Despite commendable progress in control of malaria in India and other countries, there are hidden reservoirs of parasites in human hosts that continually feed malaria transmission. Submicroscopic ...infections are a significant proportion in low-endemic settings like India, and these infections possess transmission potential. Hence, these reservoirs of infection add to the existing roadblocks for malaria elimination. It is crucial that this submerged burden of malaria is detected and treated to curtail further transmission. The currently used diagnostic tools, including the so-called "gold standard" microscopy, are incapable of detecting these submicroscopic infections and thus are suboptimal. It is an opportune time to usher in more sensitive molecular tools like polymerase chain reaction (PCR) for routine diagnosis at all levels of healthcare as an additional diagnostic tool in routine settings. PCR assays have been developed into user-friendly formats for field diagnostics and are near-point-of-collection. Because of the COVID-19 pandemic in India, these are being used rampantly across the country. The facilities created for COVID-19 diagnosis can easily be co-opted and harnessed for malaria diagnosis to augment surveillance by the inclusion of molecular techniques like PCR in the routine national malaria control program.
Compared to 2017, India achieved a significant reduction in malaria cases in 2020. Madhya Pradesh (MP) is a tribal dominated state of India with history of high malaria burden in some districts. ...District Mandla of MP state showed a considerable decline in malaria cases between 2000 and 2013, except in 2007. Subsequently, a resurgence of malaria cases was observed during 2014 and 2015. The Malaria Elimination Demonstration Project (MEDP) was launched in 2017 in Mandla with the goal to achieve zero indigenous malaria cases. This project used: (1) active surveillance and case management using T4 (Track fever, Test fever, Treat patient, and Track patient); (2) vector control using indoor residual sprays and long-lasting insecticidal nets; (3) information education communication and behaviour change communication; and (4) regular monitoring and evaluation with an emphasis on operational and management accountability. This study has investigated malaria prevalence trends from 2008 to 2020, and has predicted trends for the next 5 years for Mandla and its bordering districts.
The malaria prevalence data of the district Mandla for the period of January 2008 to August 2017 was obtained from District Malaria Office (DMO) Mandla and data for the period of September 2017 to December 2020 was taken from MEDP data repository. Further, the malaria prevalence data for the period of January 2008 to December 2020 was collected from DMOs of the neighbouring districts of Mandla. A univariate time series and forecast analysis was performed using seasonal autoregressive integrated moving average model.
Malaria prevalence in Mandla showed a sharp decline - 87% (95% CI - 90%, - 84%) from 2017 to 2020. The malaria forecast for Mandla predicts zero cases in the next 5 years (2021-2025), provided current interventions are sustained. By contrast, the model has forecasted a risk of resurgence of malaria in other districts in MP (Balaghat, Dindori, Jabalpur, Seoni, and Kawardha) that were not the part of MEDP.
The interventions deployed as part of MEDP have resulted in a sustainable zero indigenous malaria cases in Mandla. Use of similar strategies in neighbouring and other malaria-endemic districts in India could achieve similar results. However, without adding extra cost to the existing intervention, sincere efforts are needed to sustain these interventions and their impact using accountability framework, data transparency, and programme ownership from state to district level.
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The genetic diversity in Plasmodium falciparum antigens is a major hurdle in developing an effective malaria vaccine. Protective efficacy of the vaccine is dependent on the polymorphic alleles of the ...vaccine candidate antigens. Therefore, we investigated the genetic diversity of the potential vaccine candidate antigens i.e. msp-1, msp-2, glurp, csp and pfs25 from field isolates of P.falciparum and determined the natural immune response against the synthetic peptide of these antigens. Genotyping was performed using Sanger method and size of alleles, multiplicity of infection, heterogeneity and recombination rate were analyzed. Asexual stage antigens were highly polymorphic with 55 and 50 unique alleles in msp-1 and msp-2 genes, respectively. The MOI for msp-1 and msp-2 were 1.67 and 1.28 respectively. A total 59 genotype was found in glurp gene with 8 types of amino acid repeats in the conserved part of RII repeat region. The number of NANP repeats from 40 to 44 was found among 55% samples in csp gene while pfs25 was found almost conserved with only two amino acid substitution site. The level of genetic diversity in the present study population was very similar to that from Asian countries. A higher IgG response was found in the B-cell epitopes of msp-1 and csp antigens and higher level of antibodies against csp B-cell epitope and glurp antigen were recorded with increasing age groups. Significantly, higher positive responses were observed in the csp antigen among the samples with ≥42 NANP repeats. The present finding showed extensive diversity in the asexual stage antigens.
