates education awareness, entomological surveillance, outbreak warning systems and vector control through long-lasting insecticidal bed nets.

But experts say without any means of accurately calculating the extent of India’s malaria problem, it may not be feasible to set time-bound elimination targets. Under-reporting of confirmed cases makes it tough to estimate the true burden. Fewer than half of Indians with malaria ever make it to a clinic or hospital so cases and deaths are far higher than recorded. Multiple independent reports suggest actual cases could be between nine-and-50 times greater than officially reported, the Global Health Group at the University of California, San Francisco noted recently. In 2013, a government committee said the real number of malaria deaths in India annually may be 40 times higher than the official count.

“The problem with setting deadlines to eliminate malaria here is it may not make much sense until we’re able to appreciate the size of the monster,” Manish Kakkar, senior public health specialist at the Public Health Foundation of India, a public-private partnership, told the Pink Sheet. “How can we say we can eliminate malaria in 10 years until we have agreement on what is the malaria burden?” Kakkar asked.

What is known is that India has the highest malaria burden in the Asia-Pacific region and over 1bn people at risk of infection. (Sub-Saharan Africa recorded 90% of the 212m cases globally in 2015 and 92% of 429,000 of the deaths, the WHO says). India launched its first malaria control program in 1953 with the aim of eradication and in the 1960s achieved a dramatic reduction in cases using the insecticide DDT (dichloro-diphenyl-trichloroethane). But a decade later, cases began climbing as a result of what government officials concede was complacency. Health policymakers also failed to foresee vector adaptation to DDT. Still, the country in recent years has made big strides in combating the problem, nearly halving the number of reported malaria cases between 2000 and 2015, from 2mn to 1.1mn, the WHO says. Recorded deaths fell to 384 in 2015 from 1,005 in 2001. But what causes concern is that the malaria caseload is significantly higher than the 2013 tally of 880,000.

Health Minister JP Nadda said the government now “would like to eliminate malaria by 2027… the ultimate goal is elimination of malaria by 2030” to meet a WHO target. Nadda’s release of a government malaria-elimination roadmap came as India entered the peak season of mosquito-borne diseases that starts in July with the monsoon and lasts till end November. Doctors fear this season’s cases of malaria and other mosquito-borne illnesses like dengue and chikungunya may be exceptionally numerous due to abundant rains and poor mosquito control. Malaria cases in the capital, New Delhi, are already at a four-year high.

India Needs $1.65bn To Fund Plan’s First Five Years

The plan entails spending INR106bn ($1.65bn) in the first five years which the government says would come from government sources, international donors and corporate contributions. The scheme carves India into four categories – zero to three. The zero category has 75 districts which have reported no malaria cases for three years. Category 1 has 448 districts in which the annual parasite incidence (API) shown by the number of positive parasite slides is less than one per 1,000 people. In Category 2, which has 48 districts, the API is one and above, but less than two per 1,000 people. Category 3 has 107 districts, reporting an API of two and above per 1,000 people. The goal is to eliminate malaria by 2022 in Category 1 and 2 districts and in Category 3 afterward. The next phase will aim at achieving “zero local transmission” of malaria nationwide by 2027. The program seeks to achieve universal case detection and treatment.

In India, malaria is caused by the parasites Plasmodium falciparum (Pf), which results in more deadly cerebral malaria and accounts for 99% of deaths worldwide, and Plasmodium Vivax (Pv). Pf is found more in forest areas, whereas Pv is common in the plains. Malaria, spread through bites of infected female Anopheles mosquitoes, is concentrated in impoverished tribal and remote areas in eastern and central India, some of which are insurgency-racked.

The government’s new strategy to combat malaria deaths is to expand access to 10-minute Rapid Diagnostic Tests that can distinguish between malaria caused by the Pf parasite and the Pv parasite and facilitate appropriate treatment. As part of the fight, the Indian Space Research Organization also is providing remote-sensing technology to detect mosquito breeding areas in the country. Meanwhile in western Maharashtra state, trials are being conducted of genetically modified male mosquitoes which pass on a lethal gene to offspring that kills the larvae. But there are disadvantages to the scheme such as the problem of raising vast numbers of GM mosquitoes which have to compete with normal male mosquitoes for mating, government scientists note.

In India, the International Centre for Genetic Engineering and Biotechnology has been working on a malaria vaccine for at least a decade but Neena Valecha, director of the New Delhi-based National Institute for Malaria Research said there is no vaccine candidate ready for clinical trials. The world’s first vaccine against malaria, GlaxoSmithKline's malaria vaccine, Mosquirix (RTS,S,ASO1), will be rolled out in Ghana, Kenya and Malawi in pilot trials on children next year, the company announced in April. RTS,S is designed to help prevent Pf malaria in sub-Saharan Africa in tandem with other malaria controls. (Also see " GSK's Malaria Vaccine To Be Piloted In Sub-Saharan Africa " - Pink Sheet, 27 Oct, 2015.)

Sri Lanka Declared Malaria Free But India’s Challenges Are Much Bigger

Last September, the WHO certified India’s island neighbor Sri Lanka as mosquito free, the second country in southeast Asia to be declared malaria free after Maldives. Sri Lanka, though, “has a much smaller population. Here, it’s a vast country, there are different types of malaria and different big challenges,” Valecha told the Pink Sheet.

In addition to effective anti-malaria tools, Valecha said, the country “requires good quality diagnostic tests, personnel who are well qualified. We can’t afford to miss a single case.” And, she emphasized, “Every area needs a different strategy, infection also can depend on population movement. Every place has its own issues.”

One Indian government official, who did not wish to be named, told the Pink Sheet India may be suffering from “a sense of peer pressure to set deadlines for malaria elimination given the country’s growing stature. On one hand, we’re now the fastest-growing economy and on the other, we’ve got these still very major health problems like malaria and dengue and high infant mortality.”

“The health system itself is not encouraging,” he added, noting India’s public health spending which stands at a little over 1% of gross national product, abysmally low by global standards.

“It (the deadline) may be more of a political commitment than something that can be actually realized,” he said. “Right now, the malaria plan is a policy proclamation. We have to see how it gets translated into action.”