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National framework for malaria elimination in india

The National Framework for Malaria Elimination in India (2016-2030) outlines strategies to eliminate malaria with a target of zero indigenous cases by 2030. It emphasizes a structured approach using categories of transmission intensity to guide interventions, focusing on high transmission states and improving health system integration. The plan includes specific goals for reducing malaria incidence and mortality across all states and union territories, alongside cross-cutting measures for surveillance and intersectoral collaboration.

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National Framework For Malaria Elimination In India (2016-2030) Dr. Aparna Sen Chaudhary
Contents • Introduction • Malaria Situation • Malaria Control In India • National framework for Malaria Elimination in India • National Strategic Plan for Malaria Elimination in India • Malaria Elimination Plan in Karnataka • Critical Analysis • Summary • References 7/30/2018 2
7/30/2018 3
Introduction • Malaria incidence have reduced globally between 2010-2015. • Gains achieved are fragile and uneven. • Millennium Development Goal 6 – ACHIEVED (Globally & India) ⋆ Globally – cases reduced from 262 million (2000) – 211 million (2015) deaths reduced from 839000 (2000) – 446000 (2015) ⋆ India - Annual Parasite Incidence was reduced from 2.09 (2000)–0.64(2015). • Sustainable Development Goal 3 - By 2030, end the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases and combat hepatitis, water- borne diseases and other communicable diseases. 7/30/2018 4
Geographical Distribution Of Malarial Parasite 7/30/2018 5Source: Kiszewksi et al. American Journal of Tropical Medicine and Hygiene.2004.70;5:486-98.
Malaria Indigenous cases - 2016 7/30/2018 6Source: World Health Organization .World malaria report 2017. Geneva. WHO. 2017
World Malaria Report 2017 According to World Malaria Report 2017. Total cases reduced from 237 million (2010) 216 million (2016) Total deaths reduced from 591000 (2010) 445000 (2016) Incidence Rate - reduced by 18% ., from 76 – 63 (2010-16) 7/30/2018 7
World Malaria Report 2017 7/30/2018 8 Year Cases (in million) Deaths 2010 237 591000 2011 225 529000 2012 217 487000 2013 210 465000 2014 210 459000 2015 211 446000 2016 216 445000
7/30/2018 9
India • Malaria cases have shown decline from 2 million (2000) to 1.1 million (2015) • Incidence – 0.88% in a population of nearly 1.25 billion • Confirmed deaths decline from 1005 (2001) to 562 (2014). • Overall in last 10 years 1. Total Malaria cases declined 42% (1.92 m – 1.1 m) 2. Malaria-related Deaths declined 40.8% (949 - 562) 7/30/2018 10 Source: Global Malaria Report.2015
7/30/2018 11
Distribution Of Malaria Vectors In India 7/30/2018 12Source: National Vector Borne Disease Control Programme
Geographic distribution of Malaria Incidence (API) in India - 2014 7/30/2018 13 Source: National Vector Borne Disease Control Programme
7/30/2018 14 Year Confirmed Malaria Cases (in million) Pf cases (in million) Pf % Deaths 2011 1.31 0.67 50.74 754 2012 1.06 0.53 49.98 519 2013 0.88 0.46 52.61 440 2014 1.10 0.72 65.55 562 2015 1.17 0.78 66.61 384 2016 1.09 0.71 65.53 331 2017 0.84 0.53 63.39 105 2018 (till May) 0.10 0.05 54.81 6 Source: National Vector Borne Disease Control Programme. Trends in malaria parameters in India (2001-2018).
7/30/2018 15 Trends of total malaria cases, Pf and Pv and deaths(2000-2014) Source: National Vector Borne Disease Control Programme
Karnataka • Previously, categorized as one of the high transmission zones in India. • After 2003, malaria incidence started declining (reduction of 89% compared to 2000) • The API of state range from 0.1 to 22.3 • Total cases - 12,442 and deaths – 0 (As per 2015) 7/30/2018 16Source :Malaria Elimination Plan in Karnataka (2016-2025) – Framework, Strategies and Policies
Milestones In The Malaria Control Programme In India 7/30/2018 17 Prior to 1940 No organized national malaria programmes Prior to 1953 Esti. Cases- 75 m; deaths – 1 m 1953 National Malaria Control Programme 1958 National Malaria Eradication Programme 1965 Cases reduced to 0.1m Early 1970’ Resurgence of malaria 1971 Urban Malaria Scheme 1976 Malaria cases – 6.46 m 1977 Modified Plan of Operation 1984-1998 Annual Incidence of Malaria – 2-3 m 1995 Modified action plan for malaria control 1997 Enhanced Malaria Control Project 1999 National Anti-Malaria Programme 2002 NVBDCP 2005 RDT (monovalent) 2005 Intensified Malaria Control Programme 2006 ACT – chloroquine resistance areas 2008 Revised NVBDCP Drug Policy 2008 National Vector Borne Disease Control Support Project 2009 LLIN introduced 2010 Revised NVBDCP Drug Policy 2010 2013 RDT (bivalent) 2104-15 Newer insecticides and larvicides introduced
Milestones in malaria control activities 7/30/2018 18 1946Bhore Committee • 75 million cases & • 0.8 million deaths National Malaria Control Program • Residual insecticide spray • Anti-malarial drugs • Survey and monitoring 1953 1958National Malaria Elimination Program • Eradicate Malaria • Cases – 49151 (1961) 1971 Urban Malaria Scheme • Urban Malaria • Anti-larval measures
Milestones in malaria control activities 7/30/2018 19 1977 Modified Plan of Operation • Cases – 6.46 million • Eliminate malaria death • Areas divided on basis of API Malaria Action Program • 100% centrally sponsored • Demarcation of high risk areas 1995 1997 Enhanced Malaria Control Program • Reduction in malaria morbidity • Out of 100 districts, 79% recorded decline in 2003 1999 National Anti Malaria Program • Renamed programme
Milestones in malaria control activities 7/30/2018 20 2002 National Health Policy • Reduction in mortality by 50% by 2010 National Vector Borne Disease Control Programme (NVBDCP) • National Anti Malaria Programme renamed 2002 2005NVBDCP • Integral part under NRHM 2005 Intensified Malaria Control Project • Started with assistance of Global fund for AIDS, Tuberculosis, Malaria
