To qualify as malaria-free, a country has to go through four phases: control, pre-elimination, elimination and prevention of re-introduction, each with its own set of interventional programmes.
The WHO’s World Malaria Report 2013 lists both India and China as being in the control phase, where the priority is to reduce incidence and mortality of the disease as quickly and cheaply as possible.
India is currently following the Directorate of National Vector Borne Diseases Control Programme’s National Malaria Strategy Plan which aims to reduce the annual incidence to below 1 per 1,000 and the 2010’s mortality figures by at least 50 per cent before 2017.
India’s progress, however, is arguable. According to Founder Director National Institute of Malaria Research Dr. V.P. Sharma, “NVBDCP data shows declining trend of malaria year after year but this data is totally unreliable. Malaria cases may be 40-60 million against about 1 m reported.” He said via email to this correspondent that the status of intervention and elimination in India is static, except for the natural rise and fall of malaria.
While India has made progress, China seems far ahead. From 26,000 cases in 2008, the incidence dropped to 2,716 in 2012. These dramatic figures could be attributed to its elimination programme launched in 2010 and accelerated by its "1-3-7 strategy" which was rolled out in early 2012 and described by scientists from China and America in a paper published in PLoS Medicine earlier this month.
The 1-3-7 strategy demands that every suspected or confirmed case be reported by local healthcare providers to China’s Center for Disease Control and Prevention (CDC) within 24 hours. The case must then be confirmed and its origin classified (locally acquired or imported) in three days. After this, the national expert team has seven days to investigate and evaluate the risk to the local area around this case and react according to how susceptible the area is to malaria.
The backbone of this entire system is real-time reporting, speedy data collation, and a timely feedback loop between the local, provincial and national levels. This is enabled by the CDC’s web-based information system.
The authors state in the paper that the 1-3-7 strategy could be tweaked to suit other elimination settings. For example, they write, in countries like the Solomon Islands where internet and mobile phone coverage is quite poor, a “2-4-7” approach may be more realistic.
Even for China, however, challenges persist. While 1-day reporting is required by law, delaying of confirmation due to logistical limitations in-turn makes it more difficult to retrace the origin. Secondly, travel history alone has often shown to be insufficient to classify the origin correctly. The better method, called genotyping, still has no standardised methodologies and takes longer than three days.
Furthermore, assessing the risk and planning and implementing a response within seven days is daunting, “especially during the transmission season, June and July, when locally transmitted case numbers are highest.”
The authors concede that more refining will help. “Evaluating the cost-effectiveness of the 1-3-7 strategy and other time frame targets may be necessary.” But the simplicity and measurability of 1-3-7-like strategies suggest that they could be employed in other countries.
India seems a long way from reaching China’s level of malaria surveillance. Dr. Sharma said via email that detection and treatment of fever cases within 24hours as recommended by WHO is impossible in India, though the Indian government does seem to be making an attempt through its Accredited Social Health Activists (ASHA).
Keeping in mind the several daunting challenges like adequate staff training, and the rampant unrest and insurgency in India, Dr. Sharma suggested that the time may not have come from a 1-4-7 system in India. “I think the only remedy is accountability and punishment for the non-performers. Any system will fail in the hands of the prevailing system.”