Why India's goal of eliminating malaria by 2030 will be challenging

This month, the Odisha government announced that it wanted to eliminate malaria from three districts where the incidence of the disease is low.

Odisha has the highest number of malaria cases in the country – nearly four lakh cases in 2014, or 36% of the total malaria cases in India. In all, 562 malaria deaths were reported in 2014 nationwide.

Three districts – Kendrapada, Puri and Jagatsinghpur – have a low annual parasite incidence, which is less than one malaria positive case in a population of 1,000. The Odisha government's latest initiative is part of an ambitious nationwide exercise to eliminate malaria by 2030. In February, the Union government released a document in this regard, National Framework for Malaria Elimination in India (2016-2030).

The '50s experiment

Efforts to eliminate the water-related disease in India go back decades. The country had launched the National Malaria Eradication Programme in 1953. This programme was a great success with incidence dropping from about a million cases to almost 1,000 cases, and no deaths reported in 1965.

“Early diagnosis and treatment with chloroquine, use of DDT as insecticide helped bring down the cases,” said Dr Sanjay Rai, from the department of Community Medicine, All India Institute of Medical Sciences. "We had exclusive malaria workers, who were then incorporated in other programmes after the cases came down."

However, the parasite soon developed resistance to DDT, thus rendering it ineffective. In 1976, the incidence escalated to 6.4 million cases.

Dr Rai said that after the debacle, the government decided to change the target to elimination instead of eradication. While eradication is seen as a permanent reduction of infection, like in the case of polio, elimination is the reduction of cases to zero incidence with continued intervention measures as required.

The plan

With a focus on areas where the transmission of cases is high, the government wants to eliminate the disease in a phased manner. As per the document, 15 states are in elimination phase, 11 states with some high incidence districts and some low malaria incidence districts are in pre-elimination phase, and 10 states are in the intensified control phase.

In October last year, the philanthropic Global Fund signed a grant with the government giving up to $104 million with an aim to reduce mortality and morbidity by 50% by 2017 in the eight most endemic states of the country, including Odisha and seven North Eastern states – Arunachal Pradesh, Meghalaya, Assam, Mizoram, Manipur, Nagaland and Tripura.

Notifiable disease

But how can the reduction in cases be measured? More than 70% of India's population avails of treatment through private practitioners or hospitals, most of who do not report any diseases.

“The areas government has termed low endemic, such as Puri, Jagatsinghpur and Kendrapada, there are more private clinics," said Gouranga Mohapatra, an activist with the Jan Swasthya Abhiyaan NGO. "The data is surely missed by the government. These are also rapid migration areas. I have serious doubts about their calculations.”

The government wants to make the disease notifiable soon, as in the case of tuberculosis in 2012. This would make it mandatory under law to report the disease to the authorities. “We want to make this a notifiable disease first so that all sectors, whether private or public, can notify malaria cases to the authorities,” said Dr GS Sonal, additional director, National Vector Borne Disease Control Programme, who heads the malaria division. "They could also inform if the cases are local or from outside the locality."

According to Dr Sanjay Rai from the department of Community Medicine at the All India Institute of Medical Sciences, there is gross under-reporting by the private sector, even in TB. "Unless the government imposes some kind of penalty on the doctors who do not notify, it may not work,” he said.

Some solutions

Apart from reporting, measures are being taken to contain the disease. Among them is the attempt to popularise the Long Last Insecticidal Net, a factory pre-treated mosquito net that retains its insecticidal activity even after 20 standard washes, and has a minimum life of three years. In 2009, the government decided to distribute these nets to residents of high endemic districts, including in Odisha.

“When we distributed long lasting nets in 2010, the cases had suddenly declined to half," said Dr Madan Pradhan, joint director, state programme officer, Odisha government. "But after three years, when the LLIN efficiency came down, the plan boomeranged. We couldn’t sustain the programme.”

There are other challenges too. In tribal areas, people prefer sleeping under the open skies and were resistant to using mosquito nets, officials said. “People have different culture, needs and habits," said Dhirendra Panda, convener at Civil Society Forum on Human Rights, situated in Bhubaneswar. "There is a missing link in the communications. The fact that they do not use does not mean they do not want to be protected. The government should put extra effort to integrate with their culture.”

With the grant from the Global Fund, distributing such nets among high-risk populations is part of the plan again.

Apart from notification, the strategy to tackle malaria has stayed more or less the same – early diagnosis, monitoring treatment, follow up and vector control. But many hope for more commitment by the government. “We have to reduce breeding sites in the country," said Dr Sonal. "This is resource intensive work. We need to literally fill pits which fill with water and treat the drainage. We were considering integrating village health committees, MNREGA [the national rural employment guarantee scheme], Swachh Bharat Abhiyaan [the national sanitation scheme] in this work."

Dr Pradhan said the government was aiming for active surveillance in low incidence areas. "In tribal districts such as Kandhamal, we have a new programme called DAMAN [Durgama Anchalare Malaria Nirakaran] that is designed to provide access to the inaccessible," he said. "We will have mass screening there from time to time. We will go for indoor residual spray. This will kill the parasite in the mosquito as well as the parasite in the human blood.”

Can this work?

Admittedly, this is a very challenging proposition for the government, especially in high endemic areas that are also conflict zones such as Chhattisgarh, Gadchiroli district in Maharashtra, and other inaccessible tribal districts. “This is a huge challenge,” said Dr Sonal. "But if we manage to reduce the incidence by 80%-90%, we manage to prevent 4 lakh malaria cases, and up to 200 deaths."

In 2010, the medical journal Lancet, in a special issue on malaria elimination, expressed doubts about the call for elimination for malaria by international agencies such as the World Health Organisation. One of the articles also pointed out that the WHO definition of elimination, taken literally, is achieved almost nowhere. Countries such as Italy and the US still have small outbreaks of malaria occasionally. Between 1993 and 2009, the US has had 12 outbreaks of malaria.

While recently declaring Europe malaria free, the WHO warned that the achievement, while extraordinary, is also “fragile” and needs constant vigilance, so as to prevent resurgence of the disease.

An article in the same Lancet number, which measured the feasibility of elimination in different countries all over the world, stated that despite increasing wealth and development in India, “low investment in health, and a huge population at risk as well as the problem of urban malaria transmission makes elimination less feasible in India, than in most Asian countries”.

“Our environment is such that it makes it very difficult to eliminate breeding of the anopheles mosquito,” said Dr Rai. "We will need a total reform in every sector to achieve this. I don’t see this plan working for the next 10 years at least."