Today is World Mosquito Day.
Some 124 years ago in year 1897, Dr Ronald Ross established that female anopheles mosquitoes spread malaria. This was probably the single most important discovery in public health, apart from Germ Theory & the establishment of the vaccination concept. This discovery paved way for effectively targeting malaria through managing mosquitoes that have saved millions of lives every year. Later on, mosquitoes were found to be associated with multiple other diseases like Dengue, Chikungunya & Zika etc.
To commemorate this important discovery, 20 August is observed as World Mosquito Day every year across the world.
Mosquitoes borne diseases like malaria remains a big challenge for all of us in India despite all the success & progress that has been made across the decades.
In this article, I would be focusing more on Malaria, as it is still one of the primary vector-borne diseases in the country, additionally; we have an elimination target year approaching very fast.
Today in 2021 till now, we have less than 1 lac cases of malaria as per official sources, this is a significant milestone in the malaria elimination path. It becomes especially noteworthy & praiseworthy because the country has been in midst of a terrible COVID wave, that led to the diversion of resources towards COVID management.
Less than 1 lac cases might indicate that we are on brink of elimination, especially as just 5 years back, India had more than one million cases. However, it`s important to note that it`s not the first time in history that we are at this stage.
Some 55 years back in 1965, India registered less than 1 lac cases annually and it was assumed that India will eliminate this scourge from a young independent country very soon at that time. However, then the situation changed drastically & there was a phenomenal 65x increase in the number of cases & within 10 years in 1975, India reported 6.5 million cases of malaria. Instead of celebrating Malaria free India in 1960s, we landed up in another 6-decade long battle with Malaria
However, the question would be – Why did this happen?
We lost 55 years, millions of lives & billions of rupees in continuing the fight against malaria over years and the opportunity cost of allocating resources to other pressing topics in public health in the country.
According to experts & historical documents & publications, there were multiple reasons; however, the top three reasons were as below:
Complacency: Reduction of coverage of vector control, vacancies being not filled up in public health departments, less focus on urban areas & reduced surveillance.
Development of resistance to dichlorodiphenyltrichloroethane (DDT): India`s success to a large extent for DDT, however, the success of DDT & continuously reduction in cases masked the need to look for alternatives to DDT. As no other alternative to DDT was thought or planned by the health departments of that time while DDT was working, we landed up in a situation of resistance that we didn’t had any alternatives.
Resistance of Plasmodium falciparum to chloroquine: Increases in antimalarial resistance also compounded the challenge.
In last 55 years, we have made enormous progress, yet we still face many challenges that has potential to derail the progress made till date on malaria elimination front.
Some of the challenges are being summarized below :-
Dependence on one class of Insecticides: Synthetic pyrethroids has been the mainstay of India`s vector control efforts encompassing Indoor residual spray, Long-lasting/insecticide treated bed-nets, Space spray. Synthetic pyrethroids have performed well and they have been of safer profile & are cost-effective. However, presently there is no other molecules with an alternative mode of action registered in India/or are under registration against mosquitoes. The other two molecules that are registered in India are malathion & DDT, for which we already have a well-documented history of resistance.
Large Asymptomatic malaria cases: This means that we have huge reservoirs of malarial parasites, as anti-malarial treatment is not being triggered for such asymptomatic cases
Outdoor transmission: Historically malaria has been due to indoor transmission & that was normally well controlled by Indoor residual spray and bed-nets, however, outdoor transmission is enhancing the complexities.
We also have dependence on mostly one type of antimalarial like ACT & we lack strong Entomological & epidemiological data & capacity.
India must continue its fight with malaria aggressively and ensure that mistakes of the past are not repeated now as we are at same cross roads of 1960s.
I believe the below 3 things might help to strengthen our efforts for winning the war against Malaria this time
Facilitate the introduction of Innovations for Vector Control solutions
Insecticide resistance is a reality. Across the world, we are witnessing widespread resistance and we have to be ready with alternatives to face the dangers of resistance in India too. In the 1960s, there were not many alternatives available across the world; however, there has been a lot of development in new molecules & innovative combinations that are being adopted across the world successfully. It might be prudent for government & authorities to facilitate and encourage private sectors to bring innovations in the country by removing the roadblocks in the introduction of new technologies in Vector control space.
Integrating the Private sector in delivering Vector Control services
Vector Control activities are mostly public sector driven with negligible involvement of the private sector for the implementation of such services. India is a huge country and it is nearly impossible for the government to cater to all the areas effectively.
One of the first places for the resurgence in the 1960s was areas that were not under vector control but had a population of vectors. Involving Private applicators might greatly increase the coverage of the vector control initiatives. Hence, it is important that vector densities are closely monitored and continuous vector control activities are conducted.
Data, surveillance and predictive modelling
India public health system collects a huge amount of data, however, most of the data sit at different places in excel sheets. These data do not interact among themselves, hence does not provide any analytics & prediction. Real-time data collection and interaction of various kinds of data from entomological, epidemiological, meteorological, Vector control application reporting, can help to build a strong AI-driven model to provide analytics and actionable predictions
These were my personal opinion and based on my understanding of the space, I think that some of the above points will help us to prevent history from repeating itself. India has made a tremendous effort in the last 6 decades and we should not let this opportunity of eliminating malaria, go waste.