Tribal Malaria in India: An Analysis of Malaria Incidence and Mortality over 20-Year Period (2000

Abstract

Objective:

Tribal malaria is well known for its substantial share in the overall malarial load of the country. This paper examines the levels and trends of malaria incidence and mortality in the tribal population for the past two decades.

Methods:

Data on malaria incidence and mortality were collected from an online e-repository that provides statistical data and information on 19 sectors, including health.

Results:

The analysis showed that the malaria incidence and mortality in tribal-dominated regions declined at an average annual rate of 4.3% per annum between 2000 and 2020, which accompanies the tremendous progress made in malaria control at the country level during this time period. The results also showed that between 2016 and 2020, the decline in tribal-dominated regions was consistent and noteworthy in terms of magnitude, a period that marks the implementation of the national framework for malaria elimination in the country.

Conclusion:

The decisive fall in the incidence and mortality of malaria in the tribal-dominated region has put India on track to achieve the target of 3.3 of the Sustainable Development Goals. However, with the pandemic impacting service delivery, monitoring, and reporting, including malaria control programs, it is important to maintain the momentum of progress in malaria control.

Introduction

According to the World Malaria Report 2021, the world had an estimated 241 million malaria cases and 627,000 malaria deaths in 2020 with majority of the cases and deaths reported from World Health Organization African Regions (World Health Organization, 2021). Southeast Asia, including India, accounted for 5 million cases and 9000 deaths in 2020, with India contributing 83% of cases and 82% of malaria deaths in the region. Data from the past two decades indicate a declining trend in the malaria burden. The number of malaria cases in India has declined from 2.08 million (in 2001) to about 0.84 million (in 2017), whereas the mortality has declined from 932 (in 2000) to 562 (in 2014) and then to 194 (in 2017). This declining trend is encouraging, as it not only indicates the likelihood of malaria load reduction, but also alludes to the chance of eliminating it from the country in the coming years.

The National Framework for Malaria Elimination (NFME) 2016–2030, which was launched in 2016, in line with the Global Malaria Technical Strategy, reflects India's commitment to eliminate malaria and is a critical step toward realizing this possibility (Government of India, 2016; World Health Organization, 2015). This framework suggests that malaria elimination in a country needs to proceed in a phased manner, as the malaria burden is not uniform across all states. There are some states where the malarial incidence is high, whereas in others it is low.

Accordingly, the states are divided into four categories in the NFME: 0, 1, 2, and 3. The most critical among them is “category 3” which is termed as the “intensified control phase.” There are 10 states, namely, Chhattisgarh, Jharkhand, Odisha, Madhya Pradesh, Rajasthan, Gujarat, Maharashtra, Mizoram, Meghalaya, and Arunachal Pradesh, and a union territory, Dadra and Nagar Haveli, which fall in this category with Annual Parasite Incidence ranging from minimum of 1.2 to maximum of 20.7. Interestingly, these states and union territories also have substantial tribal populations ranging from 21% to 94%.

Accordingly, this article outlines how the tribal-dominated states in India have been performing in terms of malaria incidence and deaths for the past two decades, and more so since the NFME, by analyzing the trends of malaria cases and mortality during this period.

Methods

With 705 notified tribes (as per Census 2011), India has a substantial proportion of tribal population, which is spread across different states and union territories. Although they are mainly concentrated in central India and the northeastern states, a sizable tribal population is also found in other states. Altogether there are 11 such tribal-dominated states in India, namely, Arunachal Pradesh, Meghalaya, Mizoram, Nagaland, Chhattisgarh, Jharkhand, Odisha, Madhya Pradesh, Gujarat, Rajasthan, and Maharashtra, and 2 union territories, Dadra and Nagar Haveli and Lakshadweep.

The morbidity and mortality data of these states were collected from secondary data sources and analyzed. One of the primary data sources used for data collection is indiastat.com, an e-resource repository that provides statistical data and information on 19 different sectors, including health. Indiastat is a comprehensive and reliable source of secondary level data, which are sourced from different government reports, publications, policies, releases of various ministries/departments of Government of India, parliament question-answers, and so on.

