The biggest barrier to malaria treatment is lack of accurate and on time diagnosis : Sanjeev Johar, Head of Rapid Diagnostics, Asia Pacific, Abbott

Shahid Akhter, editor, ETHealthworld.com in conversation with Sanjeev Johar, Head of Rapid Diagnostics, Asia Pacific, Abbott, to know more about the challenges and advancements in malaria elimination in India.

Where does India stand today with respect to NSP goals of eliminating malaria by 2022?
Since the launch of the NSP 2017-2022, efforts to eliminate malaria have intensified. The absolute number of cases has consistently declined from 2.08 million to 1.10 million during 2001 to 2014. This indicates declining overall endemicity of malaria in the country. However,
the absolute numbers continue to be substantial.

Moreover, malaria burden in India continues to disproportionately affect certain regions. About 91% of malaria cases and 99% of deaths due to malaria occur in high disease burden states namely Northeastern States (Arunachal Pradesh, Assam, Manipur, Meghalaya, Mizoram, Nagaland, Sikkim, and Tripura), Andhra Pradesh, Chhattisgarh, Gujarat, Jharkhand, Karnataka, Madhya Pradesh, Maharashtra, Orissa, Rajasthan and West Bengal. In 2014, five out of 36 states/UTs contributed to more than 70% of the total malaria cases namely: Odisha (36%), Chhattisgarh (12%), Jharkhand (9%), Madhya Pradesh (9%) and Maharashtra (5%).

What role does surveillance play in complete elimination of malaria?
While driving awareness, diagnosis/detection and treatment are important, a robust surveillance system is critical in mapping/reaching every patient and in achieving complete elimination. The role of on ground health workers, namely ASHA (accredited social health activists) workers, is critical, as they have the responsibility of reporting the number of cases. For India to be able to meet the 2022 targets, we must follow the WHO guidelines on capacity building, mobilizing adequate health staff along with strengthening infrastructure and surveillance efforts.

What can India do to sustain the progress, and what are the present-day barriers that stop patients from accessing treatment?
Once diagnosed, patients are treated with anti-parasite medication and antibiotics. Artemisinin- based combination therapies (ACTs) and chloroquine phosphate remains most popular treatment for malaria.
The biggest barrier to accessing malaria treatment is lack of accurate and on time diagnosis. Most malaria prone zones such as Orissa, Jharkhand and Bihar have challenges leading to lower penetration of these treatments.
1. Affordability: In rural and micro-rural areas, diagnostic test affordability remains a barrier. This problem is compounded by the fact that malaria-endemic states tend to fare worse on socio–economic indicators.
2. Accessibility: A large proportion of populations in high malaria burden regions reside in geographies where access to healthcare is very limited due to socio-economic factors. Patients may not have access to a qualified HCP who can assess the need for diagnosis.
3. Awareness: A large number of malaria patients are misdiagnosed, which leads to incorrect therapy. It’s important for all to know that the antigen rapid diagnostic tests are more accurate to ensure they have the right course of medication.
4. Accurate and nationwide detection : This can ensure that every malaria patient receives targeted malaria treatment, which may significantly reduce the mortality rate while also decreasing the growth of drug resistance. Thus, diagnostics with last mile logistics, to ensure reach even to the most remote and inaccessible areas, is critical.

What does last mile logistics involve?
First, from a preventive perspective, we need to ensure provision of bed nets, conduct cleanliness drives and educate various stakeholders. Second, from a treatment perspective, we need to recognize symptoms and confirm the diagnosis of malaria in a timely manner so that treatment can be provided, while further preventive measures can be adopted in hotspots.

The use of rapid diagnostics is the most effective way for an easy, accurate and fast diagnosis compared to microscopy, which requires a trained person and is both labor and time intensive. With ease of use and intuitive testing design, rapid diagnostics can extend reach to remote areas. For most rapid diagnostic tests, only elementary training is required. Training a group of 70-80 people does not take more than an hour. Any trained individual, such as a technician, a paramedical staff or an ASHA worker, can conduct a test. The test takes 20 minutes to complete, and multiple tests can be performed at the same time. A qualified pathologist or microbiologist confirms positive reports, following which the patient is treated.

How many states deploy rapid diagnostics kits, and how do they ensure reach?
All states use rapid diagnostic kits, but the extent of use varies based on availability of funds, infrastructure and trained staff. The role of states is to support the Central Government’s Elimination programme. An ideal model to ensure reach includes effective collaboration to utilize existing resources and networks. For example, in Odisha, where Abbott and Malaria No More have partnered with the Government, the network of ASHA workers has been leveraged to conduct tests using rapid diagnostics in micro-rural markets.
In an adaptation of the same model, states could also consider empowering CBOs
(community-based organizations) to help individuals with self-testing.

In 2018, the government announced a ban on antibody (Ab) tests and directed a shift to antigen (Ag) tests. Why is this important for malaria elimination?
The number of false positive results are higher in antibody tests compared to antigen tests. This was a matter of concern, and thus the Government rightly banned the Ab Tests for Malaria which we welcome.
Abbott acted immediately to replace its antibody tests with antigen RDTs across the country. However, in some parts of North, Central and East India, the transition is taking longer than expected because of low awareness and deep penetration of antibody tests.
Another challenge faced in the transition is to ensure convergence of malaria testing practices between rural and urban markets. The use of antibody tests is widespread in rural and interior geographies, whereas antigen tests are more commonly used in urban areas. Abbott’s Rapid Diagnostics team has extensively engaged with three types of stakeholders in rural and interior markets to educate and engage them on the importance of shifting to antigen testing.

1. Smaller distributors: With our new distributor expansion strategy, we have been able to target distributors in smaller districts as well as rural markets.
2. Registered Medical Practitioners (RMPs) or lab technicians: Every year, we train and educate lab technicians and physicians on the usage and benefits of Ag testing
3. Rural market users: We have a special field team that reaches interiors of towns and villages and engages with local health authorities.

How will diagnostics evolve to detect the disease as its prevalence and incidence evolve?
Research is underway to determine the extent of HRP-2 (histidine-rich protein) gene deletion in the Indian population (which has risen significantly and has spread vertically). In the absence of HRP-2 genes in the malaria antigen, most antigen RDTs would not be able to detect malaria, which will lead to false negative results. This implies such patients will remain undiagnosed, and will thus not receive treatment.
However, if we are able to determine the extent of HRP-2 gene deletion, then the Government can take action to ensure that all commercially available tests for malaria incorporate LDH (lactic dehydrogenase) gene detection ability in addition to HRP-2