Community and health worker perspectives on malaria in Meghalaya, India: covering the last mile of elimination by 2030.

BACKGROUND: Malaria remains a public health problem in regions of Northeastern India because of favourable bio-geographic transmission conditions, poor access to routine healthcare, and inadequate infrastructure for public health and disease prevention. This study was undertaken to better understand community members' and health workers' perceptions of malaria, as well as their knowledge, attitudes, and prevention practices related to the disease in Meghalaya state. METHODS: The study included participants from three malaria endemic districts: West Khasi Hills, West Jaiñtia Hills, and South Garo Hills from 2019 to 2021. A total of 82 focus group discussions (FGD) involving 694 community members and 63 in-depth interviews (IDI) with health personnel and traditional healers residing within the three districts were conducted. A thematic content analysis approach was employed, using NVivo12 software for data management. RESULTS: Most participants reported a perceived reduction in malaria during recent years, attributing this to changes in attitudes and behaviours in health seeking, and to more effective government interventions. Local availability of testing and treatment, and an improved, more responsive health system contributed to changing attitudes. Long-lasting insecticidal nets (LLINs) were largely preferred over indoor residual spraying (IRS), as LLINs were perceived to be effective and more durable. Community members also reported using personal protective measures such as applying repellents, burning neem tree leaves, straw/egg trays, wearing long sleeve clothes, and applying ointments or oils to protect themselves from mosquito bites. While most participants acknowledged the role of mosquitoes in malaria transmission, other conditions that are not mosquito-borne were also attributed to mosquitoes by some participants. The communities surveyed have largely shifted from seeking treatment for malaria from traditional healers to using public facilities, although some participants reported switching between the two or using both simultaneously. Improved understanding of cerebral malaria, which some participants previously attributed to mental illness due to 'bad spirits', is an example of how cultural and ritualistic practices have changed. CONCLUSION: The findings reveal diverse perceptions among community members regarding malaria, its prevention, practices to prevent mosquito-transmitted diseases, and their opinions about the healthcare system. A key finding was the shift in malaria treatment-seeking preferences of community members from traditional healers to the public sector. This shift highlights the changing dynamics and increasing acceptance of modern healthcare practices for malaria treatment and prevention within tribal and/or indigenous communities. By recognizing these evolving attitudes, policymakers and healthcare providers can better tailor their interventions and communication strategies to more effectively address ongoing needs and concerns as India faces the 'last mile' in malaria elimination.

Understanding COVID-19 vaccine hesitancy in Meghalaya, India: Multiple correspondence and agglomerative hierarchical cluster analyses.

Meghalaya, a state in the northeastern region of India, had a markedly low vaccine uptake compared to the other states in the country when COVID-19 vaccines were being rolled out in 2021. This study aimed to characterize the distinct vaccine-hesitant subpopulations in healthcare and community settings in Meghalaya state in the early days of the vaccination program. We used data from a cross-sectional survey that was administered to 200 healthcare workers (HCWs) and 200 community members, who were a priori identified as 'vaccine-eligible' and 'vaccine-hesitant,' in Shillong city, Meghalaya, in May 2021. The questionnaire collected information on participants' sociodemographic characteristics, COVID-19 history, and presence of medical comorbidities. Participants were also asked to provide a dichotomous answer to a set of 19 questions, probing the reasons for their hesitancy towards COVID-19 vaccines. A multiple correspondence analysis, followed by an agglomerative hierarchical cluster analysis, was performed to identify the distinct clusters of vaccine-hesitant participants. We identified seven clusters: indecisive HCWs (n = 71), HCWs skeptical of COVID-19 and COVID-19 vaccines (n = 128), highly educated male tribal/clan leaders concerned about infertility and future pregnancies (n = 14), less educated adults influenced by leaders and family (n = 47), older adults worried about vaccine safety (n = 76), middle-aged adults without young children (n = 56), and highly educated ethnic/religious minorities with misinformation (n = 8). Across all the clusters, perceived logistical challenges associated with receiving the vaccine was identified as a common factor contributing to vaccine hesitancy. Our study findings provide valuable insights for local and state health authorities to effectively target distinct subgroups of vaccine-hesitant populations with tailored health messaging, and also call for a comprehensive approach to address the common drivers of vaccine hesitancy in communities with low vaccination rates.

Community and health worker perspectives on malaria in Meghalaya, India: Covering the last mile of elimination by 2030.

