Adult and child malaria mortality in India: a nationally representative mortality survey

Child, maternal, and adult mortality in rural Ethiopia in 2019: a cross-sectional mortality survey using electronic verbal autopsies

Background

Ethiopia, with about 10% of Africa's population, has little direct information on causes of death, particularly in rural areas where 80% of Ethiopians live. In 2019-2020, we conducted electronic verbal autopsies (e-VA) to examine causes of death and quantify cause-specific mortality rates in rural Ethiopia.

Methods

We examined deaths under 70 years in the three years prior to the survey dates (November 25, 2019-February 29, 2020) among 2% of East Gojjam Zone (Amhara Region) using registered deaths and adding random sampling in this cross-sectional study. Trained surveyors interviewed relatives of the deceased with central dual-physician assignment of causes as the main outcome. We documented details on age, sex and location of death, and derived overall rural death rates using 2007 Census data and the United Nations national estimates for 2019. To these, we applied our sample-weighted causes to derive cause-specific mortality rates. We calculated death risks for the leading causes for major age groups.

Findings

We studied 3516 deaths: 55% male, 97% rural, and 68% occurring at home. At ages 5 and older, injuries were notable, accounting for over a third of deaths at 5-14 years, half of the deaths at ages 15-29 years, and a quarter of deaths at ages 30-69 years. Neonatal mortality was high, mostly from prematurity/low birthweight and infections. Among children under 5 (excluding neonates), infections caused nearly two-thirds of deaths. Most maternal deaths (84%) arose from direct causes. After injuries, especially suicide, assaults, and road traffic accidents, vascular disease (15%) and cancer (13%) were the leading causes among adults at 30-69 years. HIV/AIDS and tuberculosis deaths were also important causes among adults.

Interpretation

Rural Ethiopia has a high burden of avoidable mortality, particularly injury, including suicide, assaults, and road traffic accidents.

Funding

International Development Research Centre, and the Canadian Institutes of Health Research.

Unlocking the potential of novel RTS, S/AS01, and R21/Matrix-M™ malaria vaccines in African nations

Introduction

Mass malaria vaccination, rather than vaccinating only children below age 5, has been proven to have the potential to reduce morbidity and mortality among those vaccinated, both young and old. Addressing vaccine scepticism and misinformation is crucial in African nations to build public trust in malaria prevention. Therefore, including a wider range of demographics in vaccine trials is necessary for equitable representation and achieving herd immunity against malaria.

Aim

This present article aims to identify some of the obstacles that impede malaria vaccination usage and acceptability in African Nations in combating malaria in the region as it continues to pose a significant global public health problem.

Methodology

A literature search was done on the Malaria vaccine between 2000 and 2023. Past and present articles/studies on this topic were consulted on PubMed, Google Scholar, Scopus and Web of Science using the following keywords; "Malaria," "Vaccines," "African Nations," "Obstacles, Strategies," and "Public Health."

Results

The recently approved RTS, S/AS01, and R21/Matrix-M™ Malaria vaccines have the potential to prevent numerous deaths and cases of Malaria in Africa. These vaccines Malaria vaccines are cost-effective in African areas with moderate to high plasmodium falciparum and can be delivered through routine immunization.

Conclusion

To combat malaria effectively in African Nations, African leaders need to set up a comprehensive approach that involves; prevention, healthcare access, implementation research strategies towards adoption and acceptance of malaria vaccines in Africa as well as community engagement with the religious leaders, the market women, community heads, schools, as well as students' union towards the willingness and acceptability of the malaria vaccines among the African populations.

Mosquito-borne diseases in India over the past 50 years and their Global Public Health Implications: A Systematic Review

Mosquito-borne diseases (MBDs) pose a significant public health concern globally, and India, with its unique eco-sociodemographic characteristics, is particularly vulnerable to these diseases. This comprehensive review aims to provide an in-depth overview of MBDs in India, emphasizing their impact and potential implications for global health. The article explores distribution, epidemiology, control or elimination, and economic burden of the prevalent diseases such as malaria, dengue, chikungunya, Japanese encephalitis, and lymphatic filariasis, which collectively contribute to millions of cases annually. It sheds light on their profound effects on morbidity, mortality, and socioeconomic burdens and the potential for international transmission through travel and trade. The challenges and perspectives associated with controlling mosquito populations are highlighted, underscoring the importance of effective public health communication for prevention and early detection. The potential for these diseases to spread beyond national borders is recognized, necessitating a holistic approach to address the challenge. A comprehensive literature search was conducted, covering the past five decades (1972-2022), utilizing databases such as Web of Science, PubMed, and Google Scholar, in addition to in-person library consultations. The literature review analyzed 4,082 articles initially identified through various databases. After screening and eligibility assessment, 252 articles were included for analysis. The review focused on malaria, dengue, chikungunya, Japanese encephalitis, and lymphatic filariasis. The included studies focused on MBDs occurrence in India, while those conducted outside India, lacking statistical analysis, or published before 1970 were excluded. This review provides valuable insights into the status of MBDs in India and underscores the need for concerted efforts to combat these diseases on both national and global scales through consilience.

Evaluation of changes in the cognitive, affective, and psychomotor domains of learning following an interprofessional intervention for malaria and its control among the Bedia tribe, a particularly vulnerable tribal group, in rural Eastern India

Background

The "Bedia" tribal people are found all over India; they are poor, illiterate, and confined culturally. In many parts of India, malaria, a disease caused by mosquitoes, is becoming more common. Raising awareness and educating people about it is the best method to stop disease and maintain good health.

Objective

This study aimed to determine the perception, attitudes, and practices of a particularly vulnerable tribal group-the "Bedia"-in the rural region of eastern India.

Methods

A questionnaire with 19 structured questions has been created. The Bedia participants received the questionnaire from us. They had already responded. The intervention took the form of several health education workshops that were created in response to the deficiencies identified in the pre-test assessment's replies. The identical questionnaire used for the pre-test evaluation was given to each participant for the post-test who attended the training sessions.

Results

The current study found that while the first cognitive domain question on malaria transmission was not statistically significant, changes in malaria breeding grounds, regions with higher mosquito numbers, and the source of information about malaria are. Their knowledge of the treatment for malaria and the agent used to treat it is statistically significant in the current study, but the fifth question on the most common symptom of malaria was not statistically significant. The answers to the questions about "What you will do if you see someone suffering from malaria," "How much time was spent in the malaria control program," "Malaria detection," and "Regular usage of bed-nets" in the affective and psychomotor domains all had statistical significance.

Conclusions

Our research on interventions to raise awareness of malaria in this tribal region of northern West Bengal, eastern India, bordering Bangladesh, was published for the first time to our knowledge. In the majority of the items from the cognitive, psychomotor, and affective learning domains, we have seen significant changes.

Could vaccinating adults against malaria materially reduce adult mortality in high-transmission areas?

After a period of unprecedented progress against malaria in the 2000s, halving the global disease burden by 2015, gains overall in sub-Saharan Africa have slowed and even reversed in some places, beginning well before the COVID-19 pandemic. The highly effective drugs, treated nets, and diagnostics that fueled the initial progress all face some threats to their effectiveness, and global funding to maintain and increase their use over the long term is not guaranteed. Malaria vaccines are among the most promising new interventions that could accelerate the elimination of malaria. Vaccines are still in early stages of rollout in children, the age group (along with pregnant women) that has been the focus of malaria strategies for a century. At the same time, over the past decade, a case has been made, based largely on evidence from verbal autopsies in at least a few high-transmission areas, that the malaria death rate among adults has been greatly underestimated. Could vaccinating adults help to bring down the adult malaria mortality rate, contribute to reduced transmission, or both? A randomized trial of a malaria vaccine is proposed in Sierra Leone, a highly endemic setting, to shed light on this proposition.

Adult malaria mortality during 2019 at Bo Government Hospital, Sierra Leone

It is uncertain whether malaria is an important cause of death among adults in endemic areas. We performed a chart review of adults admitted to Bo Government Hospital during 2019. Of 893 admissions, 149 (59% female, mean age 58.5 years) had a laboratory diagnosis of malaria and 22 (14.8%) died. Mortality was significantly higher among patients with severe malaria compared with those who had non-severe malaria (6/20 [30%] versus 16/129 [12.4%], p=0.031).  Our results suggest that malaria is a common cause of death in hospitalized Sierra Leonian adults.

