The World Malaria Report 2021 of the World Health Organization (WHO) sees India as the only high burden country to have been able to sustain a reduction in the malaria disease burden. Yet, it also notes that India accounted for about 82 per cent of all malaria deaths in the South-East Asian region. The pandemic months have only added to the woes and now with new technologies and tools being discussed, what options India has and challenges it faces while on its goal to eradicate malaria by 2030, if not earlier.
WHO’s chief scientist Dr Soumya Swaminathan took time out from her busy schedule to speak to the Indian Express Group’s E Kumar Sharma.
Here are the excerpts:
Q. Dr Soumya, thank you so much for your time. As you know, the theme for World Malaria Day 2022 is “harness innovation to reduce the malaria disease burden and save lives,” what is your view on the newer technologies being deployed to help in malaria eradication?
Swaminathan: It’s important to recognise that, although some countries have been successful in stamping out malaria, we are still a very long way from malaria eradication, which refers to the elimination of malaria in all parts of the world. In 2020 alone, there were an estimated 241 million malaria cases worldwide and 6,27,000 deaths worldwide. Sub-Saharan Africa continues to carry the heaviest burden of the disease (95 per cent of all malaria cases and 96 per cent of all deaths). Thankfully, there are a number of exciting technologies in the R&D pipeline. These include, for example, new vector control innovations such as new types of insecticide-treated nets, spatial mosquito repellents, gene-drive approaches and sugar baits designed to attract and kill Anopheles mosquitoes.
Then there are the new antimalarial medicines. The WHO welcomes, for example, the recent approval by the Australian Therapeutic Goods Administration of dispersible tablets of single-dose tafenoquine for the prevention of P. vivax malaria among children. As a single dose, tafenoquine is expected to support patient adherence to treatment. The current standard of care requires a 7- or 14-day course of medication.
Also, the new malaria vaccines. We already have a safe and effective vaccine (RTS, S/ASOI) that is currently being deployed in three African countries. In addition, the WHO welcomes progress in the development of R21/Matrix-M and other malaria vaccine candidates in early clinical development; the successful completion of clinical trials for these vaccines will be important to assess their safety and efficacy profiles. The WHO also welcomes the news from BioNTech, manufacturer of the Pfizer-BioNTech Covid-19 vaccine, that it aims to develop a malaria vaccine using mRNA technology.
Q. Dr Soumya, what about leveraging the option of genetic modification in mosquitoes. Is this an option India should be opting for?
Swaminathan: For now, gene drive is being tested only in large-scale laboratory experiments. Field trials are still several years away. Whether or not the WHO will recommend genetically modified mosquitoes as an intervention for malaria vector control will depend on the outcome of these trials. Until that point, India should not consider this as a viable option but instead focus on deploying those interventions recommended in the WHO malaria guidelines.
Q. Many experts have also been recommending reliance on Wolbachia bacteria. How significant is the scope for this and should this be an option India should seriously pursue?
Swaminathan: Introduction of Wolbachia, a naturally occurring obligate intracellular bacteria, into a mosquito population has so far only been assessed by the WHO as an intervention against Aedes mosquitoes. It is not an intervention that is currently available for the control of the anopheline vector of malaria.
Q. What would you say are the three key steps India should be taking as it pushes for greater malaria control and, ultimately, elimination?
Swaminathan: The National Centre for Vector Borne Diseases, Ministry of Health and Family Welfare, and WHO are currently conducting this week and next week a review of the malaria programme. The findings and recommendations will inform the development of the national malaria strategic plan for the period 2023-2027. I do not want to pre-empt what the experts would recommend, but from my perspective efforts at malaria elimination in India will be accelerated by strengthening human resources. The vacant key positions with managerial and technical functions at central, state and district levels, and those responsible for delivery of services at the peripheral level should be filled. Training in malaria elimination should be scaled-up and the necessary enabling environment should be put in place for staff to effectively perform their tasks.
B, revamping the surveillance system to make it a core intervention for malaria elimination. The country should harness its strength in telecommunications technology and human resources on the ground (multi-purpose workers and Accredited Social Health Activists, or ASHAs) to have an effective surveillance and response system to eliminate malaria. C, investing in research and development of new tools and approaches to deliver interventions to high risks populations in hard-to-reach areas. This will benefit not only India but also other malaria-endemic countries.
Q. What is your view on the challenges faced on account of migrant workers?
Swaminathan: Migrant workers, including those who migrate from malaria-endemic villages to urban areas, are among the high-risk groups and drivers of malaria transmission. This is one reason why urban malaria is still a problem in India. In some cases, migrant workers from areas without malaria contract the disease in places where they go for work, such as mining and agroforestry sites, where malaria transmission is still high. A good surveillance and response system and innovative ways to deliver interventions for migrant workers are needed.
Q. What about combating drug and insecticide-resistant malaria? What measures would you suggest on this?
Swaminathan: Resistance of malaria parasites to medicines and resistance of malaria vectors to insecticides are among the key challenges to malaria elimination, not only in India and in many countries around the world.
Some suggestions to combat these challenges will be: As for drug resistance, periodically review and update the malaria treatment policy based on evidence. The national malaria programme and research institutes in India, with support from the WHO, are continuously monitoring malaria drug resistance, and there is a mechanism in the country to periodically review the data and update the malaria treatment policy. This should be sustained.
Some of the challenges include inappropriate use of malaria medicines in the private formal and informal health sectors, poor adherence to treatment by patients and poor adherence of some medical staff to the treatment guidelines. It will help to strengthen the implementation of regulations that would ensure the quality of malaria medicines and prohibit the sale of medicines that are not recommended for use in the country.