Background: Malaria remains a public health problem in regions of northeastern India due to favourable bio-geographic transmission conditions, poor access to routine healthcare, and inadequate public health and healthcare infrastructure. This study was undertaken to better understand community members' and health workers' perceptions of malaria, as well as their knowledge, attitudes, and prevention practices related to the disease in Meghalaya state. Methods: The study included participants from three malaria endemic districts: West Khasi Hills, West Jaiñtia Hills, and South Garo Hills from 2019 to 2021. A total of 82 focus group discussions (FGD) with 694 community members and 63 in-depth interviews (IDI) with health personnel and traditional healers residing within the three districts were conducted. A thematic content analysis approach was employed, and NVivo12 software was utilized for data management. Results: Most participants reported a perceived reduction in malaria during recent years and attributed this to changing attitudes and behaviours in health seeking behaviour and effective government interventions. Local availability of testing and treatment, and an improved, more responsive health system contributed to changing attitudes. Long-lasting insecticidal nets (LLINs) were largely preferred over indoor residual spraying (IRS), as LLINs were perceived to be effective and more durable. Community members also reported using personal protective measures such as applying repellents, burning straw/egg trays, wearing long sleeve clothes, and applying ointments or oils to protect themselves from mosquito bites. While most participants acknowledged the role of mosquitoes in malaria transmission, other conditions that are not mosquito-borne were also attributed to mosquitoes by some participants. The communities surveyed have largely shifted from seeking traditional healers to using public facilities, although some participants reported switching between the two or using both simultaneously. Using the example of improved understanding of cerebral malaria which was previously attributed to mental illness due to 'bad spirits', participants explained how cultural and ritualistic practices had changed. Conclusions: Our findings reveal diverse perceptions among community members regarding malaria, its prevention, practices to prevent mosquito-transmitted diseases, and their opinions about the health system. A key finding was the shift in malaria treatment seeking preferences of community members from traditional healers to the public sector. This shift highlights the changing dynamics and increasing acceptance of modern healthcare practices for malaria treatment and prevention within tribal and/or indigenous communities. By recognizing these evolving attitudes, policymakers and healthcare providers can better tailor their interventions and communication strategies to more effectively address ongoing needs and concerns as India faces the 'last mile' in malaria elimination.

Social network and household exposure explain the use of malaria prevention measures in rural communities of Meghalaya, India.

Malaria remains a global concern despite substantial reduction in incidence over the past twenty years. Public health interventions to increase the uptake of preventive measures have contributed to this decline but their impact has not been uniform. To date, we know little about what determines the use of preventive measures in rural, hard-to-reach populations, which are crucial contexts for malaria eradication. We collected detailed interview data on the use of malaria preventive measures, health-related discussion networks, individual characteristics, and household composition in ten tribal, malaria-endemic villages in Meghalaya, India in 2020-2021 (n=1,530). Employing standard and network statistical models, we found that social network and household exposure were consistently positively associated with preventive measure use across villages. Network and household exposure were also the most important factors explaining behaviour, outweighing individual characteristics, opinion leaders, and network size. These results suggest that real-life data on social networks and household composition should be considered in studies of health-behaviour change.

Characterisation of Anopheles species composition and genetic diversity in Meghalaya, northeast India, using molecular identification tools.

Malaria in India is declining, in part due to the use of long-lasting insecticide-treated nets (LLINs) and vector control. Historically, the north-eastern region of India has contributed ~10%-12% of the nation's malaria burden. The important mosquito vectors in northeast India have long been considered to be Anopheles baimaii and An. minimus, both associated with forest habitats. Local deforestation and increased rice cultivation, along with widespread LLIN use, may be changing vector species composition. Understanding if and how vector species composition is changing is critical to successful malaria control. In Meghalaya state, malaria is now at a low level of endemicity with occasional seasonal outbreaks. In a biodiverse setting like Meghalaya, where >24 Anopheles mosquito species have been recorded, accurate morphological identification of all species is logistically challenging. To accurately determine Anopheles species richness in the West Khasi Hills (WKH) and West Jaintia Hills (WJH) districts, adult and larval mosquitoes were collected and identified using molecular methods of allele-specific PCR and cytochrome oxidase I DNA barcoding. In 14 villages across both districts, we identified high species richness, 19 species in total. Molecular findings indicated that An. minimus and An. baimaii were rare, while four other species (An. maculatus, An. pseudowillmori, An. jeyporiensis and An. nitidus) were abundant. Anopheles maculatus was highly prevalent in WKH (39% of light trap collections) and An. pseudowillmori in WJH (45%). Larvae of these four species were found in rice fields, suggesting that land cover change is influencing species composition change. Our results suggest that rice fields might be contributing to the observed abundance of An. maculatus and An. pseudowillmori, which could be playing a role in malaria transmission, either independently due to their high abundance, or in combination with An. baimaii and/or An. minimus.

