Mrigendra Pal Singh

Background: Conventional passive malaria surveillance may miss infections in remote, forested. Evidence on mass screening and treatment (MSaT) in forested-tribal areas of India remains limited.,Methods: Three MSaT rounds were conducted in Birsa, Balaghat, Madhya Pradesh, from November 2015 to October 2016. Residents were screened irrespective of symptoms using rapid diagnostic tests (RDTs) and treated according to national guidelines. RDT positivity was analysed using age- and sex-adjusted logistic regression. Annual malaria data from 12 CHCs (2010–2024) were analysed using controlled interrupted time-series Poisson pseudo-maximum likelihood (PPML-CITS) models with CHC/year fixed effects, population offset, and environmental covariates.,Results: RDT positivity declined from 18.99% in round 1 to 8.80% and 2.21% in rounds 2 and 3, respectively. Adjusted odds were lower in round 2 (aOR 0.57, 95% CI 0.55–0.60) and round 3 (aOR 0.32, 95% CI 0.30–0.33). By round 3, 83% of villages had positivity below 5%. PPML-CITS estimated an 18.4% annual reduction in malaria incidence (IRR 0.82, 95% CI 0.79–0.85). However, placebo and synthetic-control analyses provided inconsistent counterfactual evidence.,Conclusions: Repeated MSaT was associated with substantial reductions in malaria and village-level hotspots. It may complement existing malaria interventions in hard-to-reach hotspots, although long-term causal effects remain uncertain.

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 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.

Background. The major malaria vector in India is Anopheles culicifacies, and indoor residual spraying (IRS) and distribution of long-lasting insecticidal nets (LLINs) are the two main vector control measures in the national program. This species has shown resistance to dichlorodiphenyltrichloroethane (DDT), malathion, and synthetic pyrethroids (SP). The study was carried out in three districts, that is, Dindori of Madhya Pradesh and Kanker and Bastar from Chhattisgarh state to know the range of resistance phenotypes and to assess the strength of resistance in An. culicifacies. Methods. An. culicifacies collected from the field was tested to determine the susceptibility status to the discriminating concentration (DC) of different insecticides, that is, DDT 4.0, malathion 5.0, alphacypermethrin 0.05, and deltamethrin 0.05 following the World Health Organization (WHO) procedures. Further, intensity bioassays of the resistant An. culicifacies to 1X discriminating concentration (DC) of alphacypermethrin and deltamethrin were conducted by exposing 5X and 10X concentrations of 1X DC. Results are interpreted as per the WHO criterion. Results. The overall result of susceptibility status in An. culicifacies in districts Dindori, Kanker, and Bastar revealed confirmed resistance to DDT, malathion, alphacypermethrin, and deltamethrin registering mortality of 15 (1020), 70 (6575), 78.6 (7782.5), and 87 (84.891.3), respectively. Further, in district Dindori and Baster, the intensity bioassay test at 5X DC of alphacypermethrin and deltamethrin revealed 99 and 100, respectively, while in district Kanker, the species registered moderate resistance with 92.5 and 95 mortality, respectively, in 5X DC of alphacypermethrin and deltamethrin. However, in 10X DC, the An. culicifacies was susceptible to both pyrethroids (100) in district Kanker. Conclusion. The results of the intensity bioassay tests with SP-resistant An. culicifacies suggested no change of insecticide is required in the ongoing intervention. However, regular monitoring of insecticide susceptibility and intensity bioassays in malaria vectors in view of continued use of these interventions may increase resistance and for implementing effective vector management strategies.

Background: In India, Accredited Social Health Activists (ASHAs) deliver services for diagnosis and treatment of malaria, although unlicensed medical practitioners (UMPs) (informal health providers) are most preferred in communities. A cross sectional survey was conducted to: (i) assess knowledge and treatment-seeking practices in the community, and (ii) explore the diagnosis and treatment practices related to malaria of UMPs working in rural and tribal-dominated high malaria endemic areas of central India, and whether they adhere to the national guidelines. Methods: A multi-stage sampling method and survey technique was adopted. Heads of the households and UMPs were interviewed using a structured interview schedule to assess knowledge and malaria treatment practices. Results: Knowledge regarding malaria symptoms was generally accurate, but misconceptions emerged related to malaria transmission and mosquito breeding places. Modern preventive measures were poorly accessed by the households. UMPs were the most preferred health providers (49%) and the first choice in households for seeking treatment. UMPs typically lacked knowledge of the names of malaria parasite species and species-specific diagnosis and treatment. Further, irrational use of anti-malarial drugs was common. Conclusions: UMPs were the most preferred type of health care providers in rural communities where health infrastructure is poor. The study suggests enhancing training of UMPs on national guidelines for malaria diagnosis and treatment to strengthen their ability to contribute to achievement of India’s malaria elimination goals.

This study was undertaken with an aim of exploring community knowledge and treatment practices related to malaria and their determinants in high- and low-transmission areas of central India. A community-based cross-sectional study was carried out between August 2015 and January 2016 in two high- and two low-malaria-endemic districts of central India. A total of 1470 respondents were interviewed using a pre-tested structured interview schedule. Respondents residing in high-transmission areas with higher literacy levels, and of higher socioeconomic status, were found to practise more modern preventive measures than those living in low-transmission areas with low literacy levels and who were economically poor. Level of literacy, socioeconomic status and area (district) of residence were found to be the main factors affecting people’s knowledge of malaria aetiology and clinical features, and prevention and treatment practices, in this community in central India.