Milestones in malaria control activities 7/30/2018 21 2010Revised NVBDCP Drug Policy 2010 National Framework For Malaria Elimination In India (2016-2030) 2016
National Framework For Malaria Elimination (NFME) in India (2016-2030) • WHO has recently developed the GTS for Malaria 2016-2030 which advocates global acceleration of malaria elimination efforts by 2030. • APLMA of which India is a member has set a target for malaria elimination in all countries of the Asia Pacific by 2030. • The Hon’ble Prime Minister of India was among the 18 leaders, who endorsed the APLMA Malaria Elimination Roadmap (Kuala Lumpur, 2015), emphasizing the political commitment towards malaria elimination in the region. • National framework for Malaria Elimination is in line with GTS and APLMA. 7/30/2018 22
NFME in India (2016-2030) • Over the years, there has been a significant reduction in malaria cases. • This was made possible through the integrated general health services, strengthening of health systems. • However, still 80% of global malarial deaths occurs in India and 14 other countries in Sub-Saharan Africa. • New NFME - Targeting elimination of Malaria by 2030. 7/30/2018 23
NFME in India (2016-2030) • Vision Eliminate malaria nationally and contribute to improved health, quality of life and alleviation of poverty • Goals 1. Eliminate malaria (zero indigenous cases) throughout the country by 2030 2. Maintain malaria-free status – areas where malaria transmission has been interrupted and prevent re-introduction of malaria 7/30/2018 24
NFME in India (2016-2030) • Objectives 1. Eliminate malaria from all 26 low (Category 1) and moderate (Category 2) transmission states/ union territories by 2022; 2. Reduce the incidence of malaria to less than 1 case per 1000 population per year in all states and UTs and their districts by 2024; 3. Interrupt indigenous transmission of malaria throughout the entire country (Category 3) by 2027; 4. Prevent re-establishment of local transmission of malaria and maintain malaria- free status by 2030 and beyond. 7/30/2018 25
NFME in India (2016-2030) • Strategy: 1. Programme Phasing 2. District as the unit of planning and implementation 3. Focus on high transmission areas 4. Special strategy for P. vivax elimination 7/30/2018 26
Strategy 1. Programme Phasing Phased manner Subdivided into four categories • Annual Parasite Incidence (API) – primary criteria • Annual Blood examination rate (ABER) & Slide positivity rate (SPR) – secondary criteria 7/30/2018 27
Strategy cont.. S. No. Categories of States/UTs Definition 1. Category 0: Prevention of re- establishment phase Zero indigenous cases 2. Category 1: Elimination Phase (15) API of <1 case per 1000 population at risk 3. Category 2: Pre-elimination Phase (11) API of <1 case per 1000 population at risk , with some districts of API of 1/1000 or above 4. Category 3: Intensified control Phase (10) API of 1 case per 1000 population at risk or above 7/30/2018 28 Classification of States/UTs based on API as primary criteria
Strategy cont.. 2. District as the unit of planning and implementation • State/UTs to be further classify and sub-classify their districts. • For localized planning and implementation • District is functional unit for planning as well as monitoring malaria elimination interventions 7/30/2018 29
Strategy cont.. 3. Focus on high transmission areas • In 2014, 5 out of 36 states/UTs contributed to more than 70% of total malaria cases. • Aggressive scaling up of existing interventions and intensification of all malaria control activities will be carried out. • Intersectoral collaboration and partnerships will be strengthened for filling gaps 7/30/2018 30
Strategy cont.. 4. Special strategy for P. vivax elimination • WHO Malaria Report – 80% of global P. vivax contributed by 3 countries including India. • Special measures – good quality microscopy, prevalence of G6PD deficiency, vector control measures, good compliance to 14-day radical treatment. 7/30/2018 31
Milestones and Targets 7/30/2018 32 201 6 • All states/UTs - include malaria elimination in their broader health policies and planning frameworks 202 0 • Interrupt malaria transmission & zero indigenous cases and death to malaria in all 15 states/UTs under Category 1 (2014) • All 11 states/UTs under Category 2 enter into Category 1 • Five states/UTs under Category 3 enter in Category 2 • Five states/UTs under Category 3 to reduce malaria transmission • Estimated reduction in malaria if 15-20% at national level • Accelerate malaria eradication programme and early elimination - states with strong health system.
Milestones and Targets cont.. 7/30/2018 33 202 2 • Interrupt malaria transmission and zero indigenous cases and deaths due to malaria in 26 state/UTs under Category 1 and 2. • Five states/UTs under category 3 to enter elimination phase • Five states/UTs under category 3 to enter into pre-elimination phase • Estimated reduction in malaria of 30-35% at national level. 202 4 • All states/UTs and their respective districts reduce API of <1 case per 1000 population; zero malaria deaths; fully functional malaria surveillance • Interrupt malaria transmission and zero indigenous cases and deaths due to malaria in 31 states/UTs. • Five states/UTs under category 3 to enter elimination phase
Milestones and Targets cont.. 7/30/2018 34 202 7 • Indigenous transmission of malaria in India interrupted. 203 0 • The re-establishment of local transmission prevented in areas where malaria is eliminated. • Malaria-free status maintained throughout the nation. • India initiates the process of WHO certification of malaria elimination.
