Last year’s annual report on malaria contained some startling and worrying figures. In 10 of the countries with some of the highest rates of the disease there were 3.5 million more cases of the deadly infection in 2017 than in 2016.
Nigeria had a million more cases of malaria in 2017 compared to the previous year, while the Democratic Republic of Congo and Madagascar each experienced half a million more infections in 2017 compared to 2016.
However, one high-burden nation is bucking this concerning trend. India reported three million fewer cases of malaria in 2017 than in 2016, an incredible 24 per cent decrease.
“Of the countries hardest hit by malaria, only India showed progress in reducing its disease burden,” a WHO spokesperson said.
And it is the east coast state of Odisha, responsible for 40 per cent of cases in the entire country, which is driving the reduction. This is a remarkable feat considering that both its topography and population make it perfectly suited to the spread of the disease.
Odisha is an ideal breeding ground for the malaria-carrying mosquito: it lies on several river deltas and is traversed by hundreds of slow-moving rivers and streams. A remaining third of the state is covered by dense forest while 2.75 million hectares of land are waterlogged paddy fields.
And nearly a quarter of Odisha’s population is tribal, living in remote areas far from immediate medical care and with poor access to transport.
In 2016, the state recorded 444,850 cases of malaria and 77 deaths. By 2018, this had dropped to 55,360 infections and just four deaths.
Odisha’s success can be attributed to a three-pronged approach. Firstly, the National Vector Borne Disease Control Programme – a Ministry of Health body – has worked with the state government to distribute long-lasting insecticidal nets (LLINs).
Between 2010 and 2013, 3.9 million LLINs were handed to those most at risk from the disease in the state, such as pregnant women and those in isolated areas.
Secondly, it implemented mass screening programmes to identify those already living with malaria.
The state government worked alongside international NGOs, such as Malaria No More, to identify high-risk and endemic areas. It then launched widespread testing in 21 of the highest-burden districts across Odisha.
Those suffering from malaria were given immediate treatment while endemic regions received heightened mosquito control measures, such as filling in of water sources known to be breeding grounds.
Thirdly, the government realised it had to raise awareness about the disease across its diverse and disconnected population.
Female accredited social health activists (ASHAs) have long carried out day-to-day healthcare in remote communities. Typically, they assist pregnant women and ensure children obtain necessary vaccinations.
As the ASHAs are considered trusted members of communities, the government realised they would be the perfect vehicle to advance knowledge about malaria in remote areas.
When the government secured a further delivery of 11 million LLINs from the Global Fund to Fight AIDS, Tuberculosis and Malaria in 2017 it had the perfect opportunity to harness the power of the ASHAs.
ASHAs distributed the nets across 28 high-risk districts and held weekly meetings with villagers to explain the risky activities that could lead to catching malaria. Different methods were employed to suit the needs of diverse communities.
“In the night time some districts have taken to new innovative methods like ringing a bell at nightfall,” says Dr Pramila Baral, a director of the vector control programme.
“Rural tribal people would come from working in the fields and make their dinner and go to sleep.
“So, by 8 o’clock she will [ring the bell] and when that happens the villagers become alert that they have to hang their mosquito nets.”
The government also trained ASHAs to carry out on-the-spot rapid diagnostic malaria testing.
Meenakhi Maharana has been an ASHA in the village of Kusumati for 11 years. Now it is part of her daily routine to go door-to-door to search for fever cases. Usually, she visits around 10 people a day and those displaying malaria symptoms will be tested.
Any positive cases are immediately sent to the nearest regional healthcare centre so the patient can be treated.
When the Telegraph joined Maharana on a her daily rounds her first stop was to test Swarnalata Jena, 35, who lives in Kusumati with three generations of her family.
“Before the ASHAs were here I would have to travel four to five kilometres away to test,” Jena said.
“If I need it, Maharana can now provide medicine immediately.
“She has also educated villagers about how to use the nets correctly so that the mosquitoes cannot bite us.”
There are now over 47,000 ASHAs working to identify and prevent malaria in 51,000 villages in Odisha.
Dr Hara Prasad Pattanaik, director of public health in the government of Odisha, has recently returned from the International Conference on Disease Surveillance in San Diego where he was lauded for his success in reducing malaria infections.
However, Dr Pattanaik he does not want to become complacent. He intends to secure millions more LLINs over the upcoming years and train increasing numbers of ASHAs across the state.
Working alongside Malaria No More the state government is also using technology to better monitor cases that do occur.
Social media advertisements are being used to target those in remote areas of Odisha and warn about malaria risks. And 30 WhatsApp groups have been created – one per district – for real-time sharing of information on infections and to co-ordinate response.
At a meeting in London on the eve of World Malaria Day on April 25, Peter Sands, executive director of the Global Fund, emphasised the crucial role of key people in the community, such as the ASHAs.
“It’s the person in the village who walks around and makes sure that new mothers are using their bed nets properly and tucking them in. It’s the person in the village who knows that if a child has a fever which could be malaria then you don’t hang around and get people to a clinic,” he said.
Dr Baral has vowed to eradicate malaria entirely in one-third of the state by 2030.
“It’s not a single person, it’s team work that will give this result.”
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