The meeting on cross-border collaboration for elimination of malaria, kala-azar and lymphatic filariasis along the India-Nepal international border was successfully held from 12-14 September 2023 at Lucknow, Uttar Pradesh, India. The meeting was attended by participants and experts from India and Nepal including: relevant national, state/provincial and district level focal points to cultivate their close working relationship and network, share malaria, kala-azar and lymphatic filariasis data in the border districts including cross-border cases and ongoing interventions, jointly discuss constraints and challenges, and agree on the concrete action points to put in place a system and capacity to sustain detection, cross-referral, and joint investigation and interventions of cross-border cases. The meeting was attended by the national focal points (4 in India and 5 in Nepal) and state/provincial/district focal points (25 in India - from UP, Sikkim, West Bengal, Uttarakhand and Gujarat - and 26 in Nepal, from Province 1, 2, 4, 5 and 7).
The above meeting was jointly organized by the Malaria and NTD units 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 Nepal. The meeting provided an opportunity to build on the success of ongoing collaboration on malaria to benefit similar efforts for the elimination of kala-azar and lymphatic filariasis in both India and Nepal.
Background
It is well recognized that no country can achieve and sustain malaria elimination in isolation. Given that each international border has specific characteristics and challenges requiring focus on local context across the border with the involvement of decision makers and implementers at that level, it was a long felt need to focus on India-Nepal border, to accelerate efforts towards malaria elimination to benefit both sides of the border. Since the national programmes in both countries - National Center for Vector-borne Diseases Control (NCVBDC) in India and the VBD Control Section of EDCD in Nepal - deal with not only malaria but two other VBDs (kala-azar and lymphatic filariasis) which are targeted for elimination, a joint meeting on cross-border collaboration for malaria, kala-azar and lymphatic filariasis elimination was the most appropriate approach that could have been taken. This meeting was the result of such thinking, a first of this nature, demonstrating the potential for integration of activities that could have a common goal.
Malaria:
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 neighbour on the other side of the international border continuing to be having significant malaria burden as in the case of Nepal 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 socio-economically vulnerable minorities, and disadvantaged in terms of access to health care & 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 Nepal share a friendly international border with almost unrestricted population movement, mainly for economic and socio-cultural reasons. Malaria has declined in both countries, although at different speeds. Nepal aims to achieve malaria elimination by 2023, yet struggles to reach the last mile of elimination, being unable to do so due to the constant threat of imported cases that lead to re-introduction of malaria. In 2022, Nepal reported 512 malaria cases, of which 92% were imported, almost all from neighbouring India. Interestingly, majority of these cases arises from locations even beyond the bordering districts in India, more precisely, from the States of Maharashtra and Gujarat (among the Nepal migrant workers).
The high malaria transmission in India, which is the highest burden country in the Region, warrants special attention when it comes to cross-border collaboration. Undoubtedly, Nepal would immensely benefit from cross-border collaboration with India for malaria elimination.
Kala-azar:
Historically, the majority of the cases of visceral leishmaniasis (VL or kala-azar) in the world occurred in the Indian subcontinent, comprising Bangladesh, India and Nepal. These three countries reported over 40 000 cases annually between 2004 and 2008, accounting for 70% of the global burden of VL. However, over the past 15 years, endemic countries in the South-East Asia Region have made unprecedented strides towards kala-azar elimination. Between 2011 and 2022, reported kala-azar cases in the Region declined by 97%, with 772 (99.6%) of 775 implementation units having achieved the target for elimination of kala-azar as a public health problem (the annual incidence of one per 10,000 cases at the district or sub-district level – upazilas in Bangladesh, blocks in India or districts in Nepal). Bangladesh has sustained this statis since 2017 and currently developing a dossier for WHO validation of elimination of kala-azar as a public health problem. India and Nepal too have only 1 and 2 implementation units yet to achieve the elimination target.
In India, kala-azar is endemic in 4 States, of which Bihar, Utter Pradesh and West Bengal share a long international border with Nepal, with 15 districts in India side and 21 districts in Nepal side, 89% of which are reporting kala-azar cases in the last five years. In addition, three districts in Province 3 and 1 district in Province of 1 of Nepal sharing the border with Uttaranchal and Sikkim State are also endemic with kala-azar and in recent years, districts across the border in India side are also reporting kala-azar cases.
To accelerate the last mile of Regional efforts to achieve and sustain the elimination of kala-azar as a public health problem in the WHO South-East Asia Region, WHO-SEARO launched a Regional Strategic Framework for accelerating and sustaining elimination of kala-azar in the South-East Asia Region 2022–2026, with particular focus on establishment and sustainment of post-validation surveillance and response strategy. As the number of reported kala-azar cases declines and countries progress towards validation of elimination as a public health problem, it is increasingly becoming of a critical importance to put in place a system and capacity to sustain detection, cross-referral and joint investigation of cross-border cases between two countries/states/districts sharing an international border in the pre- and post-validation phase.