Key Interventions • Category 3 (Intensified Control Phase) 7/30/2018 35 Specific Objectives Key Interventions • Achieve universal coverage – Malaria preventive and curative measures  Massive scaling up – disease management and preventive approach • Efficient system to reduce ongoing transmission  Screening of suspected cases  Area classification – malaria epidemiology • Reduce malaria specific mortality and morbidity  Strengthening of intersectoral collaboration
Key Interventions cont.. • Category 3 (Intensified Control Phase) 7/30/2018 36 Specific Objectives Key Interventions • Prevent malaria outbreaks (non-immune high risk population)  One-stops/ mobile clinics in tribal/high risk areas • Emphasize reducing malaria morbidity and mortality (high transmission pockets)  Timely referral & treatment  Robust supply chain  Optimum level of surveillance  Equipping all health institutions
Key Interventions cont.. • Category 2 (Pre-elimination Phase) a) Interventions will be introduced with focus on setting up an elimination surveillance system and initiating elimination phase activities b) Introduced – Districts where API is reduced to less than 1 case per 1000 population at risk per year. c) Measures are based on epidemiological investigations and classification of each malaria foci 7/30/2018 37
Key Interventions cont.. • Category 1 (Elimination Phase) 7/30/2018 38 Specific Objectives Key Interventions • Interrupt malaria transmission  Interrupting local transmission - elimination areas • Immediate notification of cases  Mandatory notification of each case (private sectors) • Detect continuation of malaria transmission  Adequate case based surveillance and case management • Determine cause of residual transmission  Investigate and classification of all foci of malaria  Strict coverage of foci
Key Interventions cont.. • Category 1 (Elimination Phase) 7/30/2018 39 Specific Objectives Key Interventions • Ensure epidemic preparedness • Prevent re-establishment of local transmission of malaria • Ascertain malaria elimination  Early detection and treatment of all cases  State and national malaria elimination database  Screening, management and prevention interventions along with surveillance among mobile and migrant population (special groups)  Effective epidemic forecasting and response team  Rigorous quality assurance  Setting up national level reference laboratory
Key Interventions cont.. • Category 0 When an area has achieved malaria elimination, specific objectives will be as follows: • Detect any re-introduced case of malaria • Notify immediately • Determine the underlying cause of resumed local transmission • Apply rapid curative and preventive measures • Prevent re-introduction & re-establishment of malaria transmission • Maintain malaria-free status. 7/30/2018 40
Cross- cutting Interventions • Common to all categories of states/UTs ⋆Policy and Planning ▸Formation of a National Malaria Elimination Committee ▸Revision of national guidelines for prevention, intensified control and elimination of malaria ▸Revision of national or state level policy/legislation for all the states and UTs ▸New surveillance and reporting strategy (China’s 1-3-7 strategy) ▸Clear parameters for states/UTs classification ▸Verification of malaria elimination 7/30/2018 41
Cross- cutting Interventions cont.. ⋆Monitoring and Evaluation ▸New web-based reporting system ▸Revision of monitoring and evaluation formats ▸Estimation of vector control coverage ▸Use of annual scoring system for evaluating progress against elimination milestones and targets ▸Data validation by external agency ▸Grading of all areas based on fixed parameters 7/30/2018 42
Cross- cutting Interventions cont.. ⋆Stratification ▸Stratification of States/UTs based on – API, ABER and SPR ▸Sub-stratification of all districts ▸Further stratification of CHCs, PHCs, SCs and villages ▸Feasibility assessment of each state/UTs ⋆Surveillance ▸Entomological surveillance ▸Strengthening of routine surveillance 7/30/2018 43
Cross- cutting Interventions cont.. ⋆Quality assurance ▸Quality assurance of all medicines, diagnostic, treatment ▸Private sector providing diagnostics to be certified ⋆Intersectoral Collaboration ▸Formulation of clearly defined roles and responsibilities ▸Collaboration with private sectors and NGOs ▸Training and refreshing courses ▸Integration of data on malaria endemicity ▸Establish collaboration with various public works department 7/30/2018 44
Cross- cutting Interventions cont.. ⋆Cross-border Collaboration ▸Screening of population at international border crossing ▸Training of security personnel; provision of diagnostic and treatment facilities ▸Monthly data collections and integration ▸Joint planning and implementation of malaria prevention and control activities ⋆Initiatives for special population groups ▸Implementation of TRIBAL MALARIA PLAN ▸Screening of mobile or migrant workers in each state/UT ▸Community action group ▸Training of mobile, migrant workers 7/30/2018 45
Cross- cutting Interventions cont.. ⋆IEC/BCC ▸Revision of IEC/BCC strategy with special emphasis on malaria elimination ▸Strategy to be tailored according to the endemicity of malaria ⋆Innovation ▸Vector control ▸Standard Operating procedures for outbreaks of malaria ▸Avenues for innovative financing ▸Innovative ways of service delivery 7/30/2018 46
Cross- cutting Interventions cont.. ⋆Capacity Building ▸Preparatory of annual training curriculum and schedules for health officers ▸Review of training status and schedules ⋆Research ▸Facilitate research on devising methods to increase efficacy of IRS/LLIN ▸Survey by states/UTs on behaviour of mosquito vectors & community ▸Longitudinal survey on malaria vector population dynamics ▸Research on drug resistance, therapy efficacy studies ▸Cost-benefit analysis of intervention used 7/30/2018 47
Measuring Progress and Impact • Focus on monitoring ∼Operational aspects – coverage and quality interventions ∼Epidemiological indicators • National and state level independent malaria elimination committee • Progress towards reaching elimination goals 7/30/2018 48
Key indicators S. No IMPACT 1 No. and incidence rate of confirmed malaria cases 2 No. and incidence of severe malaria cases as well as case fatality rate 3 No. of malaria cases in pregnancy 4 No. and type of malaria foci 5 No. of confirmed deaths due to malaria 6 No. of states/UTs eliminated malaria and in phase of prevention of re- establishment of transmission 7 No. of states/UTs in elimination; pre-elimination and intensified phase 7/30/2018 49
Key indicators cont.. S. No OUTCOME 1 Proportion of population at risk who slept under an insecticides-treated net/LLIN the previous night 2 Proportion of population at risk protected by IRS within the past 12 months 3 Proportion of patients with confirmed malaria who received anti-malarial treatment 4 Proportion of cases investigated and classified 5 Proportion of foci investigated and classified 6 Proportion of expected monthly reports received from health facilities 7/30/2018 50
Cost of Implementing • It has been estimated that a 10% reduction in malaria is associated with 0.3% increase in growth of a country. • Global Technical Strategy for Malaria 2016-2030 – US $ 101.8 billion (15 years) • In India, economic burden of malaria was US$ 1940 million (2012) • Estimates showed that every Rupee invested in malaria control a direct return of Rs. 19.70 could be expected 7/30/2018 51
Challenges in Malaria Control 1. Population movements, often uncontrolled across states/UTs, and sharing of large international borders with neighbouring malaria endemic countries 2. Shortage of skilled human resources 3. Insecticides resistance 7/30/2018 52
Next Steps… 1. Strategic Action Plan 2016-2030 is rolled out 2. Sustain adequate financial resources 3. National malaria elimination committee and technical working group 4. National monitoring and evaluation database will be strengthened 7/30/2018 53
National Strategic Plan for Malaria Elimination in India 2017-2022 • Specific Objectives 1. Universal coverage of case detection and treatment services in endemic districts ensuring 100% parasitological diagnosis 2. Strengthen the surveillance system 3. Universal coverage of population at risk of malaria with a vector control measure 4. Universal coverage by appropriate BCC activities 5. Effective programme management and coordination at all levels to deliver targeted interventions 7/30/2018 54
Malaria Elimination Plan in Karnataka (2016-2025) • Goal – attain ZERO malaria status by 2022 • Objectives 1. Reduction of malaria to less than1 case per 1000 population per year in Dakshina Kannada and Udupi by 2018. 2. Elimination – in 15 low transmission districts by 2018 and sustain 3. Elimination – in 13 moderate transmission districts by 2020 4. Interruption of indigenous transmission in entire state by 2022 5. Prevent local transmission from 2023 7/30/2018 55
Malaria Elimination Plan in Karnataka (2016-2025) • Strategic Plan 1. Detection of all malaria cases and their notification, foci identification and cut down further transmission 2. Universal coverage and quality assurance of malarial microscopy 3. Universalization of common drug policy, monitoring of drug efficacy and resistance 4. Reduction of man-mosquito contact 5. All levels of malaria control programme have sufficient capacity 6. Intersectoral collaboration 7. IEC, social mobilization 8. Financial investment from different sources 9. Execution of regulatory policies necessary to achieve goals of malaria elimination 7/30/2018 56
Critical Analysis 7/30/2018 57 • District as the unit • Special strategy for P. vivax • Case-based surveillance • Involving PP. • For migratory population •Strengthens • Diagnostic Challenges. • Ensuring completion of treatment. • Resistance. • Funding. • Asymptomatic malaria cases. • Mandatory notification Challenges
7/30/2018 58
Summary 1. NFME is India’s commitment to GTS and APLMA. 2. National framework for Malaria Elimination (NFME) – to eliminate malaria by 2030. 3. National strategic plan for Malaria Elimination in India 2017-2022 - to support NFME to achieve malaria elimination 4. Malaria elimination Plan in Karnataka (2016-2025)- to attain zero malaria status by 2022 7/30/2018 59
7/30/2018 60
References 1. World Health Organization. World malaria report 2017. Geneva.WHO.2017. 2. National Vector Borne Disease Control Programme. Trend of Malaria Parameters in India (2001-2018). Ministry of Health and Family Welfare. Government of India. Available from: http://nvbdcp.gov.in/index4.php?lang=1&level=0&linkid=427&lid=3705 3. Directorate of National Vector Borne Disease Control Programme. National Framework for Malaria Elimination in India (2016-2030). Ministry of Health and Family Welfare. Government of India. New Delhi.2016 4. Directorate of Health and Family Welfare Services. Malaria Elimination Plan in Karnataka (2016-2025) – Framework, Strategies and Policies. Government of Karnataka. Bengaluru. 2017. 5. J.Kishore. National Health Programs of India – National Policies & Legislations Related to Health. Twelfth Edition. New Delhi, India. Century Publications. 2017. 6. Chourasia MK, Raghavendra K, Bhatt RM, Swain DK, Valecha N, Kleinschmidt I. Burden of asymptomatic malaria among a tribal population in a forested village of central India: a hidden challenge for malaria control in India. Public Health.2017;147:92-7. 7. Singh US, Siwal N, Pande V, Das A. Can Mixed Parasite Infections Thwart Targeted Malaria Elimination Program in India?. BioMed Research International.2017. Available from: https://doi.org/10.1155/2017/2847548 7/30/2018 61
References 8. World Health Organization. A framework for malaria elimination. Geneva. WHO.2017 9. Shah NK, Dhariwal AC, Sonal GS, Gunasekar A, Dye C, Cibulskis R. Malaria-attributed death rates in India. The Lancet.2011;377:991-2. 10. Hay SI, Gething PW, Snow RW. India’s invisible malaria burden. Lancet. 2010; 376(9754):1716-7. 11. Farooquia HH, Hussainb MA, Zodpeya S. Malaria control in India: has sub-optimal rationing of effective interventions compromised programme efficiency?. WHO South-East Asia Journal of Public Health 2012;1(2):128-32. 12. Park KS1, Malik SK, Lee JH, Karim AM, Lee SH. Commentary: Malaria elimination in India and regional implications. Frontiers in Microbiology.2018;9. doi: 10.3389/fmicb.2018.00992. 13. APLMA Strategic Plan. Roadmap Phase 1:2016-2020. Singapore. Asia Pacific Leaders Malaria Alliance. 2016. 7/30/2018 62
THANK YOU 7/30/2018 63

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National framework for malaria elimination in india

  • 1.
    National Framework For MalariaElimination In India (2016-2030) Dr. Aparna Sen Chaudhary
  • 2.