Protocol for estimating the willingness-to-pay-based value for a quality-adjusted life year to aid health technology assessment in India: a cross-sectional study.

INTRODUCTION: To ensure that the evidence generated by health technology assessment (HTA) is translated to policy, it is important to generate a threshold value against which the outcomes of HTA studies can be compared. In this context, the present study delineates the methods that will be deployed to estimate such a value for India. METHODS AND ANALYSIS: The proposed study will deploy a multistage sampling approach considering economic and health status for selection of states, followed by selection of districts based on Multidimensional Poverty Index (MPI) and identification of primary sampling units (PSUs) using the 30-cluster approach. Further, households within PSU will be identified using systematic random sampling and block randomisation based on gender will be done to select respondent from the household. A total of 5410 respondents will be interviewed for the study. The interview schedule will comprise of three sections including background questionnaire to elicit socioeconomic and demographic characteristics, followed by assessment of health gains, and willingness to pay (WTP). To assess the health gains and corresponding WTP, the respondent will be presented with hypothetical health states. Using time trade off method, the respondent will indicate the amount of time he/she is willing to give up at the end of life to avoid morbidities in the hypothetical health condition. Further, respondents will be interviewed about their WTP for treatment of respective hypothetical conditions using contingent valuation technique. These estimates of health gains and corresponding WTP will then be combined to ascertain the value of WTP per quality-adjusted life year. ETHICS AND DISSEMINATION: The ethical approval has been obtained from the Institutional Ethics Committee (IEC) of Postgraduate Institute of Medical Education and Research, Chandigarh, India. The study outcomes will be made available for general use and interpretation of HTA studies commissioned by India's central HTA Agency.

The need for a holistic approach toward pandemic control: lessons from a cross-sectional study on COVID-19 in Meghalaya, India.

We conducted a community-based cross-sectional survey of 416 participants from Meghalaya, India to assess knowledge, perceptions, and practices toward recommended COVID-19 preventive measures, and to explore health-seeking behavior and stigma during early phase of the pandemic. Most participants had knowledge of the signs and symptoms of COVID-19 (94%) and its spread (96%), and reported positive behavior change such as handwashing ≥ 6 times/day (41% pre-COVID-19 vs. 81% during COVID-19, P < 0.001), sneezing or coughing into sleeves (65% pre-COVID-19 vs. 89% during COVID-19, P < 0.001) and staying home if having flu-like symptoms (44% pre-COVID-19 vs. 94% during COVID-19, P < 0.001). We found delayed healthcare seeking for non-COVID-19 illnesses (16%). Fear of losing life was reported by 26% participants, as was discrimination toward migrant returnees, with 35% blaming returnees for the spread of COVID-19. We highlight the need for a holistic approach toward pandemic control, including social and mental health interventions, in public health strategies.

Advances in Basic and Translational Research as Part of the Center for the Study of Complex Malaria in India.

The Center for the Study of Complex Malaria in India (CSCMi) is one of 10 International Centers of Excellence in Malaria Research funded by the National Institutes of Health since 2010. The Center combines innovative research with capacity building and technology transfer to undertake studies with clinical and translational impact that will move malaria control in India toward the ultimate goal of malaria elimination/eradication. A key element of each research site in the four states of India (Tamil Nadu, Gujarat, Odisha, and Meghalaya) has been undertaking community- and clinic-based epidemiology projects to characterize the burden of malaria in the region. Demographic and clinical data and samples collected during these studies have been used in downstream projects on, for example, the widespread use of mosquito repellants, the population genomics of Plasmodium vivax, and the serological responses to P. vivax and Plasmodium falciparum antigens that reflect past or present exposure. A focus has been studying the pathogenesis of severe malaria caused by P. falciparum through magnetic resonance imaging of cerebral malaria patients. Here we provide a snapshot of some of the basic and applied research the CSCMi has undertaken over the past 12 years and indicate the further research and/or clinical and translational impact these studies have had.

The Impact, Emerging Needs, and New Research Questions Arising from 12 Years of the Center for the Study of Complex Malaria in India.