Long-term impacts of climate change on coastal and transitional eco-systems in India: an overview of its current status, future projections, solutions, and policies

Urbanization and industrial development are increasing rapidly. These are accompanied by problems of population explosion, encroachment of agricultural, and construction lands, increased waste generation, effluent release, and escalated concentrations of several greenhouse gases (GHGs) and pollutants in the atmosphere. This has led to wide-scale adverse impacts. Visible effects are fluctuations in temperatures and precipitation, rising sea levels, unpredictable floods, storms and cyclones, and disruption to coastal and transitional ecosystems. In a country like India with a massive population of nearly 1.4 billion and around 420 million people dwelling on or near the coasts, this effect is pre-dominant. India has extensive coastlines on both sides that are subject to greater contact and high impact from the water bodies. The factors impacting climate change, its consequences, and future predictions must be analyzed immediately for implementing precautionary measures to ameliorate the detrimental effects. Several endemic species have been endangered as these changes have resulted in the loss of habitat and interfered with the food webs. Climatic impacts on transitional ecosystems also need to be considered to preserve the diversity of each. The cooperation of governmental, independent organizations and policymakers throughout the world is essential to control and mediate the impacts on health, agriculture, and other related sectors, the details of which have been elaborated in this review. The review analyses the trends in climatic variation with time and discusses a few extremities which have left permanent effects on the population primarily concerning the coastal - Indian scenario and its eco-systems.

Adult malaria mortality during 2019 at Bo Government Hospital, Sierra Leone

It is uncertain whether malaria is an important cause of death among adults in endemic areas. We performed a chart review of adults admitted to Bo Government Hospital during 2019. Of 893 admissions, 149 (59% female, mean age 58.5 years) had a laboratory diagnosis of malaria and 22 (14.8%) died. Mortality was significantly higher among patients with severe malaria compared with those who had non-severe malaria (6/20 [30%] versus 16/129 [12.4%], p=0.031).  Our results suggest that malaria is a common cause of death in hospitalized Sierra Leonian adults.

Spatio-temporal modelling of malaria mortality in India from 2004 to 2013 from the Million Death Study

BACKGROUND

India has a substantial burden of malaria, concentrated in specific areas and population groups. Spatio-temporal modelling of deaths due to malaria in India is a critical tool for identifying high-risk groups for effective resource allocation and disease control policy-making, and subsequently for the country's progress towards United Nations 2030 Sustainable Development Goals.

METHODS

In this study, a spatio-temporal model with the objective of understanding the spatial distribution of malaria mortality rates and the rate of temporal decline, across the country, has been constructed. A spatio-temporal "random slope" model was used, with malaria risk depending on a spatial relative risk surface and a linear time effect with a spatially-varying coefficient. The models were adjusted for urban/rural status (residence of the deceased) and Normalized Difference Vegetation Index (NDVI), using 2004-13 data from the Million Death Study (MDS) (the most recent data available), with nationwide geographic coverage. Previous studies based on MDS had focused only on aggregated analyses.

RESULTS

The rural population had twice the risk of death due to malaria compared to the urban population. Malaria mortality in some of the highest-risk regions, namely the states of Odisha and Jharkhand, are declining faster than other areas; however, the rate of decline was not uniformly correlated with the level of risk. The overall decline was faster after 2010.

CONCLUSION

The results suggest a need for increased attention in high-risk rural populations, which already face challenges like inadequate infrastructure, inaccessibility to health care facilities, awareness, and education around malaria mortality and prevalence. It also points to the urgent need to restart the MDS to document changes since 2013, to develop appropriate malaria control measures.

The Political Economy of Public Health Inequalities and Inequities in India: Complexities, Challenges, and Strategies for Inclusive Public Health Care Policy

This article examines the political economy of health inequalities and inequities in the public health care system in India and identifies potential areas for interventions to promote equal and equitable health care for marginalized people. Drawing on the Political Economy of Health Model of Research, this article reiterates the inadequacy of policy frameworks and programs in ensuring accessible, affordable, and quality public health care services to all. We argue that for policies to be successful, policymakers should consider the diverse social registries of class, caste, religion, gender, region, ethnicity, and age, as well as their intersections. We also argue that health care policies and programs need to be: (a) dynamic and flexible, (b) intersectional and backed up by sufficient grassroots research, and (c) equitable at every stage of policy formulation, implementation, and evaluation.

Child, maternal, and adult mortality in Sierra Leone: nationally representative mortality survey 2018-20

BACKGROUND

Sierra Leone's child and maternal mortality rates are among the highest in the world. However, little is known about the causes of premature mortality in the country. To rectify this, the Ministry of Health and Sanitation of Sierra Leone launched the Sierra Leone Sample Registration System (SL-SRS) of births and deaths. Here, we report cause-specific mortality from the first SL-SRS round, representing deaths from 2018 to 2020.

METHODS

The Countrywide Mortality Surveillance for Action platform established the SL-SRS, which involved conducting electronic verbal autopsies in 678 randomly selected villages and urban blocks throughout the country. 61 surveyors, in teams of four or five, enrolled people and ascertained deaths of individuals younger than 70 years in 2019-20, capturing verbal autopsies on deaths from 2018 to 2020. Centrally, two trained physicians independently assigned causes of death according to the International Classification of Diseases (tenth edition). SL-SRS death proportions were applied to 5-year mortality averages from the UN World Population Prospects (2019) to derive cause-specific death totals and risks of death nationally and in four Sierra Leone regions, with comparisons made with the Western region where Freetown, the capital, is located. We compared SL-SRS results with the cause-specific mortality estimates for Sierra Leone in the 2019 WHO Global Health Estimates.

FINDINGS

Between Sept 1, 2019, and Dec 15, 2020, we enrolled 343 000 people and ascertained 8374 deaths of individuals younger than 70 years. Malaria was the leading cause of death in children and adults, nationally and in each region, representing 22% of deaths under age 70 years in 2020. Other infectious diseases accounted for an additional 16% of deaths. Overall maternal mortality ratio was 510 deaths per 100 000 livebirths (95% CI 483-538), and neonatal mortality rate was 31·1 deaths per 1000 livebirths (95% CI 30·4-31·8), both among the highest rates in the world. Haemorrhage was the major cause of maternal mortality and birth asphyxia or trauma was the major cause of neonatal mortality. Excess deaths were not detected in the months of 2020 corresponding to the peak of the COVID-19 pandemic. Half of the deaths occurred in rural areas and at home. If the Northern, Eastern, and Southern regions of Sierra Leone had the lower death rates observed in the Western region, about 20 000 deaths (just over a quarter of national total deaths in people younger than 70 years) would have been avoided. WHO model-based data vastly underestimated malaria deaths and some specific causes of injury deaths, and substantially overestimated maternal mortality.

INTERPRETATION

Over 60% of individuals in Sierra Leone die prematurely, before age 70 years, most from preventable or treatable causes. Nationally representative mortality surveys such as the SL-SRS are of high value in providing reliable cause-of-death information to set public health priorities and target interventions in low-income countries.

FUNDING

Bill & Melinda Gates Foundation, Canadian Institutes of Health Research, Queen Elizabeth Scholarship Program.

Intolerable Burden of Malaria among Primitive Tribal Community in Odisha: Examining the Fundamental Cause

This study seeks to examine the living conditions, working conditions, and health seeking behaviour for malaria among Kondho community after one is infected with malaria. The residential surroundings of those diagnosed with malaria positive cases were extremely conducive for mosquito breeding. For instance, the majority of households threw garbage near their house, went for open defecation, the cowshed was beside their houses, and above all the houses were mostly situated in the jungle or near thick forest. Sub-centre followed by the community health centres was the first point of contact in most cases but medical care was sought only after routine life was affected. While malaria treatment plans are changing towards administering more powerful drugs as a result of chloroquine resistance but not as much has been done in the ground to prevent malaria at the first place. Therefore, together with continuing curative care for malaria—more emphasis is needed on its prevention. Community, civil society and the government need to work in tandem to improve the living and working conditions of backward communities particularly those living in malaria endemic zone so as to be able to take effective preventive measures for malaria.

Comparison of machine learning algorithms applied to symptoms to determine infectious causes of death in children: national survey of 18,000 verbal autopsies in the Million Death Study in India

BACKGROUND

Machine learning (ML) algorithms have been successfully employed for prediction of outcomes in clinical research. In this study, we have explored the application of ML-based algorithms to predict cause of death (CoD) from verbal autopsy records available through the Million Death Study (MDS).

METHODS

From MDS, 18826 unique childhood deaths at ages 1-59 months during the time period 2004-13 were selected for generating the prediction models of which over 70% of deaths were caused by six infectious diseases (pneumonia, diarrhoeal diseases, malaria, fever of unknown origin, meningitis/encephalitis, and measles). Six popular ML-based algorithms such as support vector machine, gradient boosting modeling, C5.0, artificial neural network, k-nearest neighbor, classification and regression tree were used for building the CoD prediction models.

RESULTS

SVM algorithm was the best performer with a prediction accuracy of over 0.8. The highest accuracy was found for diarrhoeal diseases (accuracy = 0.97) and the lowest was for meningitis/encephalitis (accuracy = 0.80). The top signs/symptoms for classification of these CoDs were also extracted for each of the diseases. A combination of signs/symptoms presented by the deceased individual can effectively lead to the CoD diagnosis.

CONCLUSIONS

Overall, this study affirms that verbal autopsy tools are efficient in CoD diagnosis and that automated classification parameters captured through ML could be added to verbal autopsies to improve classification of causes of death.

Trends in maternal mortality in India over two decades in nationally representative surveys

OBJECTIVE

To assess national and regional trends and causes-specific distribution of maternal mortality in India.