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Despite the progress made in this decade towards malaria elimination, it remains a significant public health concern in India and many other countries in South Asia and Asia Pacific region. ...Understanding the historical trends of malaria incidence in relation to various commodity and policy interventions and identifying the factors associated with its occurrence can inform future intervention strategies for malaria elimination goals.
This study analysed historical malaria cases in India from 1990 to 2022 to assess the annual trends and the impact of key anti-malarial interventions on malaria incidence. Factors associated with malaria incidence were identified using univariate and multivariate linear regression analyses. Generalized linear, smoothing, autoregressive integrated moving averages (ARIMA) and Holt's models were used to forecast malaria cases from 2023 to 2030.
The reported annual malaria cases in India during 1990-2000 were 2.38 million, which dropped to 0.73 million cases annually during 2011-2022. The overall reduction from 1990 (2,018,783) to 2022 (176,522) was 91%. The key interventions of the Enhanced Malaria Control Project (EMCP), Intensified Malaria Control Project (IMCP), use of bivalent rapid diagnostic tests (RDT-Pf/Pv), artemisinin-based combination therapy (ACT), and involvement of the Accredited Social Health Activists (ASHAs) as front-line workers were found to result in the decline of malaria significantly. The ARIMA and Holt's models projected a continued decline in cases with the potential for reaching zero indigenous cases by 2027-2028. Important factors influencing malaria incidence included tribal population density, literacy rate, health infrastructure, and forested and hard-to-reach areas.
Studies aimed at assessing the impact of major commodity and policy interventions on the incidence of disease and studies of disease forecasting will inform programmes and policymakers of steps needed during the last mile phase to achieve malaria elimination. It is proposed that these time series and disease forecasting studies should be performed periodically using granular (monthly) and meteorological data to validate predictions of prior studies and suggest any changes needed for elimination efforts at national and sub-national levels.
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Malaria is known as a disease of poverty because of its dominance in poverty-stricken areas. Madhya Pradesh state in central India is one of the most vulnerable states for malaria morbidity and ...mortality. Socio-economic, environmental and demographic factors present challenges in malaria control and elimination. As part of the Malaria Elimination Demonstration Project in the tribal district of Mandla in Madhya Pradesh, this study was undertaken to assess the role of different social-economic factors contributing to malaria incidence.
The study was conducted in the 1233 villages of district Mandla, where 87% population resides in rural areas. The data was collected using the android based mobile application-SOCH for a period of 2 years (September 2017 to August 2019). A wealth index was computed along with analysis of the socio-economic characteristics of houses with malaria cases. Variables with significant variation in malaria cases were used in logistic regression.
More than 70% of houses in Mandla are Kuccha (made of thatched roof or mud), 20% do not have any toilet facilities, and only 11% had an annual income of more than 50,000 INR, which converts to about $700 per year. Households with younger heads, male heads, more number of family members were more likely to have malaria cases. Kuccha construction, improper water supply, low household income houses were also more likely to have a malaria case and the odds doubled in houses with no toilet facilities.
Based on the results of the study, it has been found that there is an association between the odds of having malaria cases and different household variables such as age, gender, number of members, number of rooms, caste, type of house, toilet facilities, water supply, cattle sheds, agricultural land, income, and vector control interventions. Therefore, a better understanding of the association of various risk factors that influence the incidence of malaria is required to design and/or deploy effective policies and strategies for malaria elimination. The results of this study suggest that appropriate economic and environmental interventions even in low-income and poverty-stricken tribal areas could have huge impact on the success of the national malaria elimination goals.
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Many malaria endemic countries are heading towards malaria elimination through the use of case management and vector control strategies, which employ surveillance, improving access to early ...diagnosis, prompt treatment., and integrated vector control measures. There is a consensus that elimination of malaria is feasible when rapid detection and prompt treatment is combined with mosquito-human contact interruption in an efficient and sustainable manner at community levels. This paper describes results of an integrated case management and vector control strategy for reducing malaria cases in 1233 villages over 3 years in district Mandla, Madhya Pradesh, India.
The project enrolled the entire population (1,143,126) of Mandla district for fever surveillance followed by testing of febrile cases and treatment of positive subjects using T4 strategy, which is Track (by fever), Test (by RDTs), Treat (by ACT) and Track (for completion of treatment). In addition to the active and passive surveillance for detection and treatment of febrile cases, the project conducted mass screening and treatment to clear the asymptomatic reservoirs of infection. Febrile cases were also tested in the out-patient department of the District Hospital from June 2018 to September, 2018 and in a community-based medical camp from November 7 to 14, 2019. The project also used vector control measures for interrupting human-mosquito contact, and information, education and communication (IEC) campaigns to increase demand for malaria services at community level.
