outlines India’s strategy for elimination of the disease by 2030. The framework has been developed with a vision to eliminate malaria from the country and contribute to improved health and quality of life and alleviation of poverty.

1. National Framework For
Malaria Elimination In India
(2016-2030)
Dr. Aparna Sen Chaudhary

2. Contents
• Introduction
• Malaria Situation
• Malaria Control In India
• National framework for Malaria Elimination in India
• National Strategic Plan for Malaria Elimination in India
• Malaria Elimination Plan in Karnataka
• Critical Analysis
• Summary
• References
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3. 7/30/2018 3

4. Introduction
• Malaria incidence have reduced globally between 2010-2015.
• Gains achieved are fragile and uneven.
• Millennium Development Goal 6 – ACHIEVED (Globally & India)
⋆ Globally – cases reduced from 262 million (2000) – 211 million (2015)
deaths reduced from 839000 (2000) – 446000 (2015)
⋆ India - Annual Parasite Incidence was reduced from 2.09 (2000)–0.64(2015).
• Sustainable Development Goal 3 - By 2030, end the epidemics of AIDS,
tuberculosis, malaria and neglected tropical diseases and combat hepatitis, water-
borne diseases and other communicable diseases.
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5. Geographical Distribution Of Malarial Parasite
7/30/2018
5Source: Kiszewksi et al. American Journal of Tropical Medicine and Hygiene.2004.70;5:486-98.

6. Malaria Indigenous cases - 2016
7/30/2018 6Source: World Health Organization .World malaria report 2017. Geneva. WHO. 2017

7. World Malaria Report 2017
According to World Malaria Report 2017.
Total cases reduced from
237 million (2010) 216 million (2016)
Total deaths reduced from
591000 (2010) 445000 (2016)
Incidence Rate - reduced by 18% ., from 76 – 63
(2010-16)
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8. World Malaria Report 2017
7/30/2018 8
Year Cases
(in million)
Deaths
2010 237 591000
2011 225 529000
2012 217 487000
2013 210 465000
2014 210 459000
2015 211 446000
2016 216 445000

9. 7/30/2018 9

10. India
• Malaria cases have shown decline from 2 million (2000) to 1.1 million
(2015)
• Incidence – 0.88% in a population of nearly 1.25 billion
• Confirmed deaths decline from 1005 (2001) to 562 (2014).
• Overall in last 10 years
1. Total Malaria cases declined 42% (1.92 m – 1.1 m)
2. Malaria-related Deaths declined 40.8% (949 - 562)
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Source: Global Malaria Report.2015

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11

12. Distribution Of
Malaria Vectors
In India
7/30/2018 12Source: National Vector Borne Disease Control Programme

13. Geographic
distribution of
Malaria Incidence
(API) in India -
2014
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Source: National Vector Borne Disease Control Programme

14. 7/30/2018
14
Year Confirmed Malaria Cases (in
million)
Pf cases
(in million)
Pf % Deaths
2011 1.31 0.67 50.74 754
2012 1.06 0.53 49.98 519
2013 0.88 0.46 52.61 440
2014 1.10 0.72 65.55 562
2015 1.17 0.78 66.61 384
2016 1.09 0.71 65.53 331
2017 0.84 0.53 63.39 105
2018
(till May)
0.10 0.05 54.81 6
Source: National Vector Borne Disease Control Programme. Trends in malaria parameters in India (2001-2018).