DESIGN

Nationally representative cross-sectional surveys.

SETTING

All of India from 1997 to 2020.

SAMPLE

About 10 000 maternal deaths among 4.3 million live births over two decades.

METHODS

We analysed trends in the maternal mortality ratio (MMR) from 1997 through 2020, estimated absolute maternal deaths and examined the causes of maternal death using nationally representative data sources. We partitioned female deaths (aged 15-49 years) and live birth totals, based on the 2001-2014 Million Death Study to United Nations (UN) demographic totals for the country.

MAIN OUTCOME MEASURES

Maternal mortality burden and distribution of causes.

RESULTS

The MMR declined in India by about 70% from 398/100 000 live births (95% CI 378-417) in 1997-98 to 99/100 000 (90-108) in 2020. About 1.30 million (95% CI 1.26-1.35 million) maternal deaths occurred between 1997 and 2020, with about 23 800 (95% CI 21 700-26 000) in 2020, with most occurring in poorer states (63%) and among women aged 20-29 years (58%). The MMRs for Assam (215), Uttar Pradesh/Uttarakhand (192) and Madhya Pradesh/Chhattisgarh (170) were highest, surpassing India's 2016-2018 estimate of 113 (95% CI 103-123). After adjustment for education and other variables, the risks of maternal death were highest in rural and tribal areas of north-eastern and northern states. The leading causes of maternal death were obstetric haemorrhage (47%; higher in poorer states), pregnancy-related infection (12%) and hypertensive disorders of pregnancy (7%).

CONCLUSIONS

India could achieve the UN 2030 MMR goals if the average rate of reduction is maintained. However, without further intervention, the poorer states will not.

TWEETABLE ABSTRACT

We estimated that 1.3 million Indian women died from maternal causes over the last two decades. Although maternal mortality rates have fallen by 70% overall, the poorer states lag behind.

Malaria Elimination in India: Bridging the Gap Between Control and Elimination

India observed a significant reduction in malaria cases in the previous year, reaffirming our trust and efficiency of the existing tools to achieve malaria elimination. On 25 April, 2019, countries around the world marked World Malaria Day under the theme “Zero malaria starts with me”. This provides an opportunity to rejoice the success and re-evaluate ongoing challenges in the fight against this preventable and treatable parasitic disease. We highlight the potential gaps in the malaria elimination program, and underscore potential solutions and strategies to implement, improve and intensify the success of the national goal of malaria elimination by 2030.

Surveillance-based estimation of the malaria disease burden in a low endemic state of Punjab, India, targeted for malaria elimination

BACKGROUND

The state of Punjab in India qualifies for malaria elimination because the number of cases reported through routine surveillance is in decline. However, surveillance system prevalence mainly provides malaria trends. Therefore, a prospective epidemiological study was designed to estimate the malaria burden in the state.

METHODS

District-wise annual parasite incidence (API) was used for identification of three strata, representing high, moderate and low API zones. A total of 0.9 million people from nine districts was under malaria surveillance for 1 y. The weighted estimates of API for the three regions was calculated and combined to give an estimate of API for the total population of the state.

RESULTS

Based upon the primary data generated, malaria cases from high, moderate and low malaria-endemic areas were estimated to be 3727, 904 and 106, respectively. Further, the total number of malaria cases in the state was estimated to be 4737 (95% CI 4006 to 5469) cases per annum.

CONCLUSION

Actual burden of malaria in the state of Punjab, India, is about seven to eight times higher than that reported by routine surveillance activities. However, the state still qualifies for malaria elimination but needs vigorous efforts to strengthen the active surveillance and reporting system along with implementation of effective control strategies to achieve malaria elimination.

Accuracy of verbal autopsy, clinical data and minimally invasive autopsy in the evaluation of malaria-specific mortality: an observational study

BACKGROUND

Global malaria mortality estimates are hindered by the low reliability of the verbal autopsy (VA) and the clinical records, the most common sources of information used to estimate malaria-specific mortality. We aimed to determine the accuracy of these tools, as well as of the minimally invasive autopsy (MIA), a needle-based postmortem sampling method, to identify malaria-specific mortality in a large series of deceased patients from Mozambique, using complete autopsy as the gold standard.

METHODS

Observational study that included 264 deaths, occurring at a tertiary level hospital in Mozambique, from 1 November 2013 to 31 March 2015 (17 months-long period). Clinical data were abstracted, a computer coded VA was completed using the clinical data as source of information, and an MIA followed by a complete autopsy were performed. Screening for malaria infection was conducted postmortem to all participants using molecular and histological techniques (PCR and immunohistochemistry).

FINDINGS

Malaria infection was considered the cause of death in 6/264 (2.3%) cases: 2/54 children (3.7%, both less than 5 years old) and 4/57 (7.0%) maternal deaths. The sensitivity and specificity of the VA, the clinical data and the MIA to identify malaria-specific deaths were 33.3% and 96.1%, 66.7% and 96.1%, and 100% and 100%, respectively. In addition, malaria was identified as a possible contributor in 14 additional patients who died of other diseases. These cases were also accurately identified by the MIA (sensitivity 82.4%, specificity 100%).

INTERPRETATION

The high sensitivity and specificity of the MIA in identifying malaria may help to improve current estimates of malaria-specific mortality in endemic areas.

Advancement of chimeric hybrid drugs to cure malaria infection: An overview with special emphasis on endoperoxide pharmacophores

Emergence and spread of Plasmodium falciparum resistant to artemisinin-based combination therapy has led to a situation of haste in the scientific and pharmaceutical communities. Sincere efforts are redirected towards finding alternative chemotherapeutic agents that are capable of combating multidrug-resistant parasite strains. Extensive research yielded the concept of "Chimeric Bitherapy (CB)" which involves the linking of two molecules with individual pharmacological activity and exhibit dual mode of action into a single hybrid molecule. Current research in this field seems to endorse hybrid molecules as the next-generation antimalarial drugs and are more effective compared to the multi-component drugs because of the lower occurrence of drug-drug adverse effects. This review is an attempt to congregate complete survey on endoperoxide based hybrid antiplasmodial molecules that will give glimpse on the future directions for successful development and discovery of useful antimalarial hybrid drugs.

Digital Health Care Services to Control and Eliminate Malaria in India

In the rural and tribal areas of India, poor healthcare services for malaria are posing a great challenge to malaria control and elimination. Digitisation in malaria healthcare services, including surveillance, diagnosis, and treatment, may be helpful in malaria control and, subsequently, may move towards the elimination goal of India by 2030.

Demonstration of indigenous malaria elimination through Track-Test-Treat-Track (T4) strategy in a Malaria Elimination Demonstration Project in Mandla, Madhya Pradesh

BACKGROUND

Many malaria endemic countries are heading towards malaria elimination through the use of case management and vector control strategies, which employ surveillance, improving access to early diagnosis, prompt treatment., and integrated vector control measures. There is a consensus that elimination of malaria is feasible when rapid detection and prompt treatment is combined with mosquito-human contact interruption in an efficient and sustainable manner at community levels. This paper describes results of an integrated case management and vector control strategy for reducing malaria cases in 1233 villages over 3 years in district Mandla, Madhya Pradesh, India.

METHODS

The project enrolled the entire population (1,143,126) of Mandla district for fever surveillance followed by testing of febrile cases and treatment of positive subjects using T4 strategy, which is Track (by fever), Test (by RDTs), Treat (by ACT) and Track (for completion of treatment). In addition to the active and passive surveillance for detection and treatment of febrile cases, the project conducted mass screening and treatment to clear the asymptomatic reservoirs of infection. Febrile cases were also tested in the out-patient department of the District Hospital from June 2018 to September, 2018 and in a community-based medical camp from November 7 to 14, 2019. The project also used vector control measures for interrupting human-mosquito contact, and information, education and communication (IEC) campaigns to increase demand for malaria services at community level.

RESULTS

This project has revealed about 91% reduction of indigenous cases of malaria during the period from June 2017 to May 2020, through case management and vector control strategies. A total 357,143 febrile cases were screened, out of which 0.19% were found positive for the presence of malaria parasites, with Plasmodium falciparum and Plasmodium vivax ratio of 62:38. The prevalence of malaria was higher in individuals > 15 years of age (69% cases). The positivity rate was 0.33% in 2017-18, 0.13% in 2018-19, and 0.06% in 2019-20. In all of the 3 years of the project, the peak transmission correlated with rains. Mass screening revealed 0.18% positivity in Sep-Oct 2018, followed by 0.06% in June 2019, and 0.03% in December 2019, and these were mostly asymptomatic cases in the community. Imported cases into the district were mostly contributed by the distant state of Telangana (51.13%). Fever patients tested for malaria parasites in the District Hospital and medical camp revealed zero cases.

