DEPARTMENT OF ENVIRONMENT AND SCIENCE

7250ENV Environmental System and Climate Change

Course conveyor: APro Albert Gabric

TOPIC: Effect of Climate Change on Vector Borne Disease Malaria: ACTION PLAN
FOR MITIGATION OF MALARIA IN ODISHA STATE, INDIA

GROUP 9
Meghnaben Icecreamwala (s2879974)
Sagar Bhoyar (s5179329)
Rutvika Manojkumar Kanani (s5167023)

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Introduction
Climate change is the biggest challenge of the 21st century as it threatens all aspects of the
society in which we live. (Van Aalst, Cannon, & Burton, 2008; Urry, 2015). The impacts of
climate change on human health are increasingly clear so, further delay in mitigation strategy
will increase risks (Epstein 2005; Haines et al. 2006; McMichael et al. 2006; Costello et al.
2009; WHO, 2018). Climate change has majorly affected human health by climate related
activities such as droughts, floods, cyclones, malnutrition, and various diseases (Epstein 2005;
Haines et al. 2006; McMichael et al. 2006; Costello et al. 2009). India has been suffering from
malaria from centuries. Climate parameters governing current malaria transmission in India
will create worst situation due to effect of climate change on temperature, rainfall patterns and
humidity (Bhattacharya et. Al, 2006).
This report presents current status of malaria transmission in India and focuses on
Odisha state, which has been the major contributor towards malaria morbidity and mortality in
India (Gunanidhi et al, 2015). The projected increase in temperature and changes in relative
humidity due to climate change is likely to increase the transmission of malaria in Odisha state
(Bhattacharya et. Al, 2006). To mitigate malaria effectively, Malaria Mitigation Action Plan
for 2020-2025 is prepared with an aim of reducing malaria by 50% in 5 years and zero Malaria
by 2030 to achieve India’s vision of Zero Malaria by 2030.

Rational for selection of Study Area Odisha state, India

“Malaria is a major issue of India by contributing human morbidity, mortality, economic
burden” (Kumar et al. 2007).

India is second highest populous country of the world, which contributes more than 66% cases
of malaria and most of the malaria-related deaths cases in the South-East Asia region of World
Health Organization. (WHO, 2008). India is one of the top five malaria-affected countries with
more than 1 billion people living under the risk of malaria in the world. According to the WHO
report (2016), 90% of malaria cases in southeast Asia were from India which contributed 6%
global burden of malaria. In 2014, 275 million people which is 22% of the total population of
India lived in high transmission areas, 838 million people (67% of the total population) lived
in low transmission areas and 11% population lived in malaria-free areas (World Malaria
Report,2014). In the same year, 1 million cases were reported which resulted in 561 deaths all
over India. Although, the death rates could be higher than reported (Dhingra et al., 2010;
Basnyat., 2011; Deonarine., 2011; Kumar et al., 2011; Shah et al., 2011a, Sharma et al., 2011;
Valecha et al., 2011). However, India became the only progressive country among 11 high
malaria burden countries by 24% of the decrease in malaria cases between the years 2016 and
2017(WHO, 2017). India has the vision to mitigate malaria by 2030 like neighbour countries
Srilanka and Maldives. Though gaps in malaria surveillance, lack of proper health treatment
and control are affecting the elimination process. Considering above facts, India was selected
for present study.

In India, every year roughly 1.5 million cases of malaria and 1000 deaths are reported
from Odisha state (formerly Orissa), a part of peninsular India. Thus, Odisha has been major
contributor towards malaria transmission (Gunanidhi et al, 2015). Odisha is the second highest
state with 45% of malaria burden all over India. In 2016, 295000 malaria cases were reported,
and out of them,56 cases resulted in death in Odisha (Pradhan A. et al., 2016) The climate of
the state, rich forest area with tribal villages, widespread presence of mosquitoes and effect of
climate change creates favourable condition for Malaria transition. Considering present status
of Odisha, the present study aims to produce an action plan for mitigation of Malaria.
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Odisha is an eastern country with 3% of the total population of India and 4% of Indian landmass
(Pradhan A. et al., 2016). Odisha is the second highest state with 45% of malaria burden all
over India. In 2016, 295000 malaria cases reported, and 56 cases resulted in death in Odisha
(Pradhan A. et al., 2016). With a 50% decrease, 156000 malaria cases were reported in 2017.

Source: (Gunanidhi et al., 2015)

Figure: API and CQ resistance pattern in regions of Odisha, India.

Malaria transmission in Odisha has become persisted because of favorable climatic conditions,
large forest areas, inaccessible remote and hilly regional areas, and widely spread Anopheles
mosquitoes. Changes in weather patterns and precipitation plays a major role in malaria
transmission (Devi N. et al., 2006; Bush et al.,2011). Malaria transmission varies with different
regions and it is estimated by API (annual parasite incidence). The map shows malaria API for
different regions of Odisha. Some northern and western regions including KBK (Koraput
Bolangir Kalahandi) are majorly affected by malaria transmission and some coastal districts
are under low malaria transmission. To prevent and control the malaria many programs were
organized under national guidelines and policies, but no significant changes have been noticed
for decades. Until 2017, Odisha contributed 40% of total malaria cases in India.

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 Source: Gunanidhi et al., (2015)
Table: adopted programs to prevent malaria in Odisha

Malaria Mitigation strategies in India:

In 2016, India incorporated a national framework to eliminate malaria by 2030 (Pradhan et al.,
2016). Furthermore, it successfully eradicated nearly half of the malaria cases from 2 million
to 1.1 million since then. Tamil Nadu and Punjab are the leading states to have successfully
reduced malaria cases with Punjab potentially being the first state to declare malaria free with
596 cases in 2015 from 1,036 in 2014. With India on its way to eradicate malaria, the entire
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world to has set targets to achieve the same with stretching not only in the field of research and
vaccine but also innovations including genetically modified sterile mosquitoes (Guerin,
Dhorda, Ganguly, & Sibley, 2019).

The most effective way to prevent malaria transmission is by vector control. WHO provides
and endorses all malaria victims around the World. Indian health authorities provide free access
to mosquito nets, encourage the use of diagnostic tests and sanctions-free treatment to the
victims. WHO's global organizations for malaria eradication promote the detection of the cases
at an early stage to avoid widespread exposure in the area. The state of Punjab, India has
successfully implemented stratification to the lowest geographical levels covering all 22
districts. Although, the state also has a high risk of reintroduction of malaria as there is a
continuous flow of labor population from the nearby endemic areas like Bihar, Jharkhand,
Odisha. Therefore, to eradicate malaria completely, focus on areas with more discrete incidents
are identified, investigated and cleared.

Prevention:
There are over 900 000 Accredited Social Health Activists (ASHAs) covering a massive
number of villages and tribal areas. National Vector Borne Disease Control Program
(NVBDCP). These activists serve to facilitate health aid, promote education and awareness
about the treatment of malaria.

Source: WHO report (2017)

Figure: bed nets used to prevent mosquito biting

Odisha being at the highest risk of malaria, in 2017, ASHAs provided aid in the distribution of
40 million bed nets across the area (Guerin et al., 2019) Relatively, the distribution of these
bed nets to avoid widespread of diseases is not enough and therefore these activists ensure that
the people are using them by going door to door at night when the mosquitoes bite in the tribal
areas. As a result, ASHAs reported more than 80% of the users to use bed nets properly
(Karmakar & Pradhan, 2019).

Education as a public health tool:

ASHAs educate users about life-saving protection the nets confer to those who don't use the
nets properly. For the victims who test positive for malaria, ASHAs provide free treatment and
keep a track of detailed record of their medication. Apart from the activist's groups like ASHAs,
Public health officials facilitate folk troupes who educate on malaria control to people in
villages. Moreover, they engage the audiences with a question and answer sessions and
encourage them to promote the same to their friends and family (Pradhan et al., 2016).

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 Source: WHO report (2017)
Image: street plays to spread awareness towards malaria
Taking messages to the most remote of villages:
In areas with high transmissions, measures including vans with loudspeakers to broadcast and
educate the people are being adopted. Moreover, they play their native tunes, with song lyrics
replaced with malaria messages which are also then printed on pamphlets and distributed in
the village. People in the villages and tribal areas are mostly uneducated and cannot read.
Therefore, to reach such category of people, ASHAs park their vans in the village center and
read aloud and educate about malaria prevention in local languages and try for a one on one
conversation (Karmakar & Pradhan, 2019). Numerous other groups and organizations apart
from ASHAs have contributed to India's success towards the eradication of malaria from these
tribal regions. These organizations include malaria technical supervisors, the district vector-
borne disease team, auxiliary nurse midwives and the state programmed team.

Action Plan to Mitigate Malaria in Odisha:

Vision:
Reduce the Annual Parasite Incidence (API) to less than 1.

Goal:
Reduce malaria deaths by 100% and malaria incidence by 50% by 2025 as elimination is not
immediately possible in Odisha, so that malaria is no longer a public health problem or a barrier
to social and economic development.

Objectives:
1. Reduce malaria incidence by 50 % by 2025 and zero Malaria by 2030 to achieve vision of
Malaria free India by 2030.
2. Reduce numbers of active malaria foci.
3. Achieve zero malaria deaths by 2025.

Strategic Approaches:
The regional action plan is built on three pillars with two supporting elements, as highlighted
in the Global Technical Strategy 2016–2020.

Pillar 1. Ensure access to malaria prevention, diagnosis and treatment for everyone.

a) Promote and facilitate application of effective preventive measures against malaria for
populations at risk.
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1. Indoor residual spraying
2. Long-lasting insecticidal nets
3. Larvicide and source reduction
4. Entomological surveillance, monitoring and evaluation
5. Insecticide resistance monitoring and management
6. Pesticide management
7. Quality of vector control products and uptake of new vector control tools.
8. Implemention of malaria vector control within integrated vector management

b) Promote and facilitate universal access of populations at risk to quality-assured diagnosis

and effective treatment of malaria.
In rural communities and remote areas, mainly in countries with a higher malaria burden, lack
of access to effective treatment remains a challenge due to inadequacies in the health care
system. In such settings, early and appropriate treatment is possible through the introduction
and improvement of integrated community case management of malaria. This strategy aims to
improve the practice of case management at the community level by training and providing
rapid diagnostics and medicines to trained community health workers. The efficacy of this
strategy can be further enhanced through the use of pre-packaged medicines, treatment courses
and appropriate rapid diagnostic tests.

Pillar 2. Increase efforts for elimination and achievement of zero Malaria status.
The purpose of antimalarial measures at the stage of elimination of foci is to:
• achieve sustainable interruption of malaria transmission;
• deplete the reservoir of infection;
• prevent re-establishment of malaria from the same area.

Pillar 3. Transform malaria surveillance into a core intervention.

In malaria-endemic countries with weak or non-functioning health systems, all possible
mechanisms will be considered to strengthen the malaria surveillance system to provide the
information necessary for planning and management of control activities.

Action Plan for Mitigation of Malaria in Odisha, India:

Goal 1: Utilize environmental strategies to reduce vector breeding sites.

Strategies Key Partners Time Frame Performance
Indicators
Train district and NVBDCP Delhi Within 6 months Basic entomology
Health centre staff on can be included in
basic entomology training modules of
all staffs
Assess impact of Zonal entomological Throughout the plan Impact assessment
potential unit District VBD period can be conducted for
environmental office each foci intervened
management
intervention in
targeted foci
Hold local District VBD Office Throughout the plan Stakeholder meeting
stakeholders’ WHO period at least once before

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 meeting with all State entomology transmission season
relevant sectors in Department (for preparedness);
preparation for once during peak
implementation of transmission (for
environmental response); and once
management after the end of
transmission season
(for review).

Goal 2: Strengthen entomological surveillance for malaria elimination.

Strategies Key Partners Time Frame Performance

Indicators
Build capacity of NVBDCP Delhi Within 6 months 100% staff at state
state and zonal State NVBDCP from implementation and zonal
entomology units WHO entomological unit
Collect Zonal entomological Throughout the plan Monthly collection
entomological data at unit period and reporting of
sentinel sites District VBD office entomological data
to state NVBDCP
Monitor receptivity Zonal entomological Throughout the plan Monthly collection
and vector density in units period and reporting of
areas where entomological data
transmission has to state NVBDCP
been interrupted
Map vector Zonal entomological Throughout the plan Monthly collection
distribution, units period and reporting of
transmission foci and District VBD office entomological data
vector control State NVBDCP to state NVBDCP
intervention

Goal 3: Strengthen investigation, classification and appropriate response to all malaria

transmission foci.

Strategies Key Partners Time Frame Performance

Indicators
Investigate, classify District VBD Office Throughout the plan All foci will be
and map all foci in all (for district level) period classified within and
districts to identify WCO support reported to State
drivers of NVBDCP with 15
transmission days of detection
Establish and State NVBDCP Throughout the plan Geo-referencing of
maintain WCO support period foci can be
georeferenced completed within 7
database for all foci days of foci reporting
to the state.

Strategic goals of Malaria Mitigation Action Plan :

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 Strategy Lead Agency/ Key Time Frame Performance
Partners Indicators
1. Strengthen surveillance system to immediately investigate, classify, report and
respond to all cases
Constitute a State NVBDCP Within 6 month of District focal point
surveillance working WHO plan implementation to review and report
group to strengthen District VBD surveillance
malaria surveillance Office (for district
at public sector and level)
notification from
private sector
2. Outbreak preparedness and response

Develop guidelines State NVBDCP Within 6 months of Outbreak

for outbreak WHO implementation preparedness and
preparedness and response guidelines
response will be developed
and disseminated to
all districts
Develop outbreak Throughout the plan Outbreak warning
early warning State NVBDCP period system will develop
system in high risk WHO for high-risk area
areas District VBD
Office
3. Strengthen programme monitoring and evaluation

Update monitoring NVBDCP Delhi Initial phase of plan Module will be

and evaluation plan WCO developed to
as per NVBDCP mitigate malaria
50% by 2025.
Reprogramming and State NVBDCP 2 years Reprogramming
strategizing as per report on the basis
transition to of midterm review
elimination based on report
the strategic action
plan
Monitoring and State NVBDCP Throughout the plan Monitoring reports
mentoring all health District VBD period will be available
care providers at all Office WHO with report of action
levels to strengthen taken.
compliance to
national guidelines
Monitoring of District VBD ASHA performance Throughout the plan
ASHA performance Office report will available period
at district level from all blocks at
every quarter on
malaria case
detection, treatment
and referral

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4. Improve quality and delivery of IEC BCC messages for malaria elimination

Review and update

current state IEC
BCC strategy to
align with the
national malaria
elimination strategy
Print/ disseminate State NVBDCP 2 years Key messages will
malaria IEC BCC District VBD office be developed for
messages for mass media ASHSs
programmes, and other partners
partners and all
relevant stakeholder
5. Enhancing case detection and case management and ensuring universal coverage

Screen all suspected District VBD Throughout the plan Assurance of

malaria cases and Office, period suspected malaria
high-risk groups ASHA cases tested in all
(pregnant and U6 districts within 24
children) living in hours of reporting.
malaria endemic
areas
Train all peripheral NVBDCP Delhi & Throughout the plan Assurance that all
laboratory staff State NVBDCP period laboratory staff are
(PHC) providing trained are trained in
malaria diagnosis by malaria microscopy
malaria microscopy
Follow up of all District Vector Throughout the plan 100% patients who
treated cases with Born Disease period receive treatment
patient treatment (VBD) Office card will be
card and monitor the Accredited Social followed up as per
re-emergence of Heath Activists guideline mentioned
symptoms to suspect (ASHA) above by ASHA
poor compliance,
relapse, reinfection,
or drug resistance.
Monitor the State NVBDCP Throughout the plan Monthly prescription
prescription and District VBD period audit will be
safety of Office conducted at all
antimalarial drugs at provider level and
all facilities with random
checking of positive
cases
Enforce all State NVBDCP Throughout the plan Quarterly visit to
regulations including DCGI and State period mapped facilities or
malaria notification Drug Controller districts will ensure
on private sector mitigation strategies
provider are working

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 Develop ASHA State NVBDCP 6 months Training will help to
operational manual District VBD make malaria
and provide training Office management
on Malaria effective and
management efficient
services

6. Strengthen case detection and recording and reporting by all health care providers

Mandate malaria as State NVBDCP 6 months This will help to

a notifiable disease Government of maintain record of
Odisha disease
(Department of
Law)
Upgrade real time State NVBDCP 6 months Real time case alert
system to include WCO support and stock
immediate case alert Different sectors management system
and stock (military, launched and staffs
management paramilitary, designated and
features and link it police, railways, trained.
with MIS and other
establishments)
Scale up electronic District VBD Throughout the plan Coordination with
reporting of case by Office WCO period all providers will be
private providers support convenient
Investigate, classify State NVBDCP Throughout the plan 100% malaria cases
and report all cases District VBD period can be investigated,
from health facilities Office classified, tracked
as well as from and reported
community
providers
Carry out Reactive District VBD Throughout the plan For all villages
case detection Office All frontline period reporting new case,
(RACD) around health workers one round of RACD
index cases in all including ASHAs survey could be
districts initiated

7. Strengthen community mobilization for increase uptake of malaria interventions

Build capacity of WHO-TA support Throughout the plan Sensitization

different community District VBD period meeting with
platforms and self- Officials and Staff community
help groups and Block level staff platforms improves
organize community
sensitization awareness about
workshops with Malaria Mitigation
different Program
community-based
organizations in

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 selected villages in
priority areas

8. Strengthen programme management and coordination

Review and update State National 1 year Guidelines and/or

relevant key policy Vector borne SoPs for– a.
and standarddisease Control Diagnosis
operating procedures Program, b. Laboratory
(SoPs) to align with Health and Family methods
elimination goals Welfare c. Treatment
Department, d. Vector
Government of management
Odisha Updated
Conduct annual State NVBDCP January 2021 c. Malaria
planning and review transmission status
meeting for and logistic
development of state requirement for all
annual action plan districts reviewed
for malaria d. District-wise
elimination annual action plan
developed
Form state-level Health and Family 1 year MEC Endorsed by
independent Malaria Welfare WHO and NVBDCP
Elimination Department, Delhi
Committee (MEC) Government of MEC members
for validation of Odisha conduct first
progress towards monitoring visit to
elimination review elimination
readiness and
feasibility

9. Strengthen procurement and supply chain management system

Designate focal point State NVBDCP / 1 year Focal point will be

for procurement, district introduced for
supply and stock coordination
management
(PSSM) at state and
district level
Develop a stock State NVBDCP / 1 year PSCM Dashboard
management and district and management
supply chain module developed
dashboard for timely
indenting and supply
Quantify, procure, NVBDCP Delhi, Every month Quantification of
and distribute in time State NVBDCP, throughout the period commodities
adequate (required + District VBD completed
buffer) antimalaria office
drugs, malaria

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diagnostics and other Indent placed and
commodities at all commodities at
facilities and appropriate level
providers
Review and State NVBDCP Throughout the period prevent stock-out
monitoring of stocks District VBD and expiry at district
Office and peripheral health
facilities and
maintain adequate
buffer stock at each
level at monthly
basis

10. Advocacy for political commitment to malaria elimination

Organize annual Odisha National Throughout the plan Progress update can
advocacy meeting Health Mission, period be reviewed.
for malaria Odisha NVBDCP
elimination under the
chairmanship of
Chief Minister, Six-
monthly annual
progress report
presented to Health
minister, Quarterly
progress review
meeting under the
chairmanship of
Secretary,
Department of
Health and Family
Welfare

11. Cross-border collaboration with other bordering states

Regularly share State NVBDCP Throughout the plan Monthly report of

information of period introduced/ imported
mutual interest cases shared to
related to malaria respective states with
programme details of case
identification, travel,
source district,
diagnosis and current
treatment

12. Introduce and scale up appropriate intervention for mobile, migrant and other
underserved population at risk of malaria infection.

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 District-wise State NVBDCP Every month Monthly report of
mapping of MMPs malaria in MMPs
for screening of submitted
malaria and
treatment of positive
case

13. Data analysis and risk stratification

Analysis of State NVBDCP As soon

as Dissemination of
secondary data implementation
of document to state for
provided by State for plan implementation.
2015 -2019 Achieve 50%
reduction indigenous
in transmission by
2025.
Utilize malaria risk State NVBDCP Throughout the plan Village mapping for
stratification to District VBD period ASHA will be done
identify villages for Office
capacity building of
ASHA for malaria
case management

Conclusion:
The increase in malaria transmission due to climate change will not only depend on the
changing climate scenario but also on the mitigation path to be followed. Three simple steps-
prevention, timely detection and rapid treatment can help to mitigate malaria transmission. The
Action Plan for Odisha attempts to improve the accessibility to health services and improve
the surveillance, medical and forecasting technologies to prepare management to combat with
the exacerbated impacts of climate change. Every dollar invested in Malaria control generates
return of 19.70 dollars in terms of man/days saved (S lal, 2000; Kumar et.al., 2007).
Despite the efforts, it is almost impossible to achieve zero Malaria status for Odisha
due to favourable climatic condition for mosquitoes. Combined with existing malaria
interventions, a Malaria vaccine would have great potential to save thousands of lives, which
is available to only 3 African countries Ghana, Kenya and Malawi as pilot project (WHO,
2018).

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