The Center for the Study of Complex Malaria in India (CSCMi) was launched in 2010 with the overall goal of addressing major gaps in our understanding of "complex malaria" in India through projects on the epidemiology, transmission, and pathogenesis of the disease. The Center was mandated to adopt an integrated approach to malaria research, including building capacity, developing infrastructure, and nurturing future malaria leaders while conducting relevant and impactful studies to assist India as it moves from control to elimination. Here, we will outline some of the interactions and impacts the Center has had with malaria policy and control counterparts in India, as well as describe emerging needs and new research questions that have become apparent over the past 12 years.

A new score for life-threatening ventricular arrhythmias and sudden cardiac death in adults with transposition of the great arteries and a systemic right ventricle.

AIMS: To investigate the incidence of major adverse ventricular arrhythmias and related events (MAREs) and to develop a stratification tool predicting MAREs in adults with a systemic right ventricle (sRV). METHODS AND RESULTS: In a multicentre approach, all adults (≥16 years old) with a sRV undergoing follow-up between 2000 and 2018 were identified. The incidence of MAREs, defined as sudden cardiac death, sustained ventricular tachycardia, and appropriate implantable cardioverter-defibrillator (ICD) therapy, was analysed. The association of MAREs with clinical, electrical, and echocardiographic parameters was evaluated. A total of 1184 patients (median age 27.1 years; interquartile range 19.9-34.9 years; 59% male; 70% with atrial switch repair for D-transposition of the great arteries) were included. The incidence of MAREs was 6.3 per 1000 patient-years. On multivariate analysis, age, history of heart failure, syncope, QRS duration, severe sRV dysfunction and at least moderate left ventricular outflow tract obstruction were retained in the final model with a C-index of 0.78 [95% confidence interval (CI) 0.72-0.83] and a calibration slope of 0.93 (95% CI 0.64-1.21). For every five ICDs implanted in patients with a 5-year MARE risk >10%, one patient may potentially be spared from a MARE. CONCLUSION: Sudden cardiac death remains a devastating cause of death in a contemporary adult cohort with a sRV. A prediction model based on clinical, electrocardiographic, and echocardiographic parameters was devised to estimate MARE risk and to identify high-risk patients who may benefit from primary prevention ICD implantation.

Implementation and acceptance of government-sponsored malaria control interventions in Meghalaya, India.

BACKGROUND: India has made considerable progress in malaria reduction over the past two decades, with government-sponsored indoor residual spraying (IRS) and insecticide-treated bed net (ITN) or long-lasting insecticidal nets (LLIN) distribution being the main vector-related prevention efforts. Few investigations have used non-participant observational methods to assess malaria control measures while they were being implemented, nor documented people's perceptions and acceptance of IRS or LLINs in India, and none have done so in the northeast region. This study evaluated household (HH)-level operation of IRS and distribution of LLINs by India's National Vector Borne Disease Control Programme (NVBDCP) in 50 villages of Meghalaya state, and documented their acceptance and use. METHODS: Study field teams accompanied the government health system teams during August-October, 2019 and 2020 to observe deployment of LLINs, and record HH-level data on LLIN numbers and use. In addition, NVBDCP spray teams were followed during 2019-2021 to observe IRS preparation and administration. HH members were interviewed to better understand reasons for acceptance or refusal of spraying. RESULTS: A total of 8386 LLINs were distributed to 2727 HHs in 24 villages from five Primary Health Centres, representing 99.5% of planned coverage. Interviews with 80 HH residents indicated that they appreciated the LLIN dissemination programme, and generally made regular and appropriate use of LLINs, except during overnight travel or when working in agricultural fields. However, HH-level IRS application, which was observed at 632 HHs, did not always follow standard insecticide preparation and safety protocols. Of 1,079 occupied HHs visited by the spray team, 632 (58.6%) refused to allow any spraying. Only 198 (18.4%) HHs agreed to be sprayed, comprising 152 (14.1%) that were only partly sprayed, and 46 (4.3%) that were fully sprayed. Reasons for refusal included: inadequate time to rearrange HH items, young children were present, annoying smell, staining of walls, and threat to bee-keeping or Eri silk moth cultivation. CONCLUSIONS: These findings are among the first in India that independently evaluate people's perceptions and acceptance of ongoing government-sponsored IRS and LLIN programmes for malaria prevention. They represent important insights for achieving India's goal of malaria elimination by 2030.

An analysis of government-sponsored health insurance enrolment and claims data from Meghalaya: