MALARIA SITUATION IN INDIA Dr. Neeraj Dhingra Additional Director & Head Malaria Division, NVBDCP DGHS MOHFW India Email:dhingradr@Hotmail.com

LIFE CYCLE OF MALARIA PARASITE TYPES OF MALARIA PARASITE Plasmodium vivax (Pv)- may lead to chronicity Plasmodium falciparum (Pf) – leads to complication death In India, above 2 are common Others rarely Plasmodium malariae Plasmodium ovale

2016 NSP 1995 National Anti-Malaria Programme (NAMP) WHO 24m WHO 29m WHO 21m WHO 13m 2005 Intensified Malaria Control Project Supported by the Global fund and the National Vector Borne Disease Control project 1958 Natiional Malaria Eradication Programme 1965 Zero Malaria Deaths reported 1971 UMS 1977 Modified plan of Operation(MPO) 1982 First national anti-malaria drug policy 1995 National Anti-Malaria Programme (NAMP) 1997 Enhanced Malaria control Project 2016 NSP

REGIONAL DISTRIBUTION OF MALARIA

FALCIPARUM RATE

Decrease in total malaria cases from 354250 to 132216 (62.68%) MALARIA DECLINE CONTINUES IN 2018 June2017 vs June2018 Decrease in total malaria cases from 354250 to 132216 (62.68%) Decrease in Pf cases from 246360 to 71094 (71.14%) The Pf % has been decreased to 53.77% from 69.54%. The surveillance has decreased (1.10%) from 54086667 tests (malaria parasite) to 53489448 tests (test include slides examination and RDTs). Eleven deaths have been reported in 2018 as compared to corresponding period of 2017 (till June) were 31deaths in reported. There is decrease in SPR from 0.65 to 0.25 No. of malaria cases declined by 28 percent in last 3 years 62 percent decline in malaria cases in 2018 as compared to corresponding period in 2017 No. of deaths declined due to malaria by 49.5 percent in last 3 years

STATES CONTRIBUTING MAXIMUM BURDEN OF MALARIA IN INDIA (2017) Name of the State Total Malaria Cases PERCENTAGE CONTRIBUTION TO TOTAL MALARIA Deaths ODISHA 3,52,140 42 25 CHHATTISGARH 1,41,310 17 81 JHARKHAND 92,770 11 1 MADHYA PRADESH 46,176 5 3 MEGHALAYA 16,433 2 12 TOTAL OF ABOVE STATES 6,48,829 77.2 122 ALL INDIA 2017 8,40,838 194 ALL INDIA 2016 10,90,677 331

CATEGORISATION OF STATES BASED ON MALARIA BURDEN (API) Chandigarh, Daman & Diu, Delhi, Goa, Haryana, Himachal Pradesh, J & K, Kerala, Lakshwadeep, Manipur, Puducherry, Punjab, Rajasthan, Sikkim, Uttarakhand Category 1 (15 States) -State/Districts reporting an API of less than 1 case per 1000 population Andhra Pradesh, Assam, Bihar, Gujarat, Karnataka, Maharashtra, Nagaland, Tamil Nadu, Telangana, Uttar Pradesh, West Bengal Category 2 (11 States) - State < 1 API but some districts report API of 1 case per 1000 population A & N Islands, Arunachal Pradesh, Chhatisgarh, Dadra & Nagar Haveli, Jharkhand, Madhya Pradesh, Meghalaya, Mizoram, Odisha, Tripura Category 3 (10) - States with API of 1 or more per 1000 population

CATEGORISATION OF DISTRICTS/REPORTING UNITS (API based) Category of districts Definition (%) Prevention of re-establishment phase No local transmission and reporting no case for last 3 years. (11.0) Elimination phase Districts/units having API less than 1 per 1000 population (66.1) Pre-elimination phase Districts/units having API 1 and above, but less than 2 per 1000 population. 46 (6.8) Intensified control phase Districts/units having API 2 and above per 1000 population. 109 (16.1)

Milestones and Targets for Malaria Elimination By 2020 Eliminate malaria from all 15 low transmission states and UTs (Category 1) and 3 additional progressive states and UTs of Category 2 By 2022 Eliminate malaria from all 8 moderate transmission states and UTs (Category 2) By 2024 Reduce the incidence of malaria to less than 1 case per 1000 population in all states and UTs and their districts By 2030 and beyond Prevent the re-establishment of local transmission of malaria in areas where it has been eliminated and maintain national malaria-free status