CONCLUSION

Using the current intervention and prevention tools along with optimum utilization of human resources, a 91% reduction in indigenous cases of malaria was seen in the district in 3 years. The reduction was similar in the three high prevalence blocks of the district. These results reveal that malaria elimination is achievable in India within a stipulated time frame. The reduction of malaria at the community level was further validated when zero malaria cases were diagnosed during hospital and community-based studies in Mandla. Prompt detection and treatment of imported/migratory cases may have prevented outbreaks in the district. This project has demonstrated that field programmes backed by adequate technical, management, operational, and financial controls with robust monitoring are needed for achieving malaria elimination.

Persistence of Imported Malaria Into the United Kingdom: An Epidemiological Review of Risk Factors and At-risk Groups

BACKGROUND

The United Kingdom documented a decline of >30% in imported cases of malaria annually between 1996 and 2003; however, there are still approximately 1700 cases and 5-10 deaths each year. Prophylaxis health messages focus on families returning to their country of origin.

METHODS

We reviewed 225 records of patients seen in Cambridge University Hospital Foundation Trust [CUHFT], a tertiary referral center in Cambridge, England. All records of patients seen in CUHFT between 2002-2016 were analyzed in the context of national figures from Public Health England.

RESULTS

Between 2004-2016, there was no decrease in imported cases of malaria locally or nationally. Plasmodium falciparum remains responsible for most imported infections (66.7%); Plasmodium vivax contributed 15.1%, Plasmodium malariae 4%, and Plasmodium ovale 6.7%; 7.5% (17/225) of patients had an incomplete record. Most cases were reported in people coming from West Africa. Sierra Leone and the Ivory Coast had the highest proportions of travelers being infected at 8 and 7 per 1000, respectively. Visiting family in the country of origin (27.8%) was the commonest reason for travel. However, this was exceeded by the combined numbers traveling for business and holidays (22.5% and 20.1%, respectively). Sixty percent of patients took no prophylaxis. Of those who did, none of the patients finished their chemoprophylaxis regimen.

CONCLUSIONS

Significant numbers of travelers to malarious countries still take no chemoprophylaxis. Health advice about prophylaxis before travel should be targeted not only at those visiting family in their country of origin but also to those traveling for holiday and work.

Development of a probabilistic early health warning system based on meteorological parameters

Among the other diseases, malaria and diarrhoea have a large disease burden in India, especially among children. Changes in rainfall and temperature patterns likely play a major role in the increased incidence of these diseases across geographical locations. This study proposes a method for probabilistic forecasting of the disease incidences in extended range time scale (2–3 weeks in advance) over India based on an unsupervised pattern recognition technique that uses meteorological parameters as inputs and which can be applied to any geographical location over India. To verify the robustness of this newly developed early warning system, detailed analysis has been made in the incidence of malaria and diarrhoea over two districts of the State of Maharashtra. It is found that the increased probabilities of high (less) rainfall, high (low) minimum temperature and low (moderate) maximum temperature are more (less) conducive for both diseases over these locations, but have different thresholds. With the categorical probabilistic forecasts of disease incidences, this early health warning system is found to be a useful tool with reasonable skill to provide the climate-health outlook about possible disease incidence at least 2 weeks in advance for any location or grid over India.

Falciparum malaria-induced acute pancreatitis

Falciparum malaria is one of the most common causes of acute febrile illness in India and frequently presents as severe malaria also known as complicated malaria or cerebral malaria with associated multiple organ failure. Acute pancreatitis secondary to malaria is very rare complication. Here we are presenting a case of severe falciparum malaria with acute pancreatitis.

Trends in snakebite deaths in India from 2000 to 2019 in a nationally representative mortality study

The World Health Organization call to halve global snakebite deaths by 2030 will require substantial progress in India. We analyzed 2833 snakebite deaths from 611,483 verbal autopsies in the nationally representative Indian Million Death Study from 2001 to 2014, and conducted a systematic literature review from 2000 to 2019 covering 87,590 snakebites. We estimate that India had 1.2 million snakebite deaths (average 58,000/year) from 2000 to 2019. Nearly half occurred at ages 30-69 years and over a quarter in children < 15 years. Most occurred at home in the rural areas. About 70% occurred in eight higher burden states and half during the rainy season and at low altitude. The risk of an Indian dying from snakebite before age 70 is about 1 in 250, but notably higher in some areas. More crudely, we estimate 1.11-1.77 million bites in 2015, of which 70% showed symptoms of envenomation. Prevention and treatment strategies might substantially reduce snakebite mortality in India.

Is Malaria an Important Cause of Death among Adults?

A long-held assumption has been that nearly all malaria deaths in high-transmission areas are of children younger than 5 years and pregnant women. Most global malaria mortality estimates incorporate this assumption in their calculations. In 2010, the Indian Million Death Study, which assigns cause of death by verbal autopsy (VA), challenged the reigning perception, producing a U-shaped mortality age curve, with rates rising after age 45 years in areas of India with substantial malaria transmission. Similar patterns are seen in Africa in the International Network for the Demographic Evaluation of Populations and Their Health (INDEPTH) network, also relying on VA. Whether these results are accurate or are misidentified deaths can be resolved by improving the evidence for assigning causes for adult acute infectious deaths in high malaria transmission areas. The options for doing so include improving the accuracy of VA and adding postmortem biological evidence, steps we believe should be initiated without delay.

Surveillance based estimation of burden of malaria in India, 2015-2016

Background

India has launched the malaria elimination initiative in February 2016. Studies suggest that estimates of malaria are useful to rationalize interventions and track their impact. Hence, a national study was launched to estimate burden of malaria in India in 2015.

Methods

For sampling, all 624 districts of India were grouped in three Annual Parasite Incidence (cases per thousand population) categories, < two (low); two-five (moderate) and > five (high) API. Using probability proportional to size (PPS) method, two districts from each stratum were selected covering randomly 200,000 persons per district. Active surveillance was strengthened with 40 trained workers per study district. Data on malaria cases and deaths was collated from all health care providers i.e. pathological laboratories, private practitioners and hospitals in private and public health sectors and was used for analysis and burden estimation.

Results

Out of 1215,114 population under surveillance, 198,612 (16.3%) tests were performed and 19,386 (9.7%) malaria cases were detected. The malaria cases estimated in India were 3875,078 (95% confidence interval 3792,018–3958,137) with API of 3.05 (2.99–3.12) including 2789,483 (2740,577–2838,389) Plasmodium falciparum with Annual Falciparum Incidence of 2.2 (2.16–2.24). Out of 8025 deaths investigated, 102 (1.27%) were attributed to malaria. The estimated deaths in India were 29,341 (23,354–35,327) including 19,067 (13,665–24,470) confirmed and 10,274 (7694–12,853) suspected deaths in 2015–2016.

Conclusions

Estimated malaria incidence was about four folds greater than one million reported by the national programme, but three folds lesser than thirteen million estimated by the World Health Organization (WHO). However, the estimated deaths were 93 folds more than average 313 deaths reported by the national malaria programme in 2015–2016. The 29,341 deaths were comparable with 24,000 deaths in 2015 and 22,786 deaths in 2016 estimated by the WHO for India. These malaria estimates can serve as a benchmark for tracking the success of malaria elimination campaign in India.

Modeling an association between malaria cases and climate variables for Keonjhar district of Odisha, India: a Bayesian approach

Malaria, a vector-borne disease, is a significant public health problem in Keonjhar district of Odisha (the malaria capital of India). Prediction of malaria, in advance, is an urgent need for reporting rolling cases of disease throughout the year. The climate condition do play an essential role in the transmission of malaria. Hence, the current study aims to develop and assess a simple and straightforward statistical model of an association between malaria cases and climate variates. It may help in accurate predictions of malaria cases given future climate conditions. For this purpose, a Bayesian Gaussian time series regression model is adopted to fit a relationship of the square root of malaria cases with climate variables with practical lag effects. The model fitting is assessed using a Bayesian version of R² (RsqB). Whereas, the predictive ability of the model is measured using a cross-validation technique. As a result, it is found that the square root of malaria cases with lag 1, maximum temperature, and relative humidity with lag 3 and 0 (respectively), are significantly positively associated with the square root of the cases. However, the minimum and average temperatures with lag 2, respectively, are observed as negatively (significantly) related. The considered model accounts for moderate amount of variation in the square root of malaria cases as received through the results for RsqB. We also present Absolute Percentage Errors (APE) for each of the 12 months (January-December) for a better understanding of the seasonal pattern of the predicted (square root of) malaria cases. Most of the APEs obtained corresponding to test data points is reasonably low. Further, the analysis shows that the considered model closely predicted the actual (square root of) malaria cases, except for some peak cases during the particular months. The output of the current research might help the district to develop and strengthen early warning prediction of malaria cases for proper mitigation, eradication, and prevention in similar settings.

Efficacy of artemether-lumefantrine and artesunate-amodiaquine as first line therapy of uncomplicated malaria in Burkina Faso, 11 years after policy change

Introduction

Artemether-lumefantrine (AL) and artesunate-amodiaquine (ASAQ) are the first line therapy of uncomplicated malaria in Burkina Faso. We assessed the treatment efficacy, tolerability of these drugs 11 years following its adoption as first line treatment.

