The Review meeting on cross border collaboration for elimination of malaria along the India–Bhutan international border was successfully held from 28–29 August 2023 at Guwahati, Assam, India. The meeting was attended by participants and experts from India and Bhutan including: senior officials from National Center for Vector Borne Disease Control (NCVBDC) of Government of India; State and district teams from Arunachal Pradesh, Assam, Sikkim, West Bengal bordering Bhutan; officials from Bhutan Vector-borne Disease Control Programme & teams from districts in Bhutan bordering India; malaria focal points of WHO Country Offices - India and Bhutan; experts (including one from WCO Thailand) and partners.
The above Review meeting was organized by the Malaria Unit of the Department of Communicable Diseases of the WHO Regional Office for South-East Asia in coordination with WHO Country Offices and national malaria programmes of India and Bhutan. The meeting was a follow-up and step forward to the first meeting of its kind held in November 2019. A gap of four year was observed due to COVID-19 pandemic.
Background
WHO South-East Asia Region has demonstrated outstanding progress in its malaria elimination efforts. Two countries in the Region –Maldives and Sri Lanka– have already been declared by WHO as malaria-free while three others –Bhutan, Nepal and Timor-Leste– have either almost achieved elimination or very much closer.
It is well recognized that no country can achieve and sustain malaria elimination in isolation. A country can be at the verge of malaria elimination while its neighbors on the other side of the international border continuing to be having significant malaria burden as in the case of Bhutan and India. Areas with high endemicity have a high potential for spread across borders leading to introduced cases or even malaria outbreaks in the low endemicity malaria eliminating areas. As a result, countries near elimination may possibly miss the timelines set for achieving their targets unless malaria along the long international borders is adequately addressed. Even in countries that had hitherto been malaria-free and those aiming at elimination, there is a threat of re-establishment and resurgence.
The border areas are fraught with complex geographies and difficult settings. Malaria in such areas poses several challenges due to enormous variation and complexity of its epidemiology. Health and various social/welfare services along international borders are often weaker due to poor staffing compared to central areas. Some of these areas may be chronically affected by security concerns and tensions. Moreover, many people living in border areas, especially in remote ones, are from socioeconomically vulnerable minorities, and disadvantaged in terms of access to health care and social services, and in certain instances, they lack citizenship rights. While universal coverage of populations is being pursued by countries within national boundaries including border areas, informal reports from the field indicate the need for enhancing access to key and vulnerable populations, even for those not yet having valid identification. It is extremely important to reach out to all, who remain vulnerable and at risk or who pose risk to other vulnerable populations. Real-time epidemiological data on malaria situation in border areas is typically weak or even absent altogether.
There is, however, very limited functional inter-country or cross-border collaboration on malaria elimination (countries in greater Mekong sub-region being an exception) except periodic cross-border meetings/consultations despite countries identifying this as a critical need. This is especially true in the context of Indian subcontinent.
India and Bhutan share a friendly international border with almost unrestricted population movement, mainly for economic and socio-cultural reasons. There is a continuous stream of people crossing the border from both sides on daily basis. In Bhutan, there are also vast numbers of workers from India who work in development projects besides those who cross the border for work on a daily basis (returning on the same day). There is also very close proximity of population settlements as well. Malaria has declined in both countries, although at different speeds. Bhutan aimed to achieve malaria elimination by 2020, however in spite of being so near to the target, could not succeed due to an increase in malaria cases during the disruption of health services owing to COVID-19 pandemic. This showed how fragile the progress is, within the countries sharing an international border with a high-burden neighbour, and Bhutan is a classic example of a country struggling to reach the last mile of elimination, yet unable to do so due to the constant threat of imported cases that lead to re-introduction and re-establishment of malaria.
General Objective
To review and discuss the malaria situation and the progress in cross-border collaboration for malaria elimination along the India–Bhutan international border and determine action points to strengthen and sustain a system for data sharing, cross-referral, joint investigation and response.
Specific Objectives
- To review and discuss malaria situation and the progress in malaria elimination in line with the “Operational framework for cross-border collaboration to secure a malaria-free South-East Asia Region”, with special focus on districts along the India-Bhutan international border.
- To facilitate and strengthen local level networking among states/ provinces/ districts/ municipalities along the India-Bhutan international border towards a common goal of malaria elimination.
- To determine priorities and develop national and sub-national action plans to strengthen and sustain a system for data sharing, cross-referral, joint investigation and response to cross-border cases among districts along the India-Bhutan international border.