Limited qualitative research has been performed in India to investigate views and behaviours of pregnant women regarding malaria despite the threat of malaria-related adverse maternal and neonatal outcomes. To address this gap, a comprehensive study on malaria prevention and treatment attitudes, knowledge and behaviour among pregnant women in India was conducted. Pregnant women and healthcare workers (HCWs), encompassing clinic-based providers, traditional birth attendants, and auxiliary nurse-midwives were enrolled for in-depth interviews (IDIs) at 7 hospital sites and nearby communities in Jharkhand and Chhattisgarh States. Questions addressed health concerns and attitudes, knowledge and practices regarding malaria prevention and treatment; probing covered modern and traditional approaches. Data were analyzed using a thematic approach. A total of 83 pregnant women and 119 HCWs participated in 202 IDIs, 90 in Jharkhand and 112 in Chhattisgarh. A majority of Jharkhand respondents, but only one-fourth in Chhattisgarh, named malaria among top health issues for pregnant women. Just over half of pregnant women were willing to try new prevention methods (especially insecticide-treated bed nets), although cost-related barriers to such methods were stressed. Most respondents voiced concerns about malaria treatment during pregnancy, mainly citing potential harm to the baby. Most knew that mosquitoes transmitted malaria, but a substantial minority, including among HCWs, described incorrect transmission modes. Most knew a proven prevention method (usually bed nets or coils); a few knew other methods. A minority of pregnant women, but most HCWs, knew about malaria treatment, although some HCWs described unproven treatments. Most respondents described use of modern prevention methods in their communities, typically bed nets, although probing revealed irregular use. Half (especially in Jharkhand and particularly HCWs) described use of traditional prevention approaches such as burning leaves and rubbing oils on the body; traditional remedies for malaria treatment were common, and varied by site and population. Understanding of malaria varied as a concern for pregnant women, continued use of unproven malaria prevention and treatment strategies was evident in this population in India. These results highlight the need to educate both pregnant women and HCWs about effective malaria methods to protect pregnant women and their babies from malaria.

To elucidate the genetic diversity of Plasmodium falciparum in residual transmission foci of northern India. Clinically suspected patients with malaria were screened for malaria infection by microscopy. 48 P. falciparum-infected patients were enrolled from tertiary care hospital in Chandigarh, India. Blood samples were collected from enrolled patients, genomic DNA extraction and nested PCR was performed for further species confirmation. Sanger sequencing was carried out using block 2 region of msp1, R2 region of glurp and pfs25-specific primers. Extensive diversity was found in msp1 alleles with predominantly RO33 alleles. Overall allelic prevalence was 55.8% for RO33, 39.5% for MAD20 and 4.7% for K1. Six variants were observed in MAD20, whereas no variant was found in RO33 and K1 alleles. A phylogenetic analysis of RO33 alleles indicated more similarity to South African isolates, whereas MAD20 alleles showed similarity with South-East Asian isolates. In glurp, extensive variation was observed with eleven different alleles based on the AAU repeats. However, pfs25 showed less diversity and was the most stable among the targeted genes. Our findings document the genetic diversity among circulating strains of P. falciparum in an area of India with low malaria transmission and could have implications for control strategies to reach the national goal of malaria elimination. Elucider la diversité génétique de P. falciparum dans les foyers résiduels de transmission du nord de l'Inde. Les patients cliniquement soupçonnés du paludisme ont subi un dépistage par la microscopie pour l'infection par le paludisme. 48 patients infectés par P. falciparum ont été recrutés dans deux hôpitaux de soins tertiaires à Chandigarh, en Inde. Des échantillons de sang ont été prélevés chez les patients recrutés, l'extraction de l’ADN génomique et la PCR nichée ont été réalisées pour confirmation de l'espèce. Le séquençage de Sanger a été réalisé en utilisant des amorces spécifiques de la région block 2 de msp1, la région R2 de glurp et pfs25. Une diversité étendue a été trouvée dans msp1 avec majoritairement les allèles RO33. Globalement la prévalence allélique était de 56% pour RO33, 39% pour MAD20 et 5% pour K1. Six variantes ont été observées pour MAD20, alors qu'aucune variante n'a été trouvée dans les allèles RO33 et K1. Une analyse phylogénétique des allèles RO33 a indiqué plus de similarité avec les isolats d'Afrique du Sud, alors que les allèles MAD20 ont montré une similarité avec les isolats d'Asie du Sud-Est. Dans glurp, une grande variabilité a été observée avec onze allèles différents sur base des repeats AAU. Cependant, pfs25 a montré moins de diversité et était le plus stable parmi les gènes ciblés. Nos résultats documentent la diversité génétique parmi les souches circulantes de P. falciparum dans une région de l'Inde avec une faible transmission du paludisme et pourraient avoir des implications sur les stratégies de lutte pour atteindre l'objectif national d’élimination du paludisme.

Objectives: To determine household factors associated with treatment seeking for malaria.Methods: The study was carried out in four districts of Madhya Pradesh with different malaria endemicity. A total of 1470 households were interviewed in which at least one member suffered from microscopically confirmed malaria in the 3 months preceding the survey. Socio‐demographic, economic, cultural characteristics, their health beliefs, knowledge and practices regarding malaria and choice of treatment seeking were explored.Results: A total of 764 households were from high‐endemic and 706 from low‐endemic areas. More than half of household heads were illiterate; most are farmers. Approximately 46% sought treatment for malaria from unqualified informal providers; 19% from qualified private health practitioners and 35% from government health providers. Analysis revealed that household's area of residence, education, occupation, ethnicity, use of preventive measures, economic status, knowledge and practices, distance and delayed treatment seeking was strongly associated with the type of healthcare providers selected.Conclusions: Demand for formal health services among the poor, illiterate, tribal population living in remote areas is low. Accessible and affordable health services and a sensitisation programme to increase the demand for formal providers are needed.