Methods

In this opened randomized controlled trial carried out in 2016, participants with age over 6 months who consented to participate were randomly assigned treatment with artemether-lumefantrine or artesunate-amodiaquine and followed up for 28 days. Primary endpoint was the treatment efficacy over 28 days of follow up unadjusted by Polymerase chain reaction (PCR).

Results

Two hundred and eighty-one (281) participants were enrolled and the completion rate was 92.9%. No early treatment failure was found. Adequate clinical and parasitological responses were significantly higher in artesunate-amodiaquine group (97% versus 85.2%, p = 0.0008). On day 28, the risk of failure was 4 times higher in AL group 20.14%, 95% CI (13-30.47) against 5.16%, 95% CI (1.91-13.54) in ASAQ group. All treatments had a similar and good tolerability profile.

Conclusion

Eleven years following artemether-lumefantrine and artesunate-amodiaquine adoption as first line therapy for uncomplicated malaria in Burkina Faso, artemether-lumefantrine retained fairly good efficacy even though its efficacy fell below WHO threshold of 90% considering uncorrected outcome.

Malaria elimination transmission and costing in the Asia-Pacific: Developing an investment case

Background: The Asia-Pacific region has made significant progress against malaria, reducing cases and deaths by over 50% between 2010 and 2015. These gains have been facilitated in part, by strong political and financial commitment of governments and donors. However, funding gaps and persistent health system challenges threaten further progress. Achieving the regional goal of malaria elimination by 2030 will require an intensification of efforts and a plan for sustainable financing. This article presents an investment case for malaria elimination to facilitate these efforts. Methods: A transmission model was developed to project rates of decline of Plasmodium falciparum and Plasmodium vivax malaria and the output was used to determine the cost of the interventions that would be needed for elimination by 2030. In total, 80 scenarios were modelled under various assumptions of resistance and intervention coverage. The mortality and morbidity averted were estimated and health benefits were monetized by calculating the averted cost to the health system, individual households, and society. The full-income approach was used to estimate the economic impact of lost productivity due to premature death and illness, and a return on investment was computed. Results: The study estimated that malaria elimination in the region by 2030 could be achieved at a cost of USD 29.02 billion (range: USD 23.65-36.23 billion) between 2017 and 2030. Elimination would save over 400,000 lives and avert 123 million malaria cases, translating to almost USD 90 billion in economic benefits. Discontinuing vector control interventions and reducing treatment coverage rates to 50% will result in an additional 845 million cases, 3.5 million deaths, and excess costs of USD 7 billion. Malaria elimination provides a 6:1 return on investment. Conclusion: This investment case provides compelling evidence for the benefits of continued prioritization of funding for malaria and can be used to develop an advocacy strategy.

Malaria Severity in Mangaluru City in the Southwestern Coastal Region of India

Dakshina Kannada district in the Southwestern region of Karnataka state, India, including Mangaluru city is endemic to malaria. About 80% of malaria infections in Mangaluru and its surrounding areas are caused by Plasmodium vivax and the remainder is due to Plasmodium falciparum. Malaria-associated clinical complications significantly occur in this region. Here, we report the pathological conditions of 41 cases of fatal severe malaria, admitted to the district government hospital in Mangaluru city during January 2013 through December 2016. The results of clinical, hematological, and biochemical analyses showed that most of these severe malaria cases were associated with thrombocytopenia, anemia, metabolic acidosis, acute respiratory distress, and single or multi-organ dysfunction involving liver, kidney, and brain. Of the 41 fatal malaria cases, 24, 10, and seven patients had P. vivax, P. falciparum, and P. vivax and P. falciparum mixed infections, respectively. These data suggest that besides P. falciparum that is known to extensively cause severe and fatal malaria illnesses, P. vivax causes fatal illnesses substantially in this region, an observation that is consistent with recent findings in other regions.

Strengthening surveillance systems for malaria elimination: a global landscaping of system performance, 2015-2017

BACKGROUND

Surveillance is a core component of an effective system to support malaria elimination. Poor surveillance data will prevent countries from monitoring progress towards elimination and targeting interventions to the last remaining at-risk places. An evaluation of the performance of surveillance systems in 16 countries was conducted to identify key gaps which could be addressed to build effective systems for malaria elimination.

METHODS

A standardized surveillance system landscaping was conducted between 2015 and 2017 in collaboration with governmental malaria programmes. Malaria surveillance guidelines from the World Health Organization and other technical bodies were used to identify the characteristics of an optimal surveillance system, against which systems of study countries were compared. Data collection was conducted through review of existing material and datasets, and interviews with key stakeholders, and the outcomes were summarized descriptively. Additionally, the cumulative fraction of incident infections reported through surveillance systems was estimated using surveillance data, government records, survey data, and other scientific sources.

RESULTS

The landscaping identified common gaps across countries related to the lack of surveillance coverage in remote communities or in the private sector, the lack of adequate health information architecture to capture high quality case-based data, poor integration of data from other sources such as intervention information, poor visualization of generated information, and its lack of availability for making programmatic decisions. The median percentage of symptomatic cases captured by the surveillance systems in the 16 countries was estimated to be 37%, mostly driven by the lack of treatment-seeking in the public health sector (64%) or, in countries with large private sectors, the lack of integration of this sector within the surveillance system.

CONCLUSIONS

The landscaping analysis undertaken provides a clear framework through which to identify multiple gaps in current malaria surveillance systems. While perfect systems are not required to eliminate malaria, closing the gaps identified will allow countries to deploy resources more efficiently, track progress, and accelerate towards malaria elimination. Since the landscaping undertaken here, several countries have addressed some of the identified gaps by improving coverage of surveillance, integrating case data with other information, and strengthening visualization and use of data.

TNF-α promoter polymorphisms (G-238A and G-308A) are associated with susceptibility to Systemic Lupus Erythematosus (SLE) and P. falciparum malaria: a study in malaria endemic area

Tumor necrosis factor-α (TNF-α) is a proinflammatory cytokine associated with autoimmune and infectious diseases. Importance of TNF-α in P. falciparum malaria and systemic lupus erythematosus (SLE) have been demonstrated. However, association of functional promoter variants with SLE and malaria is lacking in malaria endemic population. A total of 204 female SLE patients and 224 age and sex matched healthy controls were enrolled in the study. Three hundred fourteen P. falciparum infected patients with different clinical phenotypes were included. TNF-α polymorphisms (G-238A & G-308A) were genotyped by PCR-RFLP. Plasma levels of TNF-α was quantified by ELISA. Heterozygous mutants and minor alleles of TNF-α (G-238A and G-308A) polymorphisms were significantly higher in SLE patients compared to healthy controls and associated with development of lupus nephritis. In addition, both promoter variants were associated with severe P. falciparum malaria. SLE patients demonstrated higher levels of plasma TNF-α compared to healthy controls. TNF-α (G-238A and G-308A) variants were associated with higher plasma TNF-α. In conclusion, TNF-α (G-238A & G-308A) variants are associated with higher plasma TNF-α levels in SLE patients residing in malaria endemic areas and could be a contributing factor in the development of SLE and susceptibility to severe P. falciparum malaria.

Dengue, chikungunya, and scrub typhus are important etiologies of non-malarial febrile illness in Rourkela, Odisha, India

BACKGROUND

We conducted a diagnostic surveillance study to identify Plasmodium, dengue virus, chikungunya virus, and Orientia tsutsugamushi infections among febrile patients who underwent triage for malaria in the outpatient department at Ispat General Hospital, Rourkela, Odisha, India.

METHODS

Febrile patients were enrolled from January 2016-January 2017. Blood smears and small volumes or vacutainers of blood were collected from study participants to carry out diagnostic assays. Malaria was diagnosed using rapid diagnostic tests (RDT), microscopy, and PCR. Dengue, chikungunya, and scrub typhus infections were identified using rapid diagnostic test kits and ELISA.

RESULTS

Nine hundred and fifty-four patients were prospectively enrolled in our study. The majority of patients were male (58.4%) and more than 15 years of age (66.4%). All 954 enrollees underwent additional testing for malaria; a subset of enrollees (293/954) that had larger volumes of plasma available was also tested for dengue, chikungunya and scrub typhus by either RDT or ELISA or both tests. Fifty-four of 954 patients (5.7%) were positive for malaria by RDT, or microscopy, or PCR. Seventy-four of 293 patients (25.3%) tested positive for dengue by either RDT or ELISA, and 17 of 293 patients (5.8%) tested positive for chikungunya-specific IgM by either ELISA or RDT. Ten of 287 patients tested (3.5%) were positive for scrub typhus by ELISA specific for scrub typhus IgM. Seventeen patients among 290 (5.9%) with results for ≥3 infections tested positive for more than one infection. Patients with scrub typhus and chikungunya had high rates of co-infection: of the 10 patients positive for scrub typhus, six were positive for dengue (p = 0.009), and five of 17 patients positive for chikungunya (by RDT or ELISA) were also diagnosed with malaria (p < 0.001).