Malaria elimination in phases in India- Stratification Year Category 0 Category 1 Category 2 Category 3 Total 2015 75 448 46 109 678 2017 106 470 68 34 2019 305 233 33 107 2020 523 48 15 92 2022 571 30 62 Technical Strategies will need to adapt to this bring this change and maintain it: HIGH ENDEMIC AREAS CASE DETECTION, TREATMENT, FOLLOW UP, EFFECTIVE VECTOR CONTROL MODERATE AREAS INTENSIFY MALARIA REPORTING AND SURVEILLANCE – early detect, contain and prevent outbreaks LOW ENDEMIC AREAS CASE BASED SURVEILLANCE AND FOLLOW UP IN INDIA- WE WILL NEED TO IMPLEMENT THE ABOVE DIFFERENT REGIONS AT SAME TIME

National Strategies for Malaria Elimination Early diagnosis and complete treatment Case based surveillance and rapid response Integrated Vector Management Indoor Residual Spray (IRS) Long Lasting Insecticidal Nets (LLINs)/ Insecticide- treated Nets (ITNs) Larval Source Management (LSM) Epidemic Preparedness and Early Response Monitoring & Evaluation Advocacy, Coordination and Partnerships Behavior Change Communication (BCC) and Community Mobilization Programme Planning and Management

Progress on Malaria Elimination Activities Launch of National Framework for Malaria Elimination (NFME) 2016- 2030 in February, 2016 Dissemination of NFME 2016- 2030 to all States and UTs with instructions to initiate key actions Launch of Operational Manual for Malaria Elimination on April, 2016 Launch of National Strategic Plan (2017-22) for Malaria Elimination document on July,2017 Formation of a National Malaria Task Force under the Union Health Secretary (July2016) and a Technical Working Group under the DGHS for oversight of all malaria elimination activities in the country. First National Task Force Meeting under Health Secretary held in Feb2018. 14 States have made malaria a notifiable disease Update this slide with addition of Strategic meeting with the states

Progress on Malaria Elimination Activities (contd) 40 million LLINs distributed/being distributed. 11.00 million proposed for the year 2018 Fourteen states successfully launched their respective plans for malaria elimination, other states/ UTs are in process of finalizing their action plans for elimination. Involvement of private medical sector through trainings, publication of special issue on VBD, regular SMS to 2.5 lakh medical practitioners under the aegis of Indian Medical Association (IMA) Quality Assurance mechanisms for Rapid diagnostics and malaria microscopy started. Rapid Diagnostic Tests: Started in 2009 Malaria microscopy – up gradation as per international standards initiated in November2016

Trend of Malaria in 7 NE states 2012-17* Total malaria cases declined in 2017 by 72.24% compared to 2015 & by 56.24% compared to 2012. Total Pf cases declined in 2017 by 72.14% compared to 2015 & by 51.34% compared to 2012. Total malaria deaths declined in 2017 by 85.93% compared to 2015 % by 83.19% compared to 2012.

Odisha - Monthly Burden of Cases & Deaths (2016 vs 2017) After July in 2017, there is sharp decline 4% 44% 56% 62% 80% 80%   Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Cases-2016 26251 19498 21741 22883 22908 36940 75550 65115 42434 34275 40584 36663 Cases-2017 23970 20841 26954 35471 40050 48644 72546 36446 18878 12911 8182 7247  Deaths-2016 2 1 3 6 7 27 12 5 4 Deaths-2017 13 0 

National Drug Policy All fever cases should preferably be investigated for malaria by microscopy or RDT P. falciparum: ACT first line antimalarial AS+SP all over India except NE states; AL in NE states PQ single dose MiP: ACT 2nd/3rd trimester; quinine in 1st trimester P. vivax: CQ 25mg/kg over 3 days + PQ 0.25 mg/kg x 14 days Primaquine in Pv: test G6PD if facilities available If no facilities; look for symptoms of hemolysis Prevention of MiP: Personal protection measures Chemoprophylaxis for travellers, migrant labourers and military personnel <6 weeks: Doxycycline; >6 weeks: Mefloquine

Challenges to Malaria Elimination Financial sustainability Uninterrupted supply of materials – procurement and supply uncertainity Highly trained and skilled manpower at all levels – hiring and continuation Developmental activities creating more malariogenic potential – identification and prevention Engagement of private sector Drug resistance Insecticide resistance Research for newer drugs, insecticides Real Time reporting from remote and inaccessible areas

THANKS