Battling malaria iceberg incorporating strategic reforms in achieving Millennium Development Goals & malaria elimination in India

Abstract

Malaria control in India has occupied high priority in health sector consuming major resources of the Central and State governments. Several new initiatives were launched from time to time supported by foreign aids but malaria situation has remained static and worsened in years of good rainfall. At times malaria relented temporarily but returned with vengeance at the local, regional and national level, becoming more resilient by acquiring resistance in the vectors and the parasites. National developments to improve the economy, without health impact assessment, have had adverse consequences by providing enormous breeding grounds for the vectors that have become refractory to interventions. As a result, malaria prospers and its control is in dilemma, as finding additional resources is becoming difficult with the ongoing financial crisis. Endemic countries must contribute to make up the needed resources, if malaria is to be contained. Malaria control requires long term planning, one that will reduce receptivity and vulnerability, and uninterrupted financial support for sustained interventions. While this seems to be a far cry, the environment is becoming more receptive for vectors, and epidemics visit the country diverting major resources in their containment, e.g. malaria, dengue and dengue haemorrhagic fevers, and Chikungunya virus infection. In the last six decades malaria has taken deep roots and diversified into various ecotypes, the control of these ecotypes requires local knowledge about the vectors and the parasites. In this review we outline the historical account of malaria and methods of control that have lifted the national economy in many countries. While battles against malaria should continue at the local level, there is a need for large scale environmental improvement. Global Fund for AIDS, Tuberculosis and Malaria has provided huge funds for malaria control worldwide touching US$ 2 billion in 2011. Unfortunately it is likely to decline to US$ 1.5 billion in the coming years against the annual requirement of US$ 5 billion. While appreciating the foreign assistance, we wish to highlight the fact that unless we have internal strength of resources and manpower, sustained battles against malaria may face serious problems in achieving the final goal of malaria elimination.

Fig. 1

Rising trend of malaria cases [total and Pf (Plasmodium falciparum)] cases in towns under the Urban Malaria Scheme (Source: NVBDCP, India.

Fig. 2

Showing yearly P. falciparum cases for the duration of P. falciparum Containment Programme (1977 to 1988). There was a rising trend of Pf cases (see the trend line) and the spread of chloroquine resistance in P. falciparum(Source: NVBDCP, India).

Fig. 3

Malaria cases in India (1970-2011) as recorded by the NVBDCP. Cases started rising in 1970, peaking in 1976 to 6.45 million cases and thereafter following the implementation of the Modified Plan of Operation in 1977, malaria cases declined but mainly P. vivax malaria due to its sensitivity to chloroquine. P. falciparum % was about 10 in 1977 but due to fall in vivax malaria, this % has risen to about 50 and the parasite has become mono- to multi-drug resistant (Source: Ref. 28 reproduced with permission).

Fig. 4

District-wise annual parasite incidence (API), slide positivity rate (SPR) and Pf% in Odisha State in 2010 (Source: NVBDCP, India).

Fig. 5

Showing epidemiological data (API.SPR and Pf%) of Madhya Pradesh in 2010. (Source: NVBDCP, India).

Fig. 6

Chloroquine resistant P. falciparum originated from Thai Cambodia border in South East Asia region and spread worldwide from at least six known origins.

Fig. 7

Distribution of major malaria vectors of India (Courtesy: NIMR, New Delhi) (Available from: http://www.mrcindia.org/contact.htm, assessed on May 13, 2012).

Fig. 8

District-wise data of malaria API, SPR and Pf% of Jharkhand for 2010 (Source: NVBDCP, India).

Fig. 9

District-wise data of malaria API, SPR and Pf% of Chhattisgarh for 2010 (Source: NVBDCP, India).