Each data set mentions the details of its original source from where it has been sourced, allowing the cross-checking of available data, and in turn confirming its reliability. The libraries of various academic, research, and development bodies in India and abroad have subscription of this e-resource. Data for two decades from 2000 to 2020 were extracted from this data source, compiled, and analyzed. The data on annual blood examination rate (ABER) and slide positivity rate (SPR) were not included in the analysis as they were not available for all the states and for all the years on this data source, as well as on any other open data source.

Results

Since 2000, there has been a marked decline in the incidence and mortality rate of malaria in India. The number of malaria cases decreased from 2,031,790 to 186,532 between 2000 and 2020, whereas the number of malaria-related deaths declined from 932 to 93 during the same time period. Malaria cases and deaths in tribal-dominated regions also showed a declining trend. In 2000, the tribal-dominated regions reported ∼1,425,803 malaria cases and 932 deaths against 132,971 cases and 93 deaths, respectively, in 2020. Although there has been a marked decline in tribal malaria cases and deaths for the past two decades, their contributions to overall malaria cases and deaths remained substantial and constant (Table 1).

Table 1.

Malaria Cases and Deaths Reported

	2000	2020
Cases (India)	2,031,790	186,532
Cases (tribal-dominated region)	1,425,803	132,971
Proportion of tribal-dominated region's cases in overall cases	70.2	71.3
Deaths (in India)	932	93
Deaths (tribal-dominated region)	735	75
Proportion of tribal-dominated region's deaths in overall deaths	78.9	80.6

Looking at the rate by which malaria cases and deaths have declined during this period, the data indicated that the decline in malaria cases and deaths was at an average annual rate of 4.3% per annum in both tribal and nontribal dominated regions. State-wise disaggregated data showed that the average annual rate of decline in malaria cases in tribal- and nontribal-dominated regions remained in the range of 4–5%, with a few exceptions in nontribal-dominated regions (Table 2). Unlike the decline in malaria incidence, the rate of decline in malaria mortality showed greater variation, particularly in tribal-dominated states, with a few of these states witnessing a decline as low as 2% to as high as 5% per annum.

Table 2.

Interstate Differentials in Malaria Cases and Deaths Reported

	Cases		% Decline^c	Deaths		% Decline^c
	2000	2020	% Decline^c	2000	2020	% Decline^c
Tribal-dominated regions
Lakshadweep	5	6	−1.0	0	0	—
Mizoram	9059	7781	0.7	33	6	3.9
Nagaland	3443	12	4.7	0	0	—
Meghalaya	13,699	2018	4.1	11	4	3.0
Arunachal Pradesh	46,165	33	4.8	0	0	—
Dadra and Nagar Haveli^a	2547	40	4.7	0	0	—
Chhattisgarh	359,155	36,667	4.3	63	34	2.2
Jharkhand	133,453	16,653	4.2	16	8	2.4
Odisha	509,497	41,739	4.4	467	9	4.7
Madhya Pradesh	194,689	6760	4.6	93	1	4.7
Gujarat	36,712	4771	4.1	2	1	2.4
Rajasthan	35,973	1276	4.6	10	0	4.8
Maharashtra	81,406	15,215	3.9	40	12	3.3
Nontribal-dominated regions
Manipur	1064	36	4.6	0	2	—
Sikkim	16	4	3.6	0	0	—
Tripura	12,245	3395	3.4	6	2	3.2
Assam	84,915	484	4.7	43	2	4.5
Jammu and Kashmir	3045	37	4.7	0	0	—
Goa	9164	102	4.7	11	0	4.8
Telangana	5189^b	870	11.9	0	0	—
Andaman and Nicobar Islands	1002	85	4.4	1	2	−4.8
Karnataka	109,118	1701	4.7	14	1	4.4
West Bengal	145,322	14,049	4.3	103	7	4.4
Himachal Pradesh	491	34	4.4	0	0	—
Andhra Pradesh	80,557	2027	4.6	6	0	4.8
Uttaranchal	2008	15	4.7	0	0	—
Kerala	2940	268	4.3	9	1	4.2
Bihar	9509	518	4.5	2	0	4.8
Tamil Nadu	43,053	891	4.7	1	0	4.8
Uttar Pradesh	96,971	28,668	3.4	0	0	—
Haryana	1050	111	4.3	0	0	—
Punjab	483	109	3.7	1	0	4.8
Chandigarh	256	7	4.6	0	0	—
Delhi	2631	135	4.5	0	1	—
Pondicherry	137	15	4.2	0	0	—

Includes Daman and Diu.