CONCLUSIONS

Dengue, chikungunya and scrub typhus are important etiologies of non-malarial febrile illness in Rourkela, Odisha, and comorbidity should be considered. Routine febrile illness surveillance is required to accurately establish the prevalence of these infections in this region, to offer timely treatment, and to implement appropriate methods of control.

Temporal trends and differential patterns in the prevalence of severe anaemia in India: observations from country-wide haemoglobin determinations 2008-2018

OBJECTIVES

To assess temporal trends in the occurrence of severe anaemia in India over the past decade, encompassing every state and union territory.

METHODS

For the period 2008-09 to 2017-18, annual estimates (%) of severe anaemia (haemoglobin < 7 g/dl) for India were derived from Health Management Information System datasets, along with 95% confidence intervals (CIs) to construct temporal trends. Differential patterns in the distribution of severe anaemia by geography, epidemiological transition level and socio-demographic index values were also investigated.

RESULTS

Severe anaemia occurred in 3.29% (95% CI: 3.28-3.30%) of all haemoglobin determinations in India in 2017-18, which was less than a third of the number in 2008-09. This decline (overall 7.8% or 0.78% per year) over the past decade was consistent (χ² _trend  = 1 557 296, P < 0.001). Distribution of severe anaemia was heterogeneous between states and union territories (in 2017-18), ranged from < 1% (in Kerala and Lakshadweep) to > 8% (in Telangana). Significant variations were observed according to geographical region (highest in Central zone), epidemiological transition level (highest at higher middle epidemiological transition level) and socio-demographic index (highest at middle socio-demographic index). Severe anaemia burden between rural and urban areas also differed significantly.

CONCLUSION

Although the prevalence of severe anaemia has decreased in India over the last decade, it remains substantial and differs widely with respect to geography, epidemiological transition level, and socio-economic conditions. A detailed assessment of the various aetiologies and documentation of their spatial epidemiology is desirable to understand their relative contribution to the severe anaemia burden and to design appropriate interventions.

Malaria elimination transmission and costing in the Asia-Pacific: Developing an investment case

Background: The Asia-Pacific region has made significant progress against malaria, reducing cases and deaths by over 50% between 2010 and 2015. These gains have been facilitated in part, by strong political and financial commitment of governments and donors. However, funding gaps and persistent health system challenges threaten further progress. Achieving the regional goal of malaria elimination by 2030 will require an intensification of efforts and a plan for sustainable financing. This article presents an investment case for malaria elimination to facilitate these efforts. Methods: A transmission model was developed to project rates of decline of Plasmodium falciparum and Plasmodium vivax malaria and the output was used to determine the cost of the interventions that would be needed for elimination by 2030. In total, 80 scenarios were modelled under various assumptions of resistance and intervention coverage. The mortality and morbidity averted were estimated and health benefits were monetized by calculating the averted cost to the health system, individual households, and society. The full-income approach was used to estimate the economic impact of lost productivity due to premature death and illness, and a return on investment was computed. Results: The study estimated that malaria elimination in the region by 2030 could be achieved at a cost of USD 29.02 billion (range: USD 23.65-36.23 billion) between 2017 and 2030. Elimination would save over 400,000 lives and avert 123 million malaria cases, translating to almost USD 90 billion in economic benefits. Discontinuing vector control interventions and reducing treatment coverage rates to 50% will result in an additional 845 million cases, 3.5 million deaths, and excess costs of USD 7 billion. Malaria elimination provides a 6:1 return on investment. Conclusion: This investment case provides compelling evidence for the benefits of continued prioritization of funding for malaria and can be used to develop an advocacy strategy.

Trends in cause-specific mortality among children aged 5-14 years from 2005 to 2016 in India, China, Brazil, and Mexico: an analysis of nationally representative mortality studies

BACKGROUND

With global survival increasing for children younger than 5 years of age, attention is required to reduce the approximately 1 million deaths of children aged 5-14 years occurring every year. Causes of death at these ages remain poorly documented. We aimed to explore trends in mortality by causes of death in India, China, Brazil, and Mexico, which are home to about 40% of the world's children aged 5-14 years and experience more than 200 000 deaths annually at these ages.

METHODS

We examined data on 244 401 deaths in children aged 5-14 years from four nationally representative data sources that obtained direct distributions of causes of death: the Indian Million Death Study, the Chinese Disease Surveillance Points, mortality data from the Mexican Instituto Nacional de Estadística y Geografía, and mortality data from the Brazilian Institute of Geography and Statistics. We present data on 12 main disease groups in all countries, with breakdown by communicable and nutritional diseases, non-communicable diseases, injuries, and ill-defined causes. To calculate age-specific and sex-specific death rates for each cause, we applied the national cause of death distribution to the UN mortality envelopes for 2005-16 for each country.

FINDINGS

Unlike Brazil, China, and Mexico, communicable diseases still account for nearly half of deaths in India in children aged 5-14 years (73 920 [46·1%] of 160 330 estimated deaths in 2016). In 2016, India had the highest death rates in nearly every category, including from communicable diseases. Fast declines among girls in communicable disease mortality narrowed the gap by 2016 with boys in India (32·6 deaths per 100 000 girls vs 26·2 per 100 000 boys) and China (1·7 vs 1·5). In China, injuries accounted for the greatest proportions of deaths (20 970 [53·2%] of 39 430 estimated deaths, in which drowning was a leading cause). The homicide death rate at ages 10-14 years was higher for boys than for girls in Brazil, increasing annually by an average of 0·7% (0·3-1·1). In India and China, the suicide death rates were higher for girls than for boys at ages 10-14 years. By contrast, in Mexico it was higher for boys than for girls, increasing annually by an average of 2·8% (2·0-3·6). Deaths from transport injuries, drowning, and cancer are common in all four countries, with transport accidents among the top three causes of death for both sexes in all countries, except for Indian girls, and cancer in the top three causes for both sexes in Mexico, Brazil, and China.

INTERPRETATION

Most of the deaths that occurred between 2005 and 2016 in children aged 5-14 years in India, China, Brazil, and Mexico arose from preventable or treatable conditions. This age group is important for extending some of the global disease-specific targets developed for children younger than 5 years of age. Interventions to control non-communicable diseases and injuries and to strengthen cause of death reporting systems are also required.

FUNDING

WHO and the University of Toronto Connaught Global Challenge.

Evolutionary interplay of single nucleotide polymorphisms at the promoter region of TNF-α gene in different clinical outcomes of malaria in India

Host genetic factors are frequently ascribed to differential malaria outcomes as a by-product of evolutionary adaptation. To this respect, Tumor Necrosis factor alpha (TNF-α), a human cytokine, is known to be associated with malaria through its differential regulation in diverse malaria manifestations. Since diversity in differential malaria outcome is uncommon in every endemic settings, possible association of TNF-α and malaria is not commonly established. In order to check for association between the occurrence of Single Nucleotide Polymorphisms (SNPs) in the TNF-α gene with different malaria manifestations, we have sequenced a 4011 bp region constituting the promoter and the whole gene of human TNF-α in 61 patients [(16 cerebral plus severe (SCM), 21 severe (SM) and 24 uncomplicated (UM)] samples in a highly malaria endemic state (Odisha) of India. Multiple sequence alignment revealed presence of six SNPs (-1031 T > C, -863C > A, -857C > T, -308G > A, -806C > T, +787C > A), out of which the -806C > T and +787C > A are novel in malaria patients in general and the +787C > A was detected for the first time in humans. Although alleles due to six different SNPs segregate differentially in the three groups of malaria (SCM, SM and UM) in the present study, interestingly, for the -1031 T > C position, the frequency of individuals possessing the homozygous rare allele was higher in the SCM group with a higher number of heterozygotes in the UM group. The Tajima's D values considering all the SNPs in a defined group were positive and statistically insignificant conforming no evolutionary constraint. However, statistically significant deviation from expectation under Hardy-Weinberg equilibrium for -1031 T > C SNP in the UM group points towards the probable role of natural selection providing some kind of protection to malaria in Odisha, India.

Nationwide Mortality Studies To Quantify Causes Of Death: Relevant Lessons From India's Million Death Study

Progress toward the United Nations 2030 Sustainable Development Goals requires improved information on mortality and causes of death. However, causes of many of the fifty million annual deaths in low- and middle-income countries remain unknown, as most of the deaths occur at home without medical attention. In 2001 India began the Million Death Study in 1.3 million nationally representative households. Nonmedical staff conduct verbal autopsies, which are structured interviews including a half-page narrative in local language of the family's story of the symptoms and events leading to death. Two physicians independently assess each death to arrive at an underlying cause of death. The study has thus far yielded information that substantially altered previous estimates of cause-specific mortality and risk factors in India. Similar robust studies are feasible at low cost in other low- and middle-income countries, particularly if they adopt electronic data management and ensure high quality of fieldwork and physician coding. Nationwide mortality studies enable the quantification of avoidable premature mortality and key risk factors for disease, and provide a practicable method to monitor progress toward the Sustainable Development Goals.

Neurodevelopmental disorders in children aged 2-9 years: Population-based burden estimates across five regions in India

BACKGROUND

Neurodevelopmental disorders (NDDs) compromise the development and attainment of full social and economic potential at individual, family, community, and country levels. Paucity of data on NDDs slows down policy and programmatic action in most developing countries despite perceived high burden.

METHODS AND FINDINGS

We assessed 3,964 children (with almost equal number of boys and girls distributed in 2-<6 and 6-9 year age categories) identified from five geographically diverse populations in India using cluster sampling technique (probability proportionate to population size). These were from the North-Central, i.e., Palwal (N = 998; all rural, 16.4% non-Hindu, 25.3% from scheduled caste/tribe [SC-ST] [these are considered underserved communities who are eligible for affirmative action]); North, i.e., Kangra (N = 997; 91.6% rural, 3.7% non-Hindu, 25.3% SC-ST); East, i.e., Dhenkanal (N = 981; 89.8% rural, 1.2% non-Hindu, 38.0% SC-ST); South, i.e., Hyderabad (N = 495; all urban, 25.7% non-Hindu, 27.3% SC-ST) and West, i.e., North Goa (N = 493; 68.0% rural, 11.4% non-Hindu, 18.5% SC-ST). All children were assessed for vision impairment (VI), epilepsy (Epi), neuromotor impairments including cerebral palsy (NMI-CP), hearing impairment (HI), speech and language disorders, autism spectrum disorders (ASDs), and intellectual disability (ID). Furthermore, 6-9-year-old children were also assessed for attention deficit hyperactivity disorder (ADHD) and learning disorders (LDs). We standardized sample characteristics as per Census of India 2011 to arrive at district level and all-sites-pooled estimates. Site-specific prevalence of any of seven NDDs in 2-<6 year olds ranged from 2.9% (95% CI 1.6-5.5) to 18.7% (95% CI 14.7-23.6), and for any of nine NDDs in the 6-9-year-old children, from 6.5% (95% CI 4.6-9.1) to 18.5% (95% CI 15.3-22.3). Two or more NDDs were present in 0.4% (95% CI 0.1-1.7) to 4.3% (95% CI 2.2-8.2) in the younger age category and 0.7% (95% CI 0.2-2.0) to 5.3% (95% CI 3.3-8.2) in the older age category. All-site-pooled estimates for NDDs were 9.2% (95% CI 7.5-11.2) and 13.6% (95% CI 11.3-16.2) in children of 2-<6 and 6-9 year age categories, respectively, without significant difference according to gender, rural/urban residence, or religion; almost one-fifth of these children had more than one NDD. The pooled estimates for prevalence increased by up to three percentage points when these were adjusted for national rates of stunting or low birth weight (LBW). HI, ID, speech and language disorders, Epi, and LDs were the common NDDs across sites. Upon risk modelling, noninstitutional delivery, history of perinatal asphyxia, neonatal illness, postnatal neurological/brain infections, stunting, LBW/prematurity, and older age category (6-9 year) were significantly associated with NDDs. The study sample was underrepresentative of stunting and LBW and had a 15.6% refusal. These factors could be contributing to underestimation of the true NDD burden in our population.

CONCLUSIONS

The study identifies NDDs in children aged 2-9 years as a significant public health burden for India. HI was higher than and ASD prevalence comparable to the published global literature. Most risk factors of NDDs were modifiable and amenable to public health interventions.

Vector-Borne Disease is a Common Cause of Hospitalized Febrile Illness in India

Acute febrile illness (AFI) is a major cause of morbidity and mortality in India and other resource-limited settings, yet systematic etiologic characterization of AFI has been limited. We prospectively enrolled adults (N = 970) and children (age 6 months to 12 years, N = 755) admitted with fever from the community to Sassoon General Hospital in Pune, India, from July 2013 to December 2015. We systematically obtained a standardized clinical history, basic laboratory testing, and microbiologic diagnostics on enrolled participants. Results from additional testing ordered by treating clinicians were also recorded. A microbiological diagnosis was found in 549 (32%) participants; 211 (12%) met standardized case definitions for pneumonia and meningitis without an identified organism; 559 (32%) were assigned a clinical diagnosis in the absence of a confirmed diagnosis; and 406 (24%) had no diagnosis. Vector-borne diseases were the most common cause of AFI in adults including dengue (N = 188, 19%), malaria (N = 74, 8%), chikungunya (N = 15, 2%), and concurrent mosquito-borne infections (N = 23, 2%) occurring most frequently in the 3 months after the monsoon. In children, pneumonia was the most common cause of AFI (N = 214, 28%) and death. Bacteremia was found in 68 (4%) participants. Central nervous system infections occurred in 58 (6%) adults and 64 (8%) children. Etiology of AFI in India is diverse, highly seasonal, and difficult to differentiate on clinical grounds alone. Diagnostic strategies adapted for season and age may reduce diagnostic uncertainty and identify causative organisms in treatable, fatal causes of AFI.

iNOS polymorphism modulates iNOS/NO expression via impaired antioxidant and ROS content in P. vivax and P. falciparum infection

Nitric oxide (NO) has dicotomic influence on modulating host-parasite interplay, synchronizing physiological orchestrations and diagnostic potential; instigated us to investigate the plausible association and genetic regulation among NO level, components of oxidative stress, iNOS polymorphisms and risk of malaria. Here, we experimentally elucidate that iNOS promoter polymorphisms are associated with risk of malaria; employing mutation specific genotyping, functional interplay using western blot and RT-PCR, quantitative estimation of NO, total antioxidant content (TAC) and reactive oxygen species (ROS).

Genotyping revealed significantly associated risk of P. vivax (adjusted OR = 1.92 and 1.72) and P. falciparum (adjusted OR = 1.68 and 1.75) infection with SNP at iNOS-954G/C and iNOS-1173C/T positions, respectively; though vivax showed higher risk of infection. Intriguingly, mutation and infection specific differential upregulation of iNOS expression/NO level was observed and found to be significantly associated with mutant genotypes. Moreover, P. vivax showed pronounced iNOS protein (2.4 fold) and mRNA (2.5 fold) expression relative to healthy subjects. Furthermore, TAC and ROS were significantly decreased in infection; and differentially decreased in mutant genotypes.

Our findings endorse polymorphic regulation of iNOS expression, altered oxidant-antioxidant components and evidences of risk association as the hallmark of malaria pathogenesis. iNOS/NO may serve as potential diagnostic marker in assessing clinical malaria.

•

Polymorphism of iNOS revealed significantly associated risk of P. vivax and P. falciparum malaria and vivax showed higher risk of infection.

•

We observed mutation and infection specific differential expression of iNOS/NO cascade.

•

We investigated mutation specific antioxidant and ROS orchestration and observed lower TAC and ROS content in infection.

•

Evaluated the clinical correlation among stratified axillary temperature, NO and haemoglobin content during infection.

A randomized, double-blind, active-control trial to evaluate the efficacy and safety of a three day course of tafenoquine monotherapy for the treatment of Plasmodium vivax malaria

Background

Tafenoquine is an investigational 8-aminoquinoline for the prevention of Plasmodium vivax relapse. Tafenoquine has a long half-life and the potential for more convenient dosing, compared with the currently recommended 14-day primaquine regimen.

Methods

This randomized, active-control, double-blind trial was conducted in Bangkok, Thailand. Seventy patients with microscopically confirmed P. vivax were randomized (2:1) to tafenoquine 400 mg once daily for 3 days or 2500 mg total dose chloroquine phosphate (1500 mg chloroquine base) given over 3 days plus primaquine 15 mg daily for 14 days. Patients were followed to day 120.

Results

Day 28 adequate clinical response rate in the per-protocol population was 93% (40/43) (90%CI 83–98%) with tafenoquine, and 100% (22/22) (90%CI 87–100%) with chloroquine/primaquine. Day 120 relapse prevention was 100% (35/35) with tafenoquine (90%CI 92–100%), and 95% (19/20) (90%CI 78–100%) with chloroquine/primaquine. Mean (SD) parasite, gametocyte and fever clearance times with tafenoquine were 82.5 h (32.3), 49.1 h (33.0), and 41.1 h (31.4) versus 40.0 h (15.7), 22.7 h (16.4), and 24.7 h (17.7) with chloroquine/primaquine, respectively. Peak methemoglobin was 1.4–25.6% (median 7.4%, mean 9.1%) in the tafenoquine arm, and 0.5–5.9% (median 1.5%, mean 1.9%) in the chloroquine/primaquine arm. There were no clinical symptoms of methemoglobinemia in any patient.

Discussion

Although there was no difference in efficacy in this study, the slow rate of parasite, gametocyte and fever clearance indicates that tafenoquine should not be used as monotherapy for radical cure of P. vivax malaria. Also, monotherapy increases the potential risk of resistance developing to this long-acting agent. Clinical trials of single-dose tafenoquine 300 mg combined with standard 3-day chloroquine or artemisinin-based combination therapy are ongoing.

