Contribution of Travelers to Plasmodium Vivax Malaria in South West Delhi, India: Cross-Sectional Survey

Abstract

Background: India is committed to malaria elimination by the year 2030. According to the classification of malaria endemicity, the National Capital Territory of Delhi falls under category 1, with an annual parasite incidence of <1, and was targeted for elimination by 2022. Among others, population movement across states is one of the key challenges for malaria control, as it can result in imported malaria, thus introducing local transmission in an area nearing elimination.

Objective: This descriptive study attempts to assess the contribution of such imported Plasmodium vivax cases to the malaria burden in South West Delhi (SWD).

Methods: A cross-sectional study was carried out at the fever clinic of the Indian Council of Medical Research-National Institute of Malaria Research in SWD from January 2017 to December 2019. Demographic and travel history data were recorded for all P vivax confirmed malaria cases diagnosed at the fever clinic. Vector and fever surveys along with reactive case detection were conducted in SWD and Bulandshahr district of Uttar Pradesh, 1 of the 6 geographical sources for a high number of imported malaria cases.

Results: A total of 355 P vivax malaria cases were reported during the study period. The proportion of imported cases was 63% (n=222). Of these, 96% (n=213) of cases were from Uttar Pradesh. The distribution of malaria cases revealed that imported cases were significantly associated with travel during the transmission season compared with that in the nontransmission season. Entomological and fever surveys and reactive case detection carried out in areas visited by imported P vivax malaria cases showed the presence of adults and larvae of Anopheles species and P vivax parasitemia.

Conclusions: Population movement is a key challenge for malaria elimination. Although additional P vivax infections and vector mosquitoes were detected at places visited by the imported malaria cases, the inability to detect the parasite in mosquitoes and the possibility of relapses associated with P vivax limit the significance of malaria associated with the travel. However, there remains a need to address migration malaria to prevent the introduction and re-establishment of malaria in areas with very low or 0 indigenous cases.

Keywords: India; Plasmodium vivax; elimination; imported malaria; malaria; population movement; transmission.

Figure 1.. Travel history among 355 patients with Plasmodium vivax malaria. Based on the epidemiologically relevant travel history, cases associated with travel were categorized into “imported” (222; shown in red font) and indigenous (133; gold colored font) cases. The geographical distribution (states) of imported cases is also mentioned.

Figure 2.. Areas traveled to by Plasmodium vivax malaria imported cases. The areas (states and union territories of India) are shown in blue (Punjab, Chandigarh, Haryana, Uttarakhand, UP, MP, and Rajasthan) whereas Delhi (study site) is shown in green. The zoomed-in image of the map in the inset shows further administrative breakdown of these 7 states and union territories (as districts) in blue. The districts within these 7 states and union territories, which are associated with the travel history of imported cases, are colored based on the number of imported cases contributed by each district: light orange (1‐5 cases); dark orange (5‐15 cases); darker orange (15‐25 cases), and red (>25 cases). It is evident that UP has 3 dark orange districts: Hathras (10 cases), Mainpuri (12 cases), and Bareilly (15 cases); 1 darker orange district: Bulandshahr (25 cases); and 2 red districts: Aligarh (37 cases) and Badaun (47 cases). MP: Madhya Pradesh; UP: Uttar Pradesh.

Figure 3.. Plasmodium vivax malaria cases reported in Delhi (2017‐2019). The figure shows the number of P vivax cases, indigenous (blue) and imported (imported), as reported each month and each year during the study period (January 2017 to December 2019) at the Indian Council of Medical Research-National Institute of Malaria Research fever clinic. The cumulative month-wise data from 2017 to 2019 are shown in the inset. The yellow semitransparent rectangles show the transmission season.