Photo: Jaya Banerji/MMV

Malaria remains one of the major public health problems in India. [1] The country carries 1.7% of the global malaria case burden, 1.2% of global malaria deaths (52% of all malaria deaths outside of sub-Saharan Africa), and 85.2% of the malaria burden in South East Asia.[2] Of importance is that India carries 47% of the global Plasmodium vivax malaria burden,[2] making the country strategically important for global malaria elimination, particularly in the South-East Asian region. 

The country has made significant gains towards malaria control and eradication. Between 2020 and 2021, the incidence of malaria cases increased by 2.3% from 3.24 to 3.17. Over the same period stagnated at 0.0056  per 1000 of the population at risk. [2] 

The epidemiology of malaria in India is complex because of geographic and ecological diversity. Malaria in India is mainly caused by two major malaria parasites – P. falciparum and P. vivax (though cases of P. ovale and P. malariae have also been reported from some parts of the country). The disease is transmitted by nine Anopheline species, of which six are primary vectors.[1] 

Malaria has a significant economic impact on Indian families with household malaria-associated direct out-of-pocket costs ranging from US$ 0.34– 7.66 (average of about US$ 2.67) and resulting in lost productivity to the tune of about 2-4 days. [3] The national malaria burden has been pegged at approximately US$1940 million per year.[4] 

A National Framework for Malaria Elimination (NFME) 2016-2030, was launched in February 2016 with a vision to eliminate malaria from the country by 2030 and contribute to improved health and quality of life and alleviation of poverty. The NFME has clearly defined goals, objectives, strategies, targets and timelines to serve as a roadmap for advocating and planning malaria elimination in the country in a phased manner.[1] 

Social and geographical distribution of malaria in India 

Malaria affects all population groups, regardless of gender/ age, although children and pregnant women are at higher risk. During June to September, the country experiences the monsoon, characterized by heavy rains across different states; maximum transmission of malaria is due to collection of rainwater that promotes mosquito breeding.  

Malaria in India is especially prevalent  in the north-eastern, eastern and central parts of the country, recording more or less perennial transmission. This is due to a number of factors, such as hilly and forest areas, number of slow moving streams, conflict-affected areas, with inadequate access and health infrastructure, and multi-ethnicity, many of whom are economically disadvantaged. Additionally, there is low community awareness on malaria prevention and control among the tribal and marginalised population.[1]  

Even in states with lower malaria transmission, the majority of the malaria is confined to pockets with the above eco-epidemiological scenario, and also influenced by the continuous influx of mobile and migrant populations from neighbouring moderate/ high endemic states and bordering countries.  

Malaria in India is also characterised by local and focal occurrences; and achievements in reducing malaria mortality and morbidity remain fragile. For example, there was an increase in cases and deaths in 2014. And in 1976, a resurgence of malaria with 6.46 million cases from 0.1 million cases was attributed to inadequate health infrastructure and diminishing monitoring and logistics in many parts of the country. 

Case management 

The policy is to treat all confirmed P. falciparum cases with a full course of artemisinin-based combination therapy (ACT) and low dose primaquine; and treating all confirmed P. vivax cases with a 3-day course of chloroquine and a 14-day course of primaquine.[1]                                         

Severe malaria policy and practice

National treatment guidelines
Recommendation Treatment
Strong Injectable artesunate (IV or IM)
Alternative Intramuscular artemether
Alternative Injectable quinine

*Since artesunate and artemether are often not available, injectable quinine continues to be the most commonly used treatment for severe malaria nationwide.

Recommendation Pre-Referral
Alternative Rectal artesunate
Alternative Intramuscular artesunate
Alternative Intramuscular artemether
Alternative Intramuscular quinine