Aligning malaria elimination with climate change

India recorded a step decline in malaria cases from 2015, with an 85% reduction in reported cases. The positive trend is attributed to the successful implementation of the National Framework for Malaria Elimination launched in 2016. There is little room for complacency due to two reasons. First, despite the sharp decline in reported cases, India accounts for 65% of the estimated malaria cases in the Southeast Asia region. Secondly, the World Health Organization (WHO) in its World Malaria Report 2023 sounded the caution that changes in temperature, humidity, and rainfall can influence the behaviour and survival of the malaria-carrying Anopheles mosquito. The global health body has also pressed the alarm bell in the report that extreme weather events, such as heatwaves and flooding, can also directly impact transmission and disease burden. The report cites the example of a catastrophic flood in Pakistan in 2002, which, it says, led to a five-fold increase in malaria cases in the country. Official data shows that India contributed 21.8% of the reported cases in the Southeast Asia region. WHO data shows that between 2000 and 2023, 25 countries were certified as malaria-free. The norm for a country or area to be granted malaria-free certification by the WHO is that the chain of mosquito-borne transmission is interrupted nationwide and results in zero indigenous malaria cases for at least the past three consecutive years. The WHO norm also requires the countries to put in place programmes for preventing the re-establishment of transmission. India adopting timely and effective flood management programmes is crucial to prevent extreme weather events precipitating the crisis, which threatens to erase the significant progress made in malaria reduction. There has been a significant decline in mortality due to malaria, from 1151 deaths in 1995 to 83 in 2022. The National Vector Borne Diseases Control Programme (NVBDCP) for prevention and control of vector-borne diseases, including malaria, has been effective in reducing transmission, morbidity, and mortality in India. Increasing malaria testing for better surveillance plays a critical role in identifying the population at risk. Currently, passive surveillance is carried out at healthcare institutes when patients visit them for treatment. The NVBDCP Guidelines state that ASHA, the community health volunteers, are to be involved in the diagnosis and treatment of malaria cases on a day-to-day basis. She is required to screen fever cases suspected of suffering from malaria using Rapid Diagnostic Test (RDT) kits and blood slides and administer anti-malarial treatment to positive cases. The “Malaria Elimination Programme Review, India 2022,” published by the WHO Country Office for India, stated that while the progress in reducing the malaria burden in India is highly commendable, it is fragile, and the disease remains a public health concern, particularly in hard-to-reach areas. The report highlights that “surveillance is the core intervention for malaria elimination, and monitoring and response are extremely important to ensure effective programme implementation, identify gaps, and address them on time.” The WHO review reveals that surveillance and reporting challenges exist in tribal, hard-to-reach, jhum cultivation, and urban areas and underscores the importance of addressing these challenges, which are of high importance to the northeastern region. The remoteness of villages in far-flung areas in hill districts in Assam and hill states in the region makes it difficult for ASHA workers to screen fever cases for suspected malaria cases on a day-to-day basis, as stipulated in the NVBDCP norm. Another critical gap identified in the report is quality control in the procurement of RDTs. “RDTs procured through decentralised procurement by states do not essentially conform to the technical specifications of NCVBDC, and deviations from procurement norms often result in the use of RDTs having low sensitivity and specificity as well as deterioration due to extreme weather conditions due to unknown heat stability thresholds,” it said. The report stressed the need for ensuring the capacities of all medical officers, health workers, and ASHAs for malaria diagnosis and treatment through regular and organised training, retraining, and assessments. India has set the goal of eliminating malaria by 2030 through the adoption of the National Framework for Malaria Elimination in India (2016–2030). The country must achieve zero indigenous malaria reporting in 2027 and sustain it for three consecutive years to be certified by the WHO as malaria-free by 2030. The gains made so far need to be consolidated through intensified surveillance and adequate treatment at all levels of healthcare over the next three years. The identified difficult areas will require more focus through increased fund allocation for RDTs, slides, laboratories, and the engagement of more trained health workers, doctors, and paramedics. The WHO review of the country’s malaria elimination programme has listed the challenges that continue to pose stumbling blocks to achieving the goal for policymakers and executives to take note of and take corrective measures. Aligning the malaria elimination programme with climate change mitigation strategies is crucial for India to meet the 2030 deadline.