    Contents • Introduction • MalariaSituation • Malaria Control In India • National framework for Malaria Elimination in India • National Strategic Plan for Malaria Elimination in India • Malaria Elimination Plan in Karnataka • Critical Analysis • Summary • References 7/30/2018 2
  • 3.
  • 4.
    Introduction • Malaria incidencehave reduced globally between 2010-2015. • Gains achieved are fragile and uneven. • Millennium Development Goal 6 – ACHIEVED (Globally & India) ⋆ Globally – cases reduced from 262 million (2000) – 211 million (2015) deaths reduced from 839000 (2000) – 446000 (2015) ⋆ India - Annual Parasite Incidence was reduced from 2.09 (2000)–0.64(2015). • Sustainable Development Goal 3 - By 2030, end the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases and combat hepatitis, water- borne diseases and other communicable diseases. 7/30/2018 4
  • 5.
    Geographical Distribution OfMalarial Parasite 7/30/2018 5Source: Kiszewksi et al. American Journal of Tropical Medicine and Hygiene.2004.70;5:486-98.
  • 6.
    Malaria Indigenous cases- 2016 7/30/2018 6Source: World Health Organization .World malaria report 2017. Geneva. WHO. 2017
  • 7.
    World Malaria Report2017 According to World Malaria Report 2017. Total cases reduced from 237 million (2010) 216 million (2016) Total deaths reduced from 591000 (2010) 445000 (2016) Incidence Rate - reduced by 18% ., from 76 – 63 (2010-16) 7/30/2018 7
  • 8.
    World Malaria Report2017 7/30/2018 8 Year Cases (in million) Deaths 2010 237 591000 2011 225 529000 2012 217 487000 2013 210 465000 2014 210 459000 2015 211 446000 2016 216 445000
  • 9.
  • 10.
    India • Malaria caseshave shown decline from 2 million (2000) to 1.1 million (2015) • Incidence – 0.88% in a population of nearly 1.25 billion • Confirmed deaths decline from 1005 (2001) to 562 (2014). • Overall in last 10 years 1. Total Malaria cases declined 42% (1.92 m – 1.1 m) 2. Malaria-related Deaths declined 40.8% (949 - 562) 7/30/2018 10 Source: Global Malaria Report.2015
  • 11.
  • 12.
    Distribution Of Malaria Vectors InIndia 7/30/2018 12Source: National Vector Borne Disease Control Programme
  • 13.
    Geographic distribution of Malaria Incidence (API)in India - 2014 7/30/2018 13 Source: National Vector Borne Disease Control Programme
  • 14.
    7/30/2018 14 Year Confirmed MalariaCases (in million) Pf cases (in million) Pf % Deaths 2011 1.31 0.67 50.74 754 2012 1.06 0.53 49.98 519 2013 0.88 0.46 52.61 440 2014 1.10 0.72 65.55 562 2015 1.17 0.78 66.61 384 2016 1.09 0.71 65.53 331 2017 0.84 0.53 63.39 105 2018 (till May) 0.10 0.05 54.81 6 Source: National Vector Borne Disease Control Programme. Trends in malaria parameters in India (2001-2018).
  • 15.
    7/30/2018 15 Trends of totalmalaria cases, Pf and Pv and deaths(2000-2014) Source: National Vector Borne Disease Control Programme
  • 16.
    Karnataka • Previously, categorizedas one of the high transmission zones in India. • After 2003, malaria incidence started declining (reduction of 89% compared to 2000) • The API of state range from 0.1 to 22.3 • Total cases - 12,442 and deaths – 0 (As per 2015) 7/30/2018 16Source :Malaria Elimination Plan in Karnataka (2016-2025) – Framework, Strategies and Policies
  • 17.
    Milestones In TheMalaria Control Programme In India 7/30/2018 17 Prior to 1940 No organized national malaria programmes Prior to 1953 Esti. Cases- 75 m; deaths – 1 m 1953 National Malaria Control Programme 1958 National Malaria Eradication Programme 1965 Cases reduced to 0.1m Early 1970’ Resurgence of malaria 1971 Urban Malaria Scheme 1976 Malaria cases – 6.46 m 1977 Modified Plan of Operation 1984-1998 Annual Incidence of Malaria – 2-3 m 1995 Modified action plan for malaria control 1997 Enhanced Malaria Control Project 1999 National Anti-Malaria Programme 2002 NVBDCP 2005 RDT (monovalent) 2005 Intensified Malaria Control Programme 2006 ACT – chloroquine resistance areas 2008 Revised NVBDCP Drug Policy 2008 National Vector Borne Disease Control Support Project 2009 LLIN introduced 2010 Revised NVBDCP Drug Policy 2010 2013 RDT (bivalent) 2104-15 Newer insecticides and larvicides introduced
  • 18.
    Milestones in malariacontrol activities 7/30/2018 18 1946Bhore Committee • 75 million cases & • 0.8 million deaths National Malaria Control Program • Residual insecticide spray • Anti-malarial drugs • Survey and monitoring 1953 1958National Malaria Elimination Program • Eradicate Malaria • Cases – 49151 (1961) 1971 Urban Malaria Scheme • Urban Malaria • Anti-larval measures
  • 19.
    Milestones in malariacontrol activities 7/30/2018 19 1977 Modified Plan of Operation • Cases – 6.46 million • Eliminate malaria death • Areas divided on basis of API Malaria Action Program • 100% centrally sponsored • Demarcation of high risk areas 1995 1997 Enhanced Malaria Control Program • Reduction in malaria morbidity • Out of 100 districts, 79% recorded decline in 2003 1999 National Anti Malaria Program • Renamed programme
  • 20.
    Milestones in malariacontrol activities 7/30/2018 20 2002 National Health Policy • Reduction in mortality by 50% by 2010 National Vector Borne Disease Control Programme (NVBDCP) • National Anti Malaria Programme renamed 2002 2005NVBDCP • Integral part under NRHM 2005 Intensified Malaria Control Project • Started with assistance of Global fund for AIDS, Tuberculosis, Malaria
  • 21.