Trial registration

Clinicaltrials.gov NCT01290601

Changes in cause-specific neonatal and 1-59-month child mortality in India from 2000 to 2015: a nationally representative survey

BACKGROUND

Documentation of the demographic and geographical details of changes in cause-specific neonatal (younger than 1 month) and 1-59-month mortality in India can guide further progress in reduction of child mortality. In this study we report the changes in cause-specific child mortality between 2000 and 2015 in India.

METHODS

Since 2001, the Registrar General of India has implemented the Million Death Study (MDS) in 1·3 million homes in more than 7000 randomly selected areas of India. About 900 non-medical surveyors do structured verbal autopsies for deaths recorded in these homes. Each field report is assigned randomly to two of 404 trained physicians to classify the cause of death, with a standard process for resolution of disagreements. We combined the proportions of child deaths according to the MDS for 2001-13 with annual UN estimates of national births and deaths (partitioned across India's states and rural or urban areas) for 2000-15. We calculated the annual percentage change in sex-specific and cause-specific mortality between 2000 and 2015 for neonates and 1-59-month-old children.

FINDINGS

The MDS captured 52 252 deaths in neonates and 42 057 deaths at 1-59 months. Examining specific causes, the neonatal mortality rate from infection fell by 66% from 11·9 per 1000 livebirths in 2000 to 4·0 per 1000 livebirths in 2015 and the rate from birth asphyxia or trauma fell by 76% from 9·0 per 1000 livebirths in 2000 to 2·2 per 1000 livebirths in 2015. At 1-59 months, the mortality rate from pneumonia fell by 63% from 11·2 per 1000 livebirths in 2000 to 4·2 per 1000 livebirths in 2015 and the rate from diarrhoea fell by 66% from 9·4 per 1000 livebirths in 2000 to 3·2 per 1000 livebirths in 2015 (with narrowing girl-boy gaps). The neonatal tetanus mortality rate fell from 1·6 per 1000 livebirths in 2000 to less than 0·1 per 1000 livebirths in 2015 and the 1-59-month measles mortality rate fell from 3·3 per 1000 livebirths in 2000 to 0·3 per 1000 livebirths in 2015. By contrast, mortality rates for prematurity or low birthweight rose from 12·3 per 1000 livebirths in 2000 to 14·3 per 1000 livebirths in 2015, driven mostly by increases in term births with low birthweight in poorer states and rural areas. 29 million cumulative child deaths occurred from 2000 to 2015. The average annual decline in mortality rates from 2000 to 2015 was 3·3% for neonates and 5·4% for children aged 1-59 months. Annual declines from 2005 to 2015 (3·4% decline for neonatal mortality and 5·9% decline in 1-59-month mortality) were faster than were annual declines from 2000 to 2005 (3·2% decline for neonatal mortality and 4·5% decline in 1-59-month mortality). These faster declines indicate that India avoided about 1 million child deaths compared with continuation of the 2000-05 declines.

INTERPRETATION

To meet the 2030 Sustainable Development Goals for child mortality, India will need to maintain the current trajectory of 1-59-month mortality and accelerate declines in neonatal mortality (to >5% annually) from 2015 onwards. Continued progress in reduction of child mortality due to pneumonia, diarrhoea, malaria, and measles at 1-59 months is feasible. Additional attention to low birthweight is required.

FUNDING

National Institutes of Health, Disease Control Priorities Network, Maternal and Child Epidemiology Estimation Group, and University of Toronto.

A systematic review and synthesis of the strengths and limitations of measuring malaria mortality through verbal autopsy

Background

Lack of valid and reliable data on malaria deaths continues to be a problem that plagues the global health community. To address this gap, the verbal autopsy (VA) method was developed to ascertain cause of death at the population level. Despite the adoption and wide use of VA, there are many recognized limitations of VA tools and methods, especially for measuring malaria mortality. This study synthesizes the strengths and limitations of existing VA tools and methods for measuring malaria mortality (MM) in low- and middle-income countries through a systematic literature review.

Methods

The authors searched PubMed, Cochrane Library, Popline, WHOLIS, Google Scholar, and INDEPTH Network Health and Demographic Surveillance System sites’ websites from 1 January 1990 to 15 January 2016 for articles and reports on MM measurement through VA. Inclusion criteria: article presented results from a VA study where malaria was a cause of death; article discussed limitations/challenges related to measurement of MM through VA. Two authors independently searched the databases and websites and conducted a synthesis of articles using a standard matrix.

Results

The authors identified 828 publications; 88 were included in the final review. Most publications were VA studies; others were systematic reviews discussing VA tools or methods; editorials or commentaries; and studies using VA data to develop MM estimates. The main limitation were low sensitivity and specificity of VA tools for measuring MM. Other limitations included lack of standardized VA tools and methods, lack of a ‘true’ gold standard to assess accuracy of VA malaria mortality.

Conclusions

Existing VA tools and methods for measuring MM have limitations. Given the need for data to measure progress toward the World Health Organization’s Global Technical Strategy for Malaria 2016–2030 goals, the malaria community should define strategies for improving MM estimates, including exploring whether VA tools and methods could be further improved. Longer term strategies should focus on improving countries’ vital registration systems for more robust and timely cause of death data.

Electronic supplementary material

The online version of this article (doi:10.1186/s12936-017-2071-x) contains supplementary material, which is available to authorized users.

Acute undifferentiated fever in India: a multicentre study of aetiology and diagnostic accuracy

Background

The objectives of this study were to determine the proportion of malaria, bacteraemia, scrub typhus, leptospirosis, chikungunya and dengue among hospitalized patients with acute undifferentiated fever in India, and to describe the performance of standard diagnostic methods.

Methods

During April 2011–November 2012, 1564 patients aged ≥5 years with febrile illness for 2–14 days were consecutively included in an observational study at seven community hospitals in six states in India.

Malaria microscopy, blood culture, Dengue rapid NS1 antigen and IgM Combo test, Leptospira IgM ELISA, Scrub typhus IgM ELISA and Chikungunya IgM ELISA were routinely performed at the hospitals.

Second line testing, Dengue IgM capture ELISA (MAC-ELISA), Scrub typhus immunofluorescence (IFA), Leptospira Microscopic Agglutination Test (MAT), malaria PCR and malaria immunochromatographic rapid diagnostic test (RDT) Parahit Total™ were performed at the coordinating centre. Convalescence samples were not available.

Case definitions were as follows: Leptospirosis: Positive ELISA and positive MAT. Scrub typhus: Positive ELISA and positive IFA. Dengue: Positive RDT and/or positive MAC-ELISA. Chikungunya: Positive ELISA. Bacteraemia: Growth in blood culture excluding those defined as contaminants. Malaria: Positive genus-specific PCR.

Results

Malaria was diagnosed in 17% (268/1564) and among these 54% had P. falciparum. Dengue was diagnosed in 16% (244/1564). Bacteraemia was found in 8% (124/1564), and among these Salmonella typhi or S. paratyphi constituted 35%. Scrub typhus was diagnosed in 10%, leptospirosis in 7% and chikungunya in 6%. Fulfilling more than one case definition was common, most frequent in chikungunya where 26% (25/98) also had positive dengue test.

Conclusions

Malaria and dengue were the most common causes of fever in this study. A high overlap between case definitions probably reflects high prevalence of prior infections, cross reactivity and subclinical infections, rather than high prevalence of coinfections. Low accuracy of routine diagnostic tests should be taken into consideration when approaching the patient with acute undifferentiated fever in India.

Severe vivax malaria: a prospective exploration at a tertiary healthcare centre in Southwestern India

Plasmodium vivax is recognized to cause severe malaria and mortality. We aimed to determine the proportion of disease severity, the spectrum of complications, underlying non-infectious comorbidities and predictors of severity in monoinfection P. vivax malaria among adults at a tertiary healthcare centre in Southwestern India. A prospective cohort study was conducted among microscopically confirmed monoinfection P. vivax acute malaria patients aged, ≥18 years. Cases with pregnancy and concomitant febrile illnesses including mixed malaria were excluded. Cases were distinguished as either 'severe' or 'non-severe' P. vivax malaria as per the definitions laid by the World Health Organization. Of total 511 acute P. vivax cases studied, 23.9% (122/511) had severe malaria. The proportion of severity did not vary between microscopy alone and additional nPCR proved monoinfection P. vivax subgroups. There was no significant difference (p = 0.296) in the occurrence of non-infectious comorbidities among non-severe (9.0%, 35/389) and severe (12.3%, 15/122) vivax groups. Multiple complications despite early parasite clearance resulted in delayed casualty in two cases, indicating overall case fatality rate of 3/1000 cases. Age >40 years, rising respiratory rate, total bilirubin, serum creatinine and falling hemoglobin were the independent predictors of disease severity in this vivax malaria cohort. Total and direct bilirubin and serum urea had good discriminatory performance for severe vivax malaria. Total bilirubin should be considered as an important prognostic marker while managing P. vivax malaria. Patients with multiple complications must be treated cautiously as there may be delayed deterioration leading to mortality despite parasite clearance.