Lymphatic filariasis (LF):
Among 9 LF-endemic countries in the Region, 4 countries have achieved validation of elimination of LF as a public health problem to date, one country (Timor-Leste) is under post-MDA surveillance, and dour countries (India, Indonesia, Myanmar and Nepal) are scaling up MDA with triple drug regimen to accelerate LF elimination. In India, LF is endemic in 328 districts of 20 States, of which 133 districts have already stopped MDA by the end of 2022 and 195 districts remain under the MDA phase. Among the districts under MDA, 14 districts in Bihar and Utter Pradesh share the border with Nepal and continue to struggle with persistent transmission. Similarly in Nepal, LF is endemic in 64 districts but 49 of them are already under post-MDA surveillance and 15 districts are implementing MDA to accelerate LF elimination. Among these remaining 15 districts, 11 districts share the national border with India (Bihar and Utter Pradesh) and continue to fail LF surveys to date. To accelerate elimination of LF across the border, the meeting of the Regional Programme Review Group from 28 June to 1 July 2022 recommended WHO to facilitate data-sharing and joint planning for synchronizing MDA against LF in districts across the border in India and Nepal.
Given the fact that both the same focal points in the National Center for Vector-borne Diseases Control (NCVBDC) under DGHS, MOHFW India, and the VBD Control Section of EDCD, MOH Nepal deal with malaria, kala-azar and LF, it is proposed to have a joint meeting on cross-border collaboration for malaria, kala-azar and LF elimination along the India-Nepal international border to facilitate cross-border collaboration and establish a mechanism for data sharing, joint investigation and synchronized interventions.
General Objective
To discuss the malaria, kala-azar and LF situation and the progress in cross-border collaboration and determine action points to strengthen and sustain a system for data sharing, cross-referral, joint investigation and synchronized interventions along the India-Nepal international border.
Specific Objectives
- To 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-Nepal international border.
- To discuss kala-azar and LF situation and the progress in elimination efforts on districts along the India-Nepal international border, including cross-border cases and ongoing interventions.
- To facilitate local level networking among States/Provinces/Districts/Municipalities along the India-Nepal international border towards a common goal of malaria, kala-azar and LF elimination.
- To determine priorities and develop Regional, national and local action plans to strengthen and sustain strengthen and sustain a system for data sharing, cross-referral, joint investigation and synchronized interventions among districts along the India-Nepal international border.
Highlights of the meeting
The meeting was held in Lucknow in Uttar Pradesh - India, a location with easy accessibility to participants from both sides of the international border. It provided an opportunity to relevant national, state/provincial and district level focal points to cultivate their close working relationship and network, share malaria, kala-azar and LF data in the border districts including cross-border cases and ongoing interventions, jointly discuss constraints and challenges, and agree on the concrete action points to put in place a system and capacity to sustain detection, cross-referral, and joint investigation and interventions of cross-border cases. The meeting was attended by the national focal points (4 in India and 5 in Nepal) and State/Provincial/district focal points (25 in India - from UP, Sikkim, West Bengal, Uttarakhand and Gujarat - and 26 in Nepal, from Province 1, 2, 4, 5 and 7. Bihar and Mumbai participants were unable to participate due to their work commitments.
The meeting was arranged under 5 sessions (excluding the opening and closing sessions) spanning over 3 days.
Day 1: Tuesday, 12 September 2023
The inaugural session commenced with welcome remarks and an overview of meeting objectives by WHO. Administrative announcements ensured smooth proceedings, followed by participant introductions, fostering networking among stakeholders.
Day 1 included sessions on:
- -Global, regional, and national updates on malaria, kala-azar, and LF provided a comprehensive understanding of the current situation. This session underscored the urgency of collaborative action, especially in border areas. Representatives from India and Nepal shared national updates, highlighting progress and challenges specific to the India-Nepal border districts.
- Discussions ensued, led by moderator, focusing on aligning strategies with the operational framework for cross-border collaboration. WHO SEARO elaborated on cross-border collaboration frameworks, drawing insights from successful initiatives. Experiences from the Greater Mekong Subregion (GMS) provided valuable lessons for the India-Nepal context. The first session, in addition, included a discussion on gaps and needs for strengthening cross-border collaboration.
- The session on good practices and innovative tools of cross-border collaboration had a series of presentations, including experiences from the Greater Mekong Subregion (GMS), India-Bhutan cross-border collaboration, migratory registers for kala-azar elimination in non-endemic states of India and GIS platform for kala-azar elimination in SEAR, and synchronized MDA for LF elimination between two countries in WPR.