    Milestones in malariacontrol activities 7/30/2018 21 2010Revised NVBDCP Drug Policy 2010 National Framework For Malaria Elimination In India (2016-2030) 2016
  • 22.
    National Framework ForMalaria Elimination (NFME) in India (2016-2030) • WHO has recently developed the GTS for Malaria 2016-2030 which advocates global acceleration of malaria elimination efforts by 2030. • APLMA of which India is a member has set a target for malaria elimination in all countries of the Asia Pacific by 2030. • The Hon’ble Prime Minister of India was among the 18 leaders, who endorsed the APLMA Malaria Elimination Roadmap (Kuala Lumpur, 2015), emphasizing the political commitment towards malaria elimination in the region. • National framework for Malaria Elimination is in line with GTS and APLMA. 7/30/2018 22
  • 23.
    NFME in India(2016-2030) • Over the years, there has been a significant reduction in malaria cases. • This was made possible through the integrated general health services, strengthening of health systems. • However, still 80% of global malarial deaths occurs in India and 14 other countries in Sub-Saharan Africa. • New NFME - Targeting elimination of Malaria by 2030. 7/30/2018 23
  • 24.
    NFME in India(2016-2030) • Vision Eliminate malaria nationally and contribute to improved health, quality of life and alleviation of poverty • Goals 1. Eliminate malaria (zero indigenous cases) throughout the country by 2030 2. Maintain malaria-free status – areas where malaria transmission has been interrupted and prevent re-introduction of malaria 7/30/2018 24
  • 25.
    NFME in India(2016-2030) • Objectives 1. Eliminate malaria from all 26 low (Category 1) and moderate (Category 2) transmission states/ union territories by 2022; 2. Reduce the incidence of malaria to less than 1 case per 1000 population per year in all states and UTs and their districts by 2024; 3. Interrupt indigenous transmission of malaria throughout the entire country (Category 3) by 2027; 4. Prevent re-establishment of local transmission of malaria and maintain malaria- free status by 2030 and beyond. 7/30/2018 25
  • 26.
    NFME in India(2016-2030) • Strategy: 1. Programme Phasing 2. District as the unit of planning and implementation 3. Focus on high transmission areas 4. Special strategy for P. vivax elimination 7/30/2018 26
  • 27.
    Strategy 1. Programme Phasing Phasedmanner Subdivided into four categories • Annual Parasite Incidence (API) – primary criteria • Annual Blood examination rate (ABER) & Slide positivity rate (SPR) – secondary criteria 7/30/2018 27
  • 28.
    Strategy cont.. S. No.Categories of States/UTs Definition 1. Category 0: Prevention of re- establishment phase Zero indigenous cases 2. Category 1: Elimination Phase (15) API of <1 case per 1000 population at risk 3. Category 2: Pre-elimination Phase (11) API of <1 case per 1000 population at risk , with some districts of API of 1/1000 or above 4. Category 3: Intensified control Phase (10) API of 1 case per 1000 population at risk or above 7/30/2018 28 Classification of States/UTs based on API as primary criteria
  • 29.
    Strategy cont.. 2. Districtas the unit of planning and implementation • State/UTs to be further classify and sub-classify their districts. • For localized planning and implementation • District is functional unit for planning as well as monitoring malaria elimination interventions 7/30/2018 29
  • 30.
    Strategy cont.. 3. Focuson high transmission areas • In 2014, 5 out of 36 states/UTs contributed to more than 70% of total malaria cases. • Aggressive scaling up of existing interventions and intensification of all malaria control activities will be carried out. • Intersectoral collaboration and partnerships will be strengthened for filling gaps 7/30/2018 30
  • 31.
    Strategy cont.. 4. Specialstrategy for P. vivax elimination • WHO Malaria Report – 80% of global P. vivax contributed by 3 countries including India. • Special measures – good quality microscopy, prevalence of G6PD deficiency, vector control measures, good compliance to 14-day radical treatment. 7/30/2018 31
  • 32.
    Milestones and Targets 7/30/201832 201 6 • All states/UTs - include malaria elimination in their broader health policies and planning frameworks 202 0 • Interrupt malaria transmission & zero indigenous cases and death to malaria in all 15 states/UTs under Category 1 (2014) • All 11 states/UTs under Category 2 enter into Category 1 • Five states/UTs under Category 3 enter in Category 2 • Five states/UTs under Category 3 to reduce malaria transmission • Estimated reduction in malaria if 15-20% at national level • Accelerate malaria eradication programme and early elimination - states with strong health system.
  • 33.
    Milestones and Targetscont.. 7/30/2018 33 202 2 • Interrupt malaria transmission and zero indigenous cases and deaths due to malaria in 26 state/UTs under Category 1 and 2. • Five states/UTs under category 3 to enter elimination phase • Five states/UTs under category 3 to enter into pre-elimination phase • Estimated reduction in malaria of 30-35% at national level. 202 4 • All states/UTs and their respective districts reduce API of <1 case per 1000 population; zero malaria deaths; fully functional malaria surveillance • Interrupt malaria transmission and zero indigenous cases and deaths due to malaria in 31 states/UTs. • Five states/UTs under category 3 to enter elimination phase
  • 34.
    Milestones and Targetscont.. 7/30/2018 34 202 7 • Indigenous transmission of malaria in India interrupted. 203 0 • The re-establishment of local transmission prevented in areas where malaria is eliminated. • Malaria-free status maintained throughout the nation. • India initiates the process of WHO certification of malaria elimination.
  • 35.
    Key Interventions • Category3 (Intensified Control Phase) 7/30/2018 35 Specific Objectives Key Interventions • Achieve universal coverage – Malaria preventive and curative measures  Massive scaling up – disease management and preventive approach • Efficient system to reduce ongoing transmission  Screening of suspected cases  Area classification – malaria epidemiology • Reduce malaria specific mortality and morbidity  Strengthening of intersectoral collaboration
  • 36.
    Key Interventions cont.. •Category 3 (Intensified Control Phase) 7/30/2018 36 Specific Objectives Key Interventions • Prevent malaria outbreaks (non-immune high risk population)  One-stops/ mobile clinics in tribal/high risk areas • Emphasize reducing malaria morbidity and mortality (high transmission pockets)  Timely referral & treatment  Robust supply chain  Optimum level of surveillance  Equipping all health institutions
  • 37.
    Key Interventions cont.. •Category 2 (Pre-elimination Phase) a) Interventions will be introduced with focus on setting up an elimination surveillance system and initiating elimination phase activities b) Introduced – Districts where API is reduced to less than 1 case per 1000 population at risk per year. c) Measures are based on epidemiological investigations and classification of each malaria foci 7/30/2018 37
  • 38.
    Key Interventions cont.. •Category 1 (Elimination Phase) 7/30/2018 38 Specific Objectives Key Interventions • Interrupt malaria transmission  Interrupting local transmission - elimination areas • Immediate notification of cases  Mandatory notification of each case (private sectors) • Detect continuation of malaria transmission  Adequate case based surveillance and case management • Determine cause of residual transmission  Investigate and classification of all foci of malaria  Strict coverage of foci
  • 39.
    Key Interventions cont.. •Category 1 (Elimination Phase) 7/30/2018 39 Specific Objectives Key Interventions • Ensure epidemic preparedness • Prevent re-establishment of local transmission of malaria • Ascertain malaria elimination  Early detection and treatment of all cases  State and national malaria elimination database  Screening, management and prevention interventions along with surveillance among mobile and migrant population (special groups)  Effective epidemic forecasting and response team  Rigorous quality assurance  Setting up national level reference laboratory
  • 40.
    Key Interventions cont.. •Category 0 When an area has achieved malaria elimination, specific objectives will be as follows: • Detect any re-introduced case of malaria • Notify immediately • Determine the underlying cause of resumed local transmission • Apply rapid curative and preventive measures • Prevent re-introduction & re-establishment of malaria transmission • Maintain malaria-free status. 7/30/2018 40
  • 41.
    Cross- cutting Interventions •Common to all categories of states/UTs ⋆Policy and Planning ▸Formation of a National Malaria Elimination Committee ▸Revision of national guidelines for prevention, intensified control and elimination of malaria ▸Revision of national or state level policy/legislation for all the states and UTs ▸New surveillance and reporting strategy (China’s 1-3-7 strategy) ▸Clear parameters for states/UTs classification ▸Verification of malaria elimination 7/30/2018 41
  • 42.
    Cross- cutting Interventionscont.. ⋆Monitoring and Evaluation ▸New web-based reporting system ▸Revision of monitoring and evaluation formats ▸Estimation of vector control coverage ▸Use of annual scoring system for evaluating progress against elimination milestones and targets ▸Data validation by external agency ▸Grading of all areas based on fixed parameters 7/30/2018 42
  • 43.
    Cross- cutting Interventionscont.. ⋆Stratification ▸Stratification of States/UTs based on – API, ABER and SPR ▸Sub-stratification of all districts ▸Further stratification of CHCs, PHCs, SCs and villages ▸Feasibility assessment of each state/UTs ⋆Surveillance ▸Entomological surveillance ▸Strengthening of routine surveillance 7/30/2018 43
  • 44.
    Cross- cutting Interventionscont.. ⋆Quality assurance ▸Quality assurance of all medicines, diagnostic, treatment ▸Private sector providing diagnostics to be certified ⋆Intersectoral Collaboration ▸Formulation of clearly defined roles and responsibilities ▸Collaboration with private sectors and NGOs ▸Training and refreshing courses ▸Integration of data on malaria endemicity ▸Establish collaboration with various public works department 7/30/2018 44
  • 45.
    Cross- cutting Interventionscont.. ⋆Cross-border Collaboration ▸Screening of population at international border crossing ▸Training of security personnel; provision of diagnostic and treatment facilities ▸Monthly data collections and integration ▸Joint planning and implementation of malaria prevention and control activities ⋆Initiatives for special population groups ▸Implementation of TRIBAL MALARIA PLAN ▸Screening of mobile or migrant workers in each state/UT ▸Community action group ▸Training of mobile, migrant workers 7/30/2018 45
  • 46.
    Cross- cutting Interventionscont.. ⋆IEC/BCC ▸Revision of IEC/BCC strategy with special emphasis on malaria elimination ▸Strategy to be tailored according to the endemicity of malaria ⋆Innovation ▸Vector control ▸Standard Operating procedures for outbreaks of malaria ▸Avenues for innovative financing ▸Innovative ways of service delivery 7/30/2018 46
  • 47.
    Cross- cutting Interventionscont.. ⋆Capacity Building ▸Preparatory of annual training curriculum and schedules for health officers ▸Review of training status and schedules ⋆Research ▸Facilitate research on devising methods to increase efficacy of IRS/LLIN ▸Survey by states/UTs on behaviour of mosquito vectors & community ▸Longitudinal survey on malaria vector population dynamics ▸Research on drug resistance, therapy efficacy studies ▸Cost-benefit analysis of intervention used 7/30/2018 47
  • 48.
    Measuring Progress andImpact • Focus on monitoring ∼Operational aspects – coverage and quality interventions ∼Epidemiological indicators • National and state level independent malaria elimination committee • Progress towards reaching elimination goals 7/30/2018 48
  • 49.
    Key indicators S. NoIMPACT 1 No. and incidence rate of confirmed malaria cases 2 No. and incidence of severe malaria cases as well as case fatality rate 3 No. of malaria cases in pregnancy 4 No. and type of malaria foci 5 No. of confirmed deaths due to malaria 6 No. of states/UTs eliminated malaria and in phase of prevention of re- establishment of transmission 7 No. of states/UTs in elimination; pre-elimination and intensified phase 7/30/2018 49
  • 50.
    Key indicators cont.. S.No OUTCOME 1 Proportion of population at risk who slept under an insecticides-treated net/LLIN the previous night 2 Proportion of population at risk protected by IRS within the past 12 months 3 Proportion of patients with confirmed malaria who received anti-malarial treatment 4 Proportion of cases investigated and classified 5 Proportion of foci investigated and classified 6 Proportion of expected monthly reports received from health facilities 7/30/2018 50
  • 51.
    Cost of Implementing •It has been estimated that a 10% reduction in malaria is associated with 0.3% increase in growth of a country. • Global Technical Strategy for Malaria 2016-2030 – US $ 101.8 billion (15 years) • In India, economic burden of malaria was US$ 1940 million (2012) • Estimates showed that every Rupee invested in malaria control a direct return of Rs. 19.70 could be expected 7/30/2018 51
  • 52.
    Challenges in MalariaControl 1. Population movements, often uncontrolled across states/UTs, and sharing of large international borders with neighbouring malaria endemic countries 2. Shortage of skilled human resources 3. Insecticides resistance 7/30/2018 52
  • 53.
    Next Steps… 1. StrategicAction Plan 2016-2030 is rolled out 2. Sustain adequate financial resources 3. National malaria elimination committee and technical working group 4. National monitoring and evaluation database will be strengthened 7/30/2018 53
  • 54.
    National Strategic Planfor Malaria Elimination in India 2017-2022 • Specific Objectives 1. Universal coverage of case detection and treatment services in endemic districts ensuring 100% parasitological diagnosis 2. Strengthen the surveillance system 3. Universal coverage of population at risk of malaria with a vector control measure 4. Universal coverage by appropriate BCC activities 5. Effective programme management and coordination at all levels to deliver targeted interventions 7/30/2018 54
  • 55.
    Malaria Elimination Planin Karnataka (2016-2025) • Goal – attain ZERO malaria status by 2022 • Objectives 1. Reduction of malaria to less than1 case per 1000 population per year in Dakshina Kannada and Udupi by 2018. 2. Elimination – in 15 low transmission districts by 2018 and sustain 3. Elimination – in 13 moderate transmission districts by 2020 4. Interruption of indigenous transmission in entire state by 2022 5. Prevent local transmission from 2023 7/30/2018 55
  • 56.
    Malaria Elimination Planin Karnataka (2016-2025) • Strategic Plan 1. Detection of all malaria cases and their notification, foci identification and cut down further transmission 2. Universal coverage and quality assurance of malarial microscopy 3. Universalization of common drug policy, monitoring of drug efficacy and resistance 4. Reduction of man-mosquito contact 5. All levels of malaria control programme have sufficient capacity 6. Intersectoral collaboration 7. IEC, social mobilization 8. Financial investment from different sources 9. Execution of regulatory policies necessary to achieve goals of malaria elimination 7/30/2018 56
  • 57.
    Critical Analysis 7/30/2018 57 •District as the unit • Special strategy for P. vivax • Case-based surveillance • Involving PP. • For migratory population •Strengthens • Diagnostic Challenges. • Ensuring completion of treatment. • Resistance. • Funding. • Asymptomatic malaria cases. • Mandatory notification Challenges
  • 58.
  • 59.
    Summary 1. NFME isIndia’s commitment to GTS and APLMA. 2. National framework for Malaria Elimination (NFME) – to eliminate malaria by 2030. 3. National strategic plan for Malaria Elimination in India 2017-2022 - to support NFME to achieve malaria elimination 4. Malaria elimination Plan in Karnataka (2016-2025)- to attain zero malaria status by 2022 7/30/2018 59
  • 60.
  • 61.
    References 1. World HealthOrganization. World malaria report 2017. Geneva.WHO.2017. 2. National Vector Borne Disease Control Programme. Trend of Malaria Parameters in India (2001-2018). Ministry of Health and Family Welfare. Government of India. Available from: http://nvbdcp.gov.in/index4.php?lang=1&level=0&linkid=427&lid=3705 3. Directorate of National Vector Borne Disease Control Programme. National Framework for Malaria Elimination in India (2016-2030). Ministry of Health and Family Welfare. Government of India. New Delhi.2016 4. Directorate of Health and Family Welfare Services. Malaria Elimination Plan in Karnataka (2016-2025) – Framework, Strategies and Policies. Government of Karnataka. Bengaluru. 2017. 5. J.Kishore. National Health Programs of India – National Policies & Legislations Related to Health. Twelfth Edition. New Delhi, India. Century Publications. 2017. 6. Chourasia MK, Raghavendra K, Bhatt RM, Swain DK, Valecha N, Kleinschmidt I. Burden of asymptomatic malaria among a tribal population in a forested village of central India: a hidden challenge for malaria control in India. Public Health.2017;147:92-7. 7. Singh US, Siwal N, Pande V, Das A. Can Mixed Parasite Infections Thwart Targeted Malaria Elimination Program in India?. BioMed Research International.2017. Available from: https://doi.org/10.1155/2017/2847548 7/30/2018 61
  • 62.
    References 8. World HealthOrganization. A framework for malaria elimination. Geneva. WHO.2017 9. Shah NK, Dhariwal AC, Sonal GS, Gunasekar A, Dye C, Cibulskis R. Malaria-attributed death rates in India. The Lancet.2011;377:991-2. 10. Hay SI, Gething PW, Snow RW. India’s invisible malaria burden. Lancet. 2010; 376(9754):1716-7. 11. Farooquia HH, Hussainb MA, Zodpeya S. Malaria control in India: has sub-optimal rationing of effective interventions compromised programme efficiency?. WHO South-East Asia Journal of Public Health 2012;1(2):128-32. 12. Park KS1, Malik SK, Lee JH, Karim AM, Lee SH. Commentary: Malaria elimination in India and regional implications. Frontiers in Microbiology.2018;9. doi: 10.3389/fmicb.2018.00992. 13. APLMA Strategic Plan. Roadmap Phase 1:2016-2020. Singapore. Asia Pacific Leaders Malaria Alliance. 2016. 7/30/2018 62
  • 63.