Dr Ajit Kumar Mohanty- Special Secretary (PH), Department of Health and Family Welfare, Government of Odisha & Dr Kaushik Sarkar, Interim Country Director, Malaria No More talks about hidden burden of Malaria and way forward
In 2016, when India launched its ambitious roadmap to eliminate malaria by 2030, Odisha, a state located in Eastern India, reportedly contributed over 40% of India’s malaria burden with only 3.4% of India’s population. However, four years later, the state’s share reduced to only 22% as the malaria burden of Odisha reduced by about 90% during the period. As a result, Odisha’s success became a trendsetter in the country as it has made the most significant contribution to India’s success against malaria.
Fundamental to the state’s success were many factors– the most critical being two interventions focused on reaching the last mile and protecting the most vulnerable. First, in 2017, the Government of Odisha launched “Durgama Anchalare Malaria Nirakaran” (DAMaN)– a program that integrated inclusive surveillance, intensive vector control, and community education targeting hard-to-reach villages in high-burden blocks of the malaria-prone districts of Odisha. The unique feature of malaria surveillance under the DAMaN program was testing the communities en masse irrespective of their fever status. The basic premise underpinning this approach is that the malaria parasite can cause infection without its manifestation as fever, while the parasite continues to break the red blood cells and weaken the immune system. The impact of this inapparent infection is profound, especially among pregnant women and children below five years of age, who develop anemia and malnutrition, respectively. An intensified surveillance through mass screening of the entire population of a village, including the vulnerable population before and after the monsoon, when malaria reaches the peak, not only levels malaria transmission, but also saves the lives of women and children from long-term consequences.
The second intervention emphasized protecting the communities from mosquito bites while reducing infection from mosquitoes to humans. Therefore, the State Government distributed Long Lasting Insecticidal Nets (1.13 Crore in 2017 and 1.56 Crore in 2020) provided by the Indian Government with support from The Global Fund in a few months through a mass campaign approach. However, unlike the targeting of DAMaN that focused on both geographical inaccessibility and the high burden of malaria, the distribution of long lasting insecticidal nets only took into account the incidence of malaria at the primary care level.
The commonality between the interventions remained in their en masse approach with macro-targeting and the core purpose of reducing transmission holistically. However, as malaria incidence goes down, the cost-effectiveness of these interventions also declines rapidly. Therefore, the paradigm shift Odisha must bring in its strategy to interrupt malaria transmission in the next five years is micro-targeting focusing on small clusters of infection.
The primary challenge in micro-targeting lies in its intrinsic requirement to detect the infection clusters precisely. Precision requires more timely and granular infection data than the current practice of planning based on monthly data at the district level. Therefore, daily or weekly reporting of malaria using a robust data-driven decision-making system is critical to ensure program managers get adequate information to promptly plan interventions to control infections before they spread horizontally to contiguous areas. Therefore, more investments are required to urgently strengthen the data-driven decision-making system so that the state can prepare optimally for the malaria endgame.
The second crucial factor in enhancing precision in planning is the holistic knowledge of malaria distribution across geographies. Although the state has made malaria a notifiable disease, reports of malaria from the private health sector still require strengthening at the execution level, as private sector reporting of malaria is still a challenge across the country. Better enforcement strategies for the malaria notification policy can be a gamechanger at this outset.
In summary, Odisha has been a trendsetter in innovating solutions that could bring down malaria quickly at a time when India needed it on priority. However, the sustainability of its success now depends on its future focus on identifying and addressing the hidden burden of malaria through a robust data-driven decision-making system, strengthening enforcement of malaria notification policy, Inter-departmental coordination and convergence, targeting high endemic Community Health Centers (CHC) for support and intensified monitoring at the last mile, and finally strong political and administrative will power and commitment.
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