Day 2: Wednesday, 13 September 2023
Day 2 focused on in-depth discussions and group work sessions. Representatives from border districts in India and Nepal made a presentation on the updates, challenges and plans on malaria, KA and LF elimination, sharing insights into local challenges and interventions. Discussions emphasized gaps and priority areas, with moderators guiding the dialogue. Case investigations and response strategies for cross-border cases were thoroughly examined, emphasizing the need for swift and coordinated action and discussions on the priority actions to strengthen India-Nepal cross-border collaboration.
Subsequently, the participants were divided into three breakout groups, and developed the work plan on cross notification, case/foci investigation and response for malaria/KA and synchronized MDA (for LF). Group work sessions, led by WHO SEARO representatives, focused on developing action plans tailored to local contexts. Participants brainstormed strategies for operationalizing data sharing, cross-referral, and joint interventions, considering logistical, cultural, and administrative factors. The outcomes of each breakout group were then presented in the plenary sessions for further discussion and consolidation.
Day 3: Thursday, 14 September 2023
The final day commenced with plenary presentations summarizing group discussions and proposed action plans. Representatives from each group articulated key findings and recommendations, fostering a shared understanding among participants. A joint exercise on data for decision-making provided practical insights into leveraging data for effective interventions.
Discussions on regional, national, and local action plans emphasized the importance of sustained collaboration and resource mobilization. Moderators facilitated discussions, ensuring all voices were heard. After plenary discussion, the recommendations were presented, then reviewed by all participants and revisions were incorporated based on their feedback. Towards the close of the meeting, a WhatsApp forum was created with all the participants included. The participants welcomed this outcome and immediately started using the forum to share information.
In the closing session, partners provided feedback and expressed commitment to the shared goal of disease elimination. Comments underscored the need for continued collaboration and innovation in addressing evolving challenges. The meeting concluded on a hopeful note, with stakeholders reaffirming their dedication to eliminating malaria, kala-azar, and LF along the India-Nepal border.
Recommendations
Member countries (India and Nepal) to consider the following:
- In districts/ areas near elimination, embark on elimination focused activities e.g. case investigation, case classification, foci investigation, foci classification and response etc., with clearcut timeline for milestones and elimination targets.
- Optimize case management, vector control and surveillance interventions within national boundaries in border areas as well as in areas/cities/towns beyond from where imported cases are emerging
- Develop/update necessary national guidelines and SOP focusing on elimination strategies and conduct cascaded training to the peripheral level at a regular basis.
- Improve in-country coordination among national/state/province/district/municipality to ensure effective case notification/investigation and foci investigation/response are implemented, with allocation of sufficient resources at all levels.
- Ensure case management and follow up irrespective of nationality and case classification. Display availability of free services for treatment at the key port of entry and specific occupational settings with migrants (e.g., factory).
- Ensure travel history is inquired and recorded at HF level for each identified case and cross-border cases notified through District Office up to the National level.
- Strengthen fever surveillance through the health systems (both public and private), particularly in low-endemic districts.
- Operationalize cross-border notification and collaboration
- Leverage the existing MoU between India and Nepal for elimination of communicable diseases (VBDs and VPDs) (2012), MoU for malaria elimination (2017) and multilateral MoU for KA elimination in SEA (2014) to operationalize the cross-border collaboration.
- Designate a district focal point for cross-border notification (DHO Chief in Nepal, District VBD officer in India) and maintain regular updated list of district focal points for all border districts along the border.
- Share a minimum set of indicators on cross-border cases to the relevant district focal point across the border – patient age, sex, original residence, mobile number, travel history, date of diagnosis and onset of fever, treatment status.
- Convene regular cross-border meetings (in person or virtual) every 6 month to jointly review the disease status or share plans on malaria, KA and LF at the border districts and other areas from where imported cases originate.
- Exchange the scheduled date of LF MDA launch in border districts in India and Nepal for synchronizing MDA. Keep updating the progress in LF MDA preparation and implementation in districts across the border.
WHO to consider the following:
- Assist and facilitate elimination focused capacity building at sub-national levels on both sides of the international border.
- To finalize the contact list of state/district VBD focal points with support of WCO India and Nepal and share among the participants.
- Facilitate development of a standardized SOP for cross-border surveillance between India and Nepal for malaria and KA (case notification/investigation, foci investigation and response).
- Update operational framework for cross-border collaboration with a roadmap.
- Support regular organization of a local-level cross-border meeting (in person or virtual) every six months to jointly review the disease status or share plans on malaria, KA and LF at the border districts and other areas from where imported cases originate.