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15
Trends of total malaria cases, Pf and Pv and deaths(2000-2014)
Source: National Vector Borne Disease Control Programme

16. Karnataka
• Previously, categorized as one of the high transmission zones in India.
• After 2003, malaria incidence started declining (reduction of 89%
compared to 2000)
• The API of state range from 0.1 to 22.3
• Total cases - 12,442 and deaths – 0 (As per 2015)
7/30/2018 16Source :Malaria Elimination Plan in Karnataka (2016-2025) – Framework, Strategies and Policies

17. Milestones In The Malaria Control Programme In India
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Prior to
1940
No organized national malaria
programmes
Prior to
1953
Esti. Cases- 75 m; deaths – 1 m
1953 National Malaria Control Programme
1958 National Malaria Eradication
Programme
1965 Cases reduced to 0.1m
Early 1970’ Resurgence of malaria
1971 Urban Malaria Scheme
1976 Malaria cases – 6.46 m
1977 Modified Plan of Operation
1984-1998 Annual Incidence of Malaria – 2-3 m
1995 Modified action plan for malaria control
1997 Enhanced Malaria Control Project
1999 National Anti-Malaria Programme
2002 NVBDCP
2005 RDT (monovalent)
2005 Intensified Malaria Control Programme
2006 ACT – chloroquine resistance areas
2008 Revised NVBDCP Drug Policy
2008 National Vector Borne Disease Control
Support Project
2009 LLIN introduced
2010 Revised NVBDCP Drug Policy 2010
2013 RDT (bivalent)
2104-15 Newer insecticides and larvicides
introduced

18. Milestones in malaria control activities
7/30/2018 18
1946Bhore Committee
• 75 million cases &
• 0.8 million deaths
National Malaria
Control Program
• Residual insecticide spray
• Anti-malarial drugs
• Survey and monitoring
1953
1958National Malaria
Elimination Program
• Eradicate Malaria
• Cases – 49151 (1961)
1971 Urban Malaria Scheme
• Urban Malaria
• Anti-larval measures

19. Milestones in malaria control activities
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1977
Modified Plan of Operation
• Cases – 6.46 million
• Eliminate malaria death
• Areas divided on basis of API Malaria Action Program
• 100% centrally sponsored
• Demarcation of high risk
areas
1995
1997
Enhanced Malaria
Control Program
• Reduction in malaria
morbidity
• Out of 100 districts, 79%
recorded decline in 2003 1999
National Anti Malaria
Program
• Renamed programme

20. Milestones in malaria control activities
7/30/2018 20
2002
National Health Policy
• Reduction in
mortality by 50% by
2010 National Vector Borne
Disease Control Programme
(NVBDCP)
• National Anti Malaria
Programme renamed
2002
2005NVBDCP
• Integral part under
NRHM
2005
Intensified Malaria
Control Project
• Started with assistance of
Global fund for AIDS,
Tuberculosis, Malaria

21. Milestones in malaria control activities
7/30/2018 21
2010Revised NVBDCP Drug
Policy 2010
National Framework For
Malaria Elimination In India
(2016-2030)
2016

22. National Framework For Malaria Elimination (NFME)
in India (2016-2030)
• WHO has recently developed the GTS for Malaria 2016-2030 which advocates global
acceleration of malaria elimination efforts by 2030.
• APLMA of which India is a member has set a target for malaria elimination in all
countries of the Asia Pacific by 2030.
• The Hon’ble Prime Minister of India was among the 18 leaders, who endorsed the
APLMA Malaria Elimination Roadmap (Kuala Lumpur, 2015), emphasizing the
political commitment towards malaria elimination in the region.
• National framework for Malaria Elimination is in line with GTS and APLMA.
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23. NFME in India (2016-2030)
• Over the years, there has been a significant reduction in malaria cases.
• This was made possible through the integrated general health services,
strengthening of health systems.
• However, still 80% of global malarial deaths occurs in India and 14 other
countries in Sub-Saharan Africa.
• New NFME - Targeting elimination of Malaria by 2030.
7/30/2018 23