This project has revealed about 91% reduction of indigenous cases of malaria during the period from June 2017 to May 2020, through case management and vector control strategies. A total 357,143 febrile cases were screened, out of which 0.19% were found positive for the presence of malaria parasites, with Plasmodium falciparum and Plasmodium vivax ratio of 62:38. The prevalence of malaria was higher in individuals > 15 years of age (69% cases). The positivity rate was 0.33% in 2017-18, 0.13% in 2018-19, and 0.06% in 2019-20. In all of the 3 years of the project, the peak transmission correlated with rains. Mass screening revealed 0.18% positivity in Sep-Oct 2018, followed by 0.06% in June 2019, and 0.03% in December 2019, and these were mostly asymptomatic cases in the community. Imported cases into the district were mostly contributed by the distant state of Telangana (51.13%). Fever patients tested for malaria parasites in the District Hospital and medical camp revealed zero cases.
Using the current intervention and prevention tools along with optimum utilization of human resources, a 91% reduction in indigenous cases of malaria was seen in the district in 3 years. The reduction was similar in the three high prevalence blocks of the district. These results reveal that malaria elimination is achievable in India within a stipulated time frame. The reduction of malaria at the community level was further validated when zero malaria cases were diagnosed during hospital and community-based studies in Mandla. Prompt detection and treatment of imported/migratory cases may have prevented outbreaks in the district. This project has demonstrated that field programmes backed by adequate technical, management, operational, and financial controls with robust monitoring are needed for achieving malaria elimination.
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About the Authors: Sri Krishna Affiliation: Department of Molecular Parasitology, National Institute for Research in Tribal Health (NIRTH), Jabalpur, Madhya Pradesh, India Sneha Bhandari Affiliation: ...Department of Molecular Parasitology, National Institute for Research in Tribal Health (NIRTH), Jabalpur, Madhya Pradesh, India Praveen K. Bharti Affiliation: Department of Molecular Parasitology, National Institute for Research in Tribal Health (NIRTH), Jabalpur, Madhya Pradesh, India Sanjay Basak Affiliation: Department of Health, District Malaria Office, Government of Chhattisgarh, Bastar, Chhattisgarh, India Neeru Singh * E-mail: neeru.singh@gmail.com Affiliation: Department of Molecular Parasitology, National Institute for Research in Tribal Health (NIRTH), Jabalpur, Madhya Pradesh, India ORCID http://orcid.org/0000-0001-5891-1577Citation: Krishna S, Bhandari S, Bharti PK, Basak S, Singh N (2017) A rare case of quadruple malaria infection from the highly malaria-endemic area of Bastar, Chhattisgarh, India. Map of India (A) showing Madhya Pradesh National Institute for Research in Tribal Health (NIRTH) and Chhattisgarh (B) and Darbha community health centre, Bastar district (C). https://doi.org/10.1371/journal.pntd.0005558.g001 Diagnosis A malaria clinic of National Institute for Research in Tribal Health (NIRTH) of the Indian Council of Medical Research (ICMR) was established at Darbha CHC of Bastar district in 2015 to provide prompt diagnosis and treatment of malaria in difficult and conflict-affected areas, as the villages in Darbha CHC are inaccessible and this region has been under continuous attack by the Maoists. Abbreviations: NC, negative control; PC, positive control. https://doi.org/10.1371/journal.pntd.0005558.g002 Download: * PPT PowerPoint slide * PNG larger image * TIFF original image Fig 3. (a) Gel image showing amplification of Pf-dhps, Pv-dhps, and Po-rbp. 1: 100 base pair (bp) ladder; Pf-dhps (2: NC, 3: PC, 4: sample); Pv-dhps (5: NC, 6: PC, 7: sample); Po-rbp (8: NC, 9: PC, 10: sample) (b) Gel image showing amplification of Pm-msp1 gene from genomic DNA sample. 1: 100 bp ladder; 2-5: samples. Abbreviations: NC, negative control; PC, positive control. https://doi.org/10.1371/journal.pntd.0005558.g003 Key learning points * A case of mixed infection of 4 Plasmodium species was found, which is very rare, and this is the first report of such a case in India. * Microscopy is the gold standard for malaria diagnosis, but in case of mixed infection, 1 or more species may be missed, especially in case of low parasitemia. * The study showed high proportion of mixed infection by molecular methods. * High proportion of mixed infections signifies the need of adequate training of health staff involved in malaria diagnosis, which is prerequisite for malaria elimination.