The figure is of 2014 (the inception year of the state).

−ve sign indicates an increase.

The year-to-year tally of malaria cases in the country, as well as in tribal-dominated regions, showed interesting patterns. The decline in malaria cases in the country and tribal-dominated regions has not been uniform for the past two decades. In some years, a decline in malaria cases was witnessed, whereas in others there was an increase in the number of cases. However, careful observation of the data shows that there was a constant decline in malaria incidence both at the national level and in tribal-dominated regions after 2015. Not only is there a constant decline but the rate of decline is also substantial.

The decline in malaria incidence, both at the national level and the tribal-dominated state level, was highest after 2015 in comparison with any other years of the previous two decades. The noteworthy 2 years when the decline was maximum were 2017–2018 and 2019–2020 at the country level, wherein malaria cases declined by 49% and 45%, respectively. Likewise, in tribal-dominated regions, 2017–2018 and 2018–2019 were two consecutive years in which the maximum decline in malaria cases was reported. A similar pattern was also seen in the malaria mortality with post-2015 years reporting the maximum decline in malaria deaths, with the exception of 2019–2020 where an increase in malaria deaths can be noticed (Table 3).

Table 3.

Changing Situation of Malaria Cases and Deaths (Year-Wise)

Year	Cases		Deaths		Year	% Change in cases^a		% Change in deaths^a
Year	India	Tribal-dominated regions	India	Tribal-dominated regions	Year	India	Tribal-dominated regions	India	Tribal-dominated regions
2000	203,1790	1,425,803	932	735	2000–2001	−2.6	0.5	−7.8	15.9
2001	2,085,484	1,418,574	1005	619	2001–2002	11.7	14.1	3.2	−9.4
2002	1,842,019	1,218,052	973	676	2002–2003	−1.5	−1.4	−3.4	0.3
2003	1,869,403	1,235,235	1006	674	2003–2004	−2.5	−8.7	5.7	5.9
2004	1,915,363	1,342,725	949	635	2004–2005	5.2	8.8	−1.5	2.5
2005	1,816,342	1,223,930	963	618	2005–2006	1.7	2.6	−77.3	−29.9
2006	1,785,129	1,191,699	1707	878	2006–2007	15.5	10.0	23.2	−17.3
2007	1,508,927	1,072,470	1311	968	2007–2008	−1.1	−0.6	19.5	19.6
2008	1,526,210	1,078,865	1055	776	2008–2009	−2.4	−3.9	−8.4	−14.7
2009	1,563,574	1,121,267	1144	903	2009–2010	−2.3	−5.0	10.6	0.5
2010	1,599,986	1,177,581	1023	878	2010–2011	20.3	15.4	26.8	24.0
2011	1,275,707	995,743	749	661	2011–2012	18.2	17.4	31.0	29.7
2012	1,043,125	822,545	517	463	2012–2013	17.4	15.2	14.9	12.6
2013	861,943	697,412	440	405	2013–2014	−27.9	−29.9	−27.7	6.4
2014	1,102,205	905,809	562	380	2014–2015	−6.1	−8.3	31.7	18.8
2015	1,169,261	981,415	384	310	2015–2016	7.0	5.0	13.8	18.9
2016	1,087,285	932,201	331	249	2016–2017	22.3	22.6	41.4	38.6
2017	844,558	721,585	194	154	2017–2018	49.1	61.9	50.5	52.9
2018	429,928	274,679	96	72	2018–2019	21.3	31.2	19.8	8.3
2019	338,494	188,873	77	66	2019–2020	44.9	29.6	−20.8	−13.6
2020	186,532	132,971	93	75

−ve sign indicates an increase.

Furthermore, post-2015 state-wise disaggregated data of tribal-dominated regions show a reduction in malaria cases among all states. Indeed, during 2017–2018 and 2018–2019, the decline in malaria cases in four states, namely, Odisha, Arunachal Pradesh, Meghalaya, and Nagaland, was greater than the aggregated decline observed in the tribal-dominated states (61.9% and 31.2% during the same time period), with Odisha reporting the maximum decline in 2017–2018 and Nagaland in 2018–2019 (Table 4). It would be apt to highlight here that five of the tribal-dominated states, namely, Odisha, Chhattisgarh, Jharkhand, Meghalaya, and Madhya Pradesh, contributed to almost 55% of the total malaria cases reported between 2000 and 2015 (which is 24,996,468). Barring three states, almost all tribal-dominated states have reported a decline in malaria cases from 2016 to 2020; a surge was observed in Mizoram (2018–2019), Maharashtra (2019–2020), and Odisha (2019–2020).

Table 4.

Interstate Differentials of Malaria Cases in Tribal-Dominated Regions

Years	MZ	NG	MG	ArP	DD	CG	JH	OR	MP	GJ	RJ	MH
Malaria cases (2000–2015)	185,043	59,414	488,262	424,796	40,935	2,850,025	2,468,634	6,208,522	1,733,963	1,365,768	989,761	1,093,938
Proportion in total malaria cases	0.7	0.2	2.0	1.7	0.2	11.4	9.9	24.8	6.9	5.5	4.0	4.4
2016	7583	828	35,147	3128	423	148,220	141,414	444,843	69,106	44,783	12,741	23,983
2017	5715	394	16,454	1546	328	140,727	94,114	347,860	47,541	38,588	10,607	17,710
2018	4296	113	6394	625	245	78,717	57,095	66,311	22,279	22,114	5728	10,757
2019	8543	20	2615	139	81	60,458	37,133	39,556	14,147	13,883	3421	8866
2020	7781	12	2018	33	40	36,667	16,653	41,739	6760	4771	1276	15,215
% Change in cases
2016–17	24.6	52.4	53.2	50.6	22.5	5.1	33.4	21.8	31.2	13.8	16.7	26.2
2017–18	24.8	71.3	61.1	59.6	25.3	44.1	39.3	80.9	53.1	42.7	46.0	39.3
2018–19	−98.9	82.3	59.1	77.8	66.9	23.2	35.0	40.3	36.5	37.2	40.3	17.6
2019–20	8.9	40.0	22.8	76.3	50.6	39.4	55.2	−5.5	52.2	65.6	62.7	−71.6

ArP, Arunachal Pradesh; CG, Chhattisgarh; DD, Dadra and Nagar Haveli; GJ, Gujarat; JH, Jharkhand; MG, Meghalaya; MH, Maharashtra. MP, Madhya Pradesh; MZ, Mizoram; NG, Nagaland; OR, Odisha; RJ, Rajasthan.

Discussion

The control of malaria in India has seen transitions, as well as ups and downs, since its inception in 1953 as the National Programme for Control of Malaria. The initial success was soon dissipated by challenges that led to lateral thinking and many changes in strategies many times over (Pattanayak et al, 1994). The persistent barrier to effective malaria control is tribal endemicity (Sharma et al, 2015). The tribal geography of being away from the mainland, forests, natural waters favoring vector breeding, housing, living habits, health-seeking behaviors, nonpercolation of appropriate health care, and other factors may have ensured that malaria continued to flourish there (Chourasia et al, 2017; Dhiman et al, 2005; Rahi and Sharma, 2022; Singh et al, 2004; Sundararajan et al, 2013; Tripathi and Preetha, 2021).

However, persistent efforts have been made to bear the fruit. Our analysis of the malaria incidence- and mortality-related data of the past two decades indicates the considerable progress and achievements of malaria control efforts made in both the tribal and nontribal regions of India.

In India, malaria control efforts are largely implemented under the National Centre for Vector Borne Disease Control. Surveillance and case management with a focus on early detection and treatment, integrated vector management through the use of insecticide-treated nets and indoor residual spray, environmental management to reduce sources and breeding grounds for mosquitoes, epidemic preparedness and early response, and supportive interventions are some of the strategies adopted and employed under the program. As a result of this program, both malaria incidence and mortality showed declining trends, but with apparent interstate variations in both tribal- and nontribal-dominated regions. The results of malaria control efforts were not found to be uniformly spread over time, and no consistent decline in malaria incidence and mortality was observed until 2015.

The NFME, launched with the ambitious aim of eliminating malaria in the entire country by 2030, has brought about a strategic shift in malaria control programs. With an emphasis on the phase-wise programming approach and on high transmission areas, which mainly include tribal-dominated regions (Government of India, 2017), the malaria control program seems to produce results that are evident in our findings. As part of its focus on high-transmission areas, the NFME has envisaged the aggressive scaling up of existing interventions, intensification of all malaria control activities, innovative strategies, and partnerships.

Our analysis clearly shows that not only is there a consistent decline in overall malaria incidence and mortality in tribal-dominated regions, but the magnitude of decline is also quite enormous post-NFME. This finding is very important, particularly in the Indian context, as these tribal-dominated regions are known for their disproportionate contribution to the overall malaria prevalence and mortality. The activities of the Tribal Malaria Action Plan (under the NFME), such as strengthening health systems, mobile-based surveillance, spot treatment, timely referrals and follow-up, risk profiling of villages, social marketing for the use of bednets, and community mobilization for awareness and behavior change, appeared to have played an instrumental role.

Our study has certain limitations in that it does not include other program-related data, mainly ABER and SPR, which could have also reflected programmatic performance and further strengthened our findings. The availability of health data in tribal population has been an issue and malaria data are not an exception. The data on malaria incidence and mortality in tribal population are not available in one source. Furthermore, the long-term tribal malaria specific data either on incidence, mortality, ABER, SPR, or other programmatic activities remain lacking and hardly readily available. From programmatic and tribal health perspective, there is a need to have a separate database. The Tribal Health and Nutrition Portal, an initiative of Ministry of Tribal Affairs, Government of India, could be a possible platform to integrate both recent, past, and long-term tribal malaria-specific data. Nonetheless, the analysis provides a positive indication of the changing situation of malaria in the tribal areas, particularly after the NFME.

Conclusion

Global malaria eradication, which remains a long-standing public health goal, will only be a reality if India, the third-highest malaria-burdened country, achieves its goal of malaria elimination. In the past two decades, many countries have eliminated malaria and many are on the verge of elimination. India has also shown tremendous progress in malaria control, and the Global Malaria Report (2021) stressed a remarkable decrease in malaria cases and mortality in India. The decisive fall in the incidence and mortality of malaria puts India on track to achieve target 3.3 of the Sustainable Development Goals, which highlights the ending of epidemics of AIDS, tuberculosis, malaria, and neglected tropical diseases and combat hepatitis, water-borne diseases, and other communicable diseases by 2030 (United Nations Development Programme, 2015).

However, history holds up earlier experiences to learn, for example, the instance of a failed attempt at malaria eradication during the 1950s and 1906s, despite major accomplishments in the reduction of the malaria incidence and mortality. The unprecedented situation posed by the COVID-19 pandemic has had a tremendous impact on health problems and programs. The pandemic seems to have affected various facets of program management, including service delivery, monitoring, and reporting, including malaria control programs. It is important that efforts continue to halt any derailment in the achievements witnessed in tribal malaria and maintain the momentum of the progress of malaria control in India.

Footnotes

Authors' Contributions

V.T. conceptualized the idea, contributed toward methodology, analysis, and wrote the original draft. G.S.P. contributed to writing the discussion and reviewing and editing the article. A.K.P. and P.V. contributed to data extraction and compilation.

Ethical Compliance

Ethical approval for this study was obtained from the institutional review board.

Author Disclosure Statement

The authors declare that they have no affiliations with or involvement in any organization or entity with any financial interest in the subject matter or materials discussed in this article.

Funding Information

This article was written under a research study supported by the Indian Council of Medical Research (ICMR), New Delhi, India. Grant No. Adhoc/148/2019/HSR.

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Tribal Malaria in India: An Analysis of Malaria Incidence and Mortality over 20-Year Period (2000–2020)

Abstract

Objective:

Methods:

Results:

Conclusion:

Introduction

Methods

Results

Discussion

Conclusion

Footnotes

Authors' Contributions

Ethical Compliance

Author Disclosure Statement

Funding Information

References