24. NFME in India (2016-2030)
• Vision
Eliminate malaria nationally and contribute to improved health, quality of life
and alleviation of poverty
• Goals
1. Eliminate malaria (zero indigenous cases) throughout the country by 2030
2. Maintain malaria-free status – areas where malaria transmission has been
interrupted and prevent re-introduction of malaria
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25. NFME in India (2016-2030)
• Objectives
1. Eliminate malaria from all 26 low (Category 1) and moderate (Category 2)
transmission states/ union territories by 2022;
2. Reduce the incidence of malaria to less than 1 case per 1000 population per
year in all states and UTs and their districts by 2024;
3. Interrupt indigenous transmission of malaria throughout the entire country
(Category 3) by 2027;
4. Prevent re-establishment of local transmission of malaria and maintain malaria-
free status by 2030 and beyond.
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26. NFME in India (2016-2030)
• Strategy:
1. Programme Phasing
2. District as the unit of planning and implementation
3. Focus on high transmission areas
4. Special strategy for P. vivax elimination
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27. Strategy
1. Programme Phasing
Phased manner
Subdivided into four categories
• Annual Parasite Incidence (API) – primary criteria
• Annual Blood examination rate (ABER) & Slide positivity rate (SPR) –
secondary criteria
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28. Strategy cont..
S. No. Categories of States/UTs Definition
1. Category 0: Prevention of re-
establishment phase
Zero indigenous cases
2. Category 1: Elimination Phase (15) API of <1 case per 1000 population at risk
3. Category 2: Pre-elimination Phase (11) API of <1 case per 1000 population at risk
, with some districts of API of 1/1000 or
above
4. Category 3: Intensified control Phase (10) API of 1 case per 1000 population at risk
or above
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Classification of States/UTs based on API as primary criteria

29. Strategy cont..
2. District as the unit of planning and implementation
• State/UTs to be further classify and sub-classify their districts.
• For localized planning and implementation
• District is functional unit for planning as well as monitoring malaria
elimination interventions
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30. Strategy cont..
3. Focus on high transmission areas
• In 2014, 5 out of 36 states/UTs contributed to more than 70% of total malaria
cases.
• Aggressive scaling up of existing interventions and intensification of all
malaria control activities will be carried out.
• Intersectoral collaboration and partnerships will be strengthened for filling
gaps
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31. Strategy cont..
4. Special strategy for P. vivax elimination
• WHO Malaria Report – 80% of global P. vivax contributed by 3 countries
including India.
• Special measures – good quality microscopy, prevalence of G6PD deficiency,
vector control measures, good compliance to 14-day radical treatment.
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32. Milestones and Targets
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201
6
• All states/UTs - include malaria elimination in their broader
health policies and planning frameworks
202
0
• Interrupt malaria transmission & zero indigenous cases and death to
malaria in all 15 states/UTs under Category 1 (2014)
• All 11 states/UTs under Category 2 enter into Category 1
• Five states/UTs under Category 3 enter in Category 2
• Five states/UTs under Category 3 to reduce malaria transmission
• Estimated reduction in malaria if 15-20% at national level
• Accelerate malaria eradication programme and early elimination -
states with strong health system.

33. Milestones and Targets cont..
7/30/2018 33
202
2
• Interrupt malaria transmission and zero indigenous cases and deaths
due to malaria in 26 state/UTs under Category 1 and 2.
• Five states/UTs under category 3 to enter elimination phase
• Five states/UTs under category 3 to enter into pre-elimination phase
• Estimated reduction in malaria of 30-35% at national level.
202
4
• All states/UTs and their respective districts reduce API of <1 case per
1000 population; zero malaria deaths; fully functional malaria
surveillance
• Interrupt malaria transmission and zero indigenous cases and deaths
due to malaria in 31 states/UTs.
• Five states/UTs under category 3 to enter elimination phase

34. Milestones and Targets cont..
7/30/2018 34
202
7
• Indigenous transmission of malaria in India interrupted.
203
0
• The re-establishment of local transmission prevented in areas
where malaria is eliminated.
• Malaria-free status maintained throughout the nation.
• India initiates the process of WHO certification of malaria
elimination.

35. Key Interventions
• Category 3 (Intensified Control Phase)
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Specific Objectives Key Interventions
• Achieve universal coverage –
Malaria preventive and curative
measures
 Massive scaling up – disease
management and preventive
approach
• Efficient system to reduce
ongoing transmission
 Screening of suspected cases
 Area classification – malaria
epidemiology
• Reduce malaria specific
mortality and morbidity
 Strengthening of intersectoral
collaboration

36. Key Interventions cont..
• Category 3 (Intensified Control Phase)
7/30/2018 36
Specific Objectives Key Interventions
• Prevent malaria outbreaks
(non-immune high risk
population)
 One-stops/ mobile clinics in
tribal/high risk areas
• Emphasize reducing malaria
morbidity and mortality (high
transmission pockets)
 Timely referral & treatment
 Robust supply chain
 Optimum level of surveillance
 Equipping all health institutions

37. Key Interventions cont..
• Category 2 (Pre-elimination Phase)
a) Interventions will be introduced with focus on setting up an elimination
surveillance system and initiating elimination phase activities
b) Introduced – Districts where API is reduced to less than 1 case per 1000
population at risk per year.
c) Measures are based on epidemiological investigations and classification of
each malaria foci
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38. Key Interventions cont..
• Category 1 (Elimination Phase)
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Specific Objectives Key Interventions
• Interrupt malaria transmission  Interrupting local transmission -
elimination areas
• Immediate notification of cases  Mandatory notification of each
case (private sectors)
• Detect continuation of malaria
transmission
 Adequate case based surveillance
and case management
• Determine cause of residual
transmission
 Investigate and classification of
all foci of malaria
 Strict coverage of foci

39. Key Interventions cont..
• Category 1 (Elimination Phase)
7/30/2018 39
Specific Objectives Key Interventions
• Ensure epidemic
preparedness
• Prevent re-establishment of
local transmission of malaria
• Ascertain malaria
elimination
 Early detection and treatment of all cases
 State and national malaria elimination database
 Screening, management and prevention
interventions along with surveillance among
mobile and migrant population (special groups)
 Effective epidemic forecasting and response team
 Rigorous quality assurance
 Setting up national level reference laboratory

40. Key Interventions cont..
• Category 0
When an area has achieved malaria elimination, specific objectives will be as
follows:
• Detect any re-introduced case of malaria
• Notify immediately
• Determine the underlying cause of resumed local transmission
• Apply rapid curative and preventive measures
• Prevent re-introduction & re-establishment of malaria transmission
• Maintain malaria-free status.
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41. Cross- cutting Interventions
• Common to all categories of states/UTs
⋆Policy and Planning
▸Formation of a National Malaria Elimination Committee
▸Revision of national guidelines for prevention, intensified control and elimination of
malaria
▸Revision of national or state level policy/legislation for all the states and UTs
▸New surveillance and reporting strategy (China’s 1-3-7 strategy)
▸Clear parameters for states/UTs classification
▸Verification of malaria elimination
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42. Cross- cutting Interventions cont..
⋆Monitoring and Evaluation
▸New web-based reporting system
▸Revision of monitoring and evaluation formats
▸Estimation of vector control coverage
▸Use of annual scoring system for evaluating progress against elimination
milestones and targets
▸Data validation by external agency
▸Grading of all areas based on fixed parameters
7/30/2018 42

43. Cross- cutting Interventions cont..
⋆Stratification
▸Stratification of States/UTs based on – API, ABER and SPR
▸Sub-stratification of all districts
▸Further stratification of CHCs, PHCs, SCs and villages
▸Feasibility assessment of each state/UTs
⋆Surveillance
▸Entomological surveillance
▸Strengthening of routine surveillance
7/30/2018 43

44. Cross- cutting Interventions cont..
⋆Quality assurance
▸Quality assurance of all medicines, diagnostic, treatment
▸Private sector providing diagnostics to be certified
⋆Intersectoral Collaboration
▸Formulation of clearly defined roles and responsibilities
▸Collaboration with private sectors and NGOs
▸Training and refreshing courses
▸Integration of data on malaria endemicity
▸Establish collaboration with various public works department
7/30/2018 44

45. Cross- cutting Interventions cont..
⋆Cross-border Collaboration
▸Screening of population at international border crossing
▸Training of security personnel; provision of diagnostic and treatment facilities
▸Monthly data collections and integration
▸Joint planning and implementation of malaria prevention and control activities
⋆Initiatives for special population groups
▸Implementation of TRIBAL MALARIA PLAN
▸Screening of mobile or migrant workers in each state/UT
▸Community action group
▸Training of mobile, migrant workers
7/30/2018 45

46. Cross- cutting Interventions cont..
⋆IEC/BCC
▸Revision of IEC/BCC strategy with special emphasis on malaria elimination
▸Strategy to be tailored according to the endemicity of malaria
⋆Innovation
▸Vector control
▸Standard Operating procedures for outbreaks of malaria
▸Avenues for innovative financing
▸Innovative ways of service delivery
7/30/2018 46

47. Cross- cutting Interventions cont..
⋆Capacity Building
▸Preparatory of annual training curriculum and schedules for health officers
▸Review of training status and schedules
⋆Research
▸Facilitate research on devising methods to increase efficacy of IRS/LLIN
▸Survey by states/UTs on behaviour of mosquito vectors & community
▸Longitudinal survey on malaria vector population dynamics
▸Research on drug resistance, therapy efficacy studies
▸Cost-benefit analysis of intervention used
7/30/2018 47

48. Measuring Progress and Impact
• Focus on monitoring
∼Operational aspects – coverage and quality interventions
∼Epidemiological indicators
• National and state level independent malaria elimination committee
• Progress towards reaching elimination goals
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49. Key indicators
S. No IMPACT
1 No. and incidence rate of confirmed malaria cases
2 No. and incidence of severe malaria cases as well as case fatality rate
3 No. of malaria cases in pregnancy
4 No. and type of malaria foci
5 No. of confirmed deaths due to malaria
6 No. of states/UTs eliminated malaria and in phase of prevention of re-
establishment of transmission
7 No. of states/UTs in elimination; pre-elimination and intensified phase
7/30/2018 49

50. Key indicators cont..
S. No OUTCOME
1 Proportion of population at risk who slept under an insecticides-treated net/LLIN
the previous night
2 Proportion of population at risk protected by IRS within the past 12 months
3 Proportion of patients with confirmed malaria who received anti-malarial
treatment
4 Proportion of cases investigated and classified
5 Proportion of foci investigated and classified
6 Proportion of expected monthly reports received from health facilities
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51. Cost of Implementing
• It has been estimated that a 10% reduction in malaria is associated with
0.3% increase in growth of a country.
• Global Technical Strategy for Malaria 2016-2030 – US $ 101.8 billion (15
years)
• In India, economic burden of malaria was US$ 1940 million (2012)
• Estimates showed that every Rupee invested in malaria control a direct
return of Rs. 19.70 could be expected
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52. Challenges in Malaria Control
1. Population movements, often uncontrolled across states/UTs, and
sharing of large international borders with neighbouring malaria
endemic countries
2. Shortage of skilled human resources
3. Insecticides resistance
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53. Next Steps…
1. Strategic Action Plan 2016-2030 is rolled out
2. Sustain adequate financial resources
3. National malaria elimination committee and technical working group
4. National monitoring and evaluation database will be strengthened
7/30/2018 53

54. National Strategic Plan for Malaria Elimination in India
2017-2022
• Specific Objectives
1. Universal coverage of case detection and treatment services in endemic districts
ensuring 100% parasitological diagnosis
2. Strengthen the surveillance system
3. Universal coverage of population at risk of malaria with a vector control measure
4. Universal coverage by appropriate BCC activities
5. Effective programme management and coordination at all levels to deliver
targeted interventions
7/30/2018 54

55. Malaria Elimination Plan in Karnataka (2016-2025)
• Goal – attain ZERO malaria status by 2022
• Objectives
1. Reduction of malaria to less than1 case per 1000 population per year in
Dakshina Kannada and Udupi by 2018.
2. Elimination – in 15 low transmission districts by 2018 and sustain
3. Elimination – in 13 moderate transmission districts by 2020
4. Interruption of indigenous transmission in entire state by 2022
5. Prevent local transmission from 2023
7/30/2018 55

56. Malaria Elimination Plan in Karnataka (2016-2025)
• Strategic Plan
1. Detection of all malaria cases and their notification, foci identification and cut down
further transmission
2. Universal coverage and quality assurance of malarial microscopy
3. Universalization of common drug policy, monitoring of drug efficacy and resistance
4. Reduction of man-mosquito contact
5. All levels of malaria control programme have sufficient capacity
6. Intersectoral collaboration
7. IEC, social mobilization
8. Financial investment from different sources
9. Execution of regulatory policies necessary to achieve goals of malaria elimination
7/30/2018 56

57. Critical Analysis
7/30/2018 57
• District as the unit
• Special strategy for P. vivax
• Case-based surveillance
• Involving PP.
• For migratory population
•Strengthens
• Diagnostic Challenges.
• Ensuring completion of treatment.
• Resistance.
• Funding.
• Asymptomatic malaria cases.
• Mandatory notification
Challenges

58. 7/30/2018 58

59. Summary
1. NFME is India’s commitment to GTS and APLMA.
2. National framework for Malaria Elimination (NFME) – to eliminate malaria by
2030.
3. National strategic plan for Malaria Elimination in India 2017-2022 - to support
NFME to achieve malaria elimination
4. Malaria elimination Plan in Karnataka (2016-2025)- to attain zero malaria
status by 2022
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60. 7/30/2018 60

61. References
1. World Health Organization. World malaria report 2017. Geneva.WHO.2017.
2. National Vector Borne Disease Control Programme. Trend of Malaria Parameters in India (2001-2018).
Ministry of Health and Family Welfare. Government of India. Available from:
http://nvbdcp.gov.in/index4.php?lang=1&level=0&linkid=427&lid=3705
3. Directorate of National Vector Borne Disease Control Programme. National Framework for Malaria
Elimination in India (2016-2030). Ministry of Health and Family Welfare. Government of India. New
Delhi.2016
4. Directorate of Health and Family Welfare Services. Malaria Elimination Plan in Karnataka (2016-2025) –
Framework, Strategies and Policies. Government of Karnataka. Bengaluru. 2017.
5. J.Kishore. National Health Programs of India – National Policies & Legislations Related to Health. Twelfth
Edition. New Delhi, India. Century Publications. 2017.
6. Chourasia MK, Raghavendra K, Bhatt RM, Swain DK, Valecha N, Kleinschmidt I. Burden of asymptomatic
malaria among a tribal population in a forested village of central India: a hidden challenge for malaria
control in India. Public Health.2017;147:92-7.
7. Singh US, Siwal N, Pande V, Das A. Can Mixed Parasite Infections Thwart Targeted Malaria Elimination
Program in India?. BioMed Research International.2017. Available from:
https://doi.org/10.1155/2017/2847548
7/30/2018 61

62. References
8. World Health Organization. A framework for malaria elimination. Geneva. WHO.2017
9. Shah NK, Dhariwal AC, Sonal GS, Gunasekar A, Dye C, Cibulskis R. Malaria-attributed death rates in
India. The Lancet.2011;377:991-2.
10. Hay SI, Gething PW, Snow RW. India’s invisible malaria burden. Lancet. 2010; 376(9754):1716-7.
11. Farooquia HH, Hussainb MA, Zodpeya S. Malaria control in India: has sub-optimal rationing of
effective interventions compromised programme efficiency?. WHO South-East Asia Journal of Public
Health 2012;1(2):128-32.
12. Park KS1, Malik SK, Lee JH, Karim AM, Lee SH. Commentary: Malaria elimination in India and regional
implications. Frontiers in Microbiology.2018;9. doi: 10.3389/fmicb.2018.00992.
13. APLMA Strategic Plan. Roadmap Phase 1:2016-2020. Singapore. Asia Pacific Leaders Malaria Alliance.
2016.
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63. THANK YOU
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