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Abstract
Background
Changes in social, belief, and behavioural practices are essential for the success of any public health delivery programme. In the planning stages of the Malaria Elimination ...Demonstration Project (MEDP), priority was given to communication with a goal to develop capacity of health workers and to improve the knowledge, attitude and practices (KAP) of the people of Mandla. This paper describes the level of community knowledge on malaria, including its prevention, diagnosis, treatment-seeking behaviour, and the level of satisfaction with the services provided by the project.
Methods
A cross sectional survey was undertaken in 1233 villages of Mandla to study the KAP and self-assessed improvement in knowledge and satisfaction level of the community. The goal of the study was to understand whether there is need for strengthening communication strategy of MEDP for better impact. The survey was conducted amongst the head/eligible members of the 733 households located in the nine blocks of the district using clustered random sampling.
Results
Though four-fifths of the respondents were able to correlate the transmission of malaria with mosquitoes, misconceptions existed among them. The types of malaria were not known to everyone. Only 39% were aware of the Indoor Residual Spray (IRS) and 41% understood the value of Long-Lasting Insecticidal Nets (LLIN). Around 71% of subjects surveyed were aware of the proper diagnostic tests for malaria. A total of 87% of the respondents knew about the MEDP staff working in their respective villages.
Conclusion
The study reported gaps in knowledge on malaria at community level. The self-assessment of the community revealed that the communication strategy established by MEDP in Mandla district has been useful to them as they are becoming better informed about the prevention and treatment aspects of disease. The lessons learned as revealed in the KAP survey will improve malaria elimination outcomes in a timely manner.
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In 8 malaria-endemic states in India, mixed Plasmodium spp. infections were detected by PCR in 17.4% (265/1,521) of blood samples that microscopy had shown to contain only P. falciparum. The quality ...of microscopy must be improved because use of PCR for detection of malaria parasites is limited in rural areas.
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The Western Ghats (WG) mountain chain in peninsular India is a global biodiversity hotspot, one in which patterns of phylogenetic diversity and endemism remain to be documented across taxa. We used a ...well‐characterized community of ancient soil predatory arthropods from the WG to understand diversity gradients, identify hotspots of endemism and conservation importance, and highlight poorly studied areas with unique biodiversity. We compiled an occurrence dataset for 19 species of scolopendrid centipedes, which was used to predict areas of habitat suitability using bioclimatic and geomorphological variables in Maxent. We used predicted distributions and a time‐calibrated species phylogeny to calculate taxonomic and phylogenetic indices of diversity, endemism, and turnover. We observed a decreasing latitudinal gradient in taxonomic and phylogenetic diversity in the WG, which supports expectations from the latitudinal diversity gradient. The southern WG had the highest phylogenetic diversity and endemism, and was represented by lineages with long branch lengths as observed from relative phylogenetic diversity/endemism. These results indicate the persistence of lineages over evolutionary time in the southern WG and are consistent with predictions from the southern WG refuge hypothesis. The northern WG, despite having low phylogenetic diversity, had high values of phylogenetic endemism represented by distinct lineages as inferred from relative phylogenetic endemism. The distinct endemic lineages in this subregion might be adapted to life in lateritic plateaus characterized by poor soil conditions and high seasonality. Sites across an important biogeographic break, the Palghat Gap, broadly grouped separately in comparisons of species turnover along the WG. The southern WG and Nilgiris, adjoining the Palghat Gap, harbor unique centipede communities, where the causal role of climate or dispersal barriers in shaping diversity remains to be investigated. Our results highlight the need to use phylogeny and distribution data while assessing diversity and endemism patterns in the WG.
Soil arthropod communities play an important role in the ecosystem, but have been poorly studied in terms of large‐scale patterns of diversity and distribution from a phylogenetic perspective. We studied centipedes, a group of ancient predatory soil arthropods, across the climatic gradient of the Western Ghats, India, a global biodiversity hotspot with a complex geological history, using extensive primary distribution data and a robust phylogeny. Our results reveal a latitudinal gradient in phylogenetic diversity of centipedes along the mountain range, identify unique hotspots of phylogenetic endemism, provide support to the existence of a past rainforest refuge, and indicate structuring of centipede communities across various subregions.
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