Research and development of new malaria medicines or test combinations of current malaria drugs should be intensified.
As for insecticide resistance, developing and implementing an insecticide resistance management plan based on evidence. To mitigate the impact of insecticide resistance, the country should regularly monitor the susceptibility of its key mosquito vectors to the insecticides that are in current use and those that are planned to be used in the near future. Depending on these data, interventions should be chosen that use effective insecticides. It is also recommended that the country tries to minimise selection pressure for resistance, for example by not using pyrethroid insecticides for indoor residual spraying (IRS) and deploying insecticide-treated nets in the same area, as these are also all treated with pyrethroids. Apart from these, invest in developing public health entomologists and invest in research to develop a new class of insecticides and other vector control tools.
Q. Dr Soumya, some have been arguing that the malaria problem in India is today really in certain pockets and tribal locations. What do you see as the barriers and the strategies that could be deployed to overcome these?
Swaminathan: India has made enormous progress in reducing its malaria burden. However, pockets of high transmission exist mainly among tribal communities in areas that are very hard to reach.
The government has trained and supported ASHAs among the tribal communities to deliver services. This should be further expanded and improved through regular supportive supervision and supply of rapid diagnostic tests and medicines. Innovative approaches of health education based on social science research should be carried out. The Tribal Health Department and other sectors, such as education and forestry departments, should be engaged. In the long term, health centres should be built closer to remote tribal communities, and (as far as possible) the staff should be from those communities to avoid socio-cultural barriers.
Pockets of high transmission are also present in some forest reserve areas, including those at international borders, where settlers are considered illegal and therefore no services are provided. I believe it is time to revisit government policies on this issue and—in the context of sustainable development, health equity and malaria elimination— health services or at least malaria interventions should be provided. The provision of services could be through NGOs or civil society if the programme cannot deliver these services.
Q. In the Indian context, since the focus is on eradication, there is also the component of cross-border movement. Do you think it is time to actively move on a cross-border health framework?
Swaminathan: Firstly, let me clarify that eradication means all countries around the world have eliminated malaria so there is no more source of human malaria. The current aim in India and in all countries in WHO South-East Asia Region is to eliminate malaria by 2030, as per the Ministerial Declaration on Malaria Elimination in South East Asia Region in November 2018. By 2030, several countries mainly in Africa will still have malaria so the risk of re-establishment of malaria in India would be high.
Cross-border collaboration on malaria between India, Bhutan, Nepal, and Bangladesh exists and should be formalised at the highest level possible. And I believe that a broader framework that addresses common health problems and not just malaria should be put in place.
Q. The National Framework for Malaria Elimination in India (2016-2030) has been an important roadmap in the country’s drive to end malaria. However, integrated programmes that target overall disease control can be highly effective in the long term. Would India benefit from implementing a triple elimination plan that brings malaria, lymphatic filariasis, and visceral leishmaniasis under its ambit? How so?
Swaminathan: The programmes to eliminate malaria, lymphatic filariasis, and visceral leishmaniasis are under the same office – the National Vector Borne Disease Control Programme. So, there is value in implementing a “triple elimination plan” in states and districts where these three diseases co-exist. While there are specific activities for each disease, some could be integrated such as annual review and planning meetings, training, supervision and monitoring. The surveillance platform could be integrated, too.
Q. Covid-19 related disruptions affected malaria control efforts around the world. Globally, the pandemic has undoubtedly brought about major changes and adaptations to health systems – enhanced surveillance and screening, data sharing, vaccine delivery and doorstep service delivery are just some of these initiatives. What can we learn from the global Covid response that can be applied to India’s strategy for improved malaria control?
Swaminathan: Disruptions in malaria diagnosis and treatment occurred in India during the Covid-19 pandemic; a WHO pulse survey, for example, showed partial disruptions of between 5 per cent to 50 per cent in 2020, and there was over 30 per cent fewer malaria diagnostic tests in 2020 compared to the year before the pandemic. The data for 2021 is not yet available, but disruptions could be higher, especially during the period when the pandemic peaked and caused devastation in the country. However, India’s malaria burden continued to decline between 2019 and 2020, even though the rate of reduction was slower compared to pre-pandemic years.
There are several lessons from the pandemic response that I believe would be applicable to India. These include: First, the health system, mainly surveillance, epidemic preparedness and response, supply chain management, and good coordination between central and states and between states and districts is essential. Second, a whole-of-society or multi-sectoral response should be adopted.
Third, a good communications strategy for each target audience, such as communities at risk and traditional leaders, health workers, private practitioners, private corporate sector, elected officials, etc. Fourth, re-purposing health workers to deliver malaria interventions when needed, such as to control malaria and mass distribution of insecticide-treated mosquito nets.
Q. Research has indicated the fact that climate change will increase malaria transmission in endemic areas. Even in regions that have been malaria-free so far, an increase in temperature, rainfall, and humidity could cause a proliferation of malaria-carrying mosquitoes. What, in your opinion, is the impact of climate change on control and elimination strategies?
Swaminathan: The basic WHO position is that climate change is likely to increase rather than decrease the risk of malaria transmission. However, to date, there is no evidence that climate change has affected malaria control and elimination strategies. The 2020 report of the Strategy Advisory Group on malaria eradication has looked at this in detail and does provide useful information, especially with respect to malaria transmission and the vulnerability of populations to malaria.