Highlights of the meeting
The meeting was comprised of an opening session, five technical sessions spanning over 2 days, and a closing session. The technical sessions started with global and regional updates on malaria, followed by presentations on national updates on malaria with a particular focus on India-Bhutan international border, made by the representatives from the national programmes of both countries.
The second session was dedicated for best practices and innovative tools of cross-border collaboration, drawing examples from malaria elimination in Greater Mekong Subregion (GMS) and kala-azar elimination in non-endemic states of India. This was followed by presentations from representatives from selected districts in Bhutan and India illustrating the malaria situation, with special emphasis on action taken along the international border. The data from the districts were critically reviewed during the discussions, and they provided an ideal setting to further analyze actions that would lead to clearing up of malaria foci and eventual achievement of malaria elimination.
Day 2 was dedicated for group work on needs, gaps and action plan to operationalize cross-referral and joint investigation of possible cross-border cases. During the plenary, the groups presented their draft plans which paved the way to discuss on regional, national and local priority actions to strengthen and sustain a system for data sharing, cross-referral, joint investigation and response among districts along the India-Bhutan international border.
The following suggestions were made by the participants during discussions:
- Development of an agreed format for Case Investigation information sharing of imported cases, to be shared through WhatsApp email, along with clear timeline for sharing and feedback.
- Complementary response measures especially in settlements close/along the border areas, e.g., IRS.
- Additional information on situation along border districts can also be shared, i.e., increasing trend of reported cases, outbreak, results of fever screening etc.
- Case Investigation (CI) and Focus Investigation (FI) forms can be standardized, and definitions will be improved through NSP.
- Foci investigation and response: details on entomological surveillance, vector control measures can be shared as part of information sharing for imported cases.
- PQ adherence and follow up should be captured in a treatment card for all patients.
- Fever screening at entry/exit point is less feasible: Further discussion is needed but identifying migrant risk populations/worksites in Bhutan could be more practical.
- Imported cases in Bhutan to be notified immediately for foci response on India side.
Participants prioritized following actions, citing them as practical and feasible:
- Existing WhatsApp group is sufficient for prompt notification. Email and google docs could be considered for additional data and information sharing – a template can be developed. For example, to track trends in active foci. WA notification to specify ‘Attention to’ and state and district level officials to follow up if action taken.
- CI template might need to be created or continue to rely on taking snap shots of CI form (current case notification practice does not have sufficient information for necessary response action on the opposite side foci).
- Not necessary/ feasible to synchronize all response measures. Rather, complementary responses, e.g., case investigation should be a priority.
- Military/border security personnel on each border area should be trained on elimination and required foci response. Line listing and reporting is less feasible, and not required, aggregates are sufficient. Responses are handled by military clinicians and PH officials.
Recommendations
Member countries (Bhutan and India) to consider the following:
Formalize the follow up action as described:
- Capacity building at district level
- Further strengthen quality of interventions e.g., reactive case detection screening on India side
- Embark on M&E of collaborative efforts
- Formalize data sharing graduating from the current practice of sharing at an informal level.
- Sharing of malaria data at district-to-district level through identified focal points: [real time (within 24/48 hours)] including complete case history that would commence with such platforms/modes as – Whatsapp, Dropbox, e-mails, phone, etc.
- District-to-district coordination meetings (quarterly) for joint review and planning.
- Synchronized implementation of interventions like LLIN distribution, IRS by districts on both sides of the border as much as possible.
- Diagnosis and treatment irrespective of nationality and follow up of treatment compliance.
- Strengthening of surveillance and M&E adjusted to burden reduction & elimination settings:
- Initiation of case/focus investigation, classification & response especially in border districts of India reporting relatively few cases.
- Screening of population coupled with IEC/BCC in identified locations (‘market places’ on certain designated days) jointly by India and Bhutan.
- Ensuring reporting from private sector to HMIS by India.
- Involvement of local school students, teachers, self-help groups, community leaders for EDCT, IEC/BCC etc. in remote and difficult-to-reach areas as alternate mechanisms of service delivery in India.
- Optimal cooperation and coordination between Bodoland Territorial Council (BTC)/BTAD and state NVBDCP in Assam.
WHO to consider the following:
- Maintain and support the existing digital platforms for malaria data sharing between India and Bhutan.
- Strengthen capacity at state, district and sub district levels especially on epidemiological analysis, as well as surveillance and M&E with special emphasis on case and focus investigation, etc.
- Facilitate review of district-to-district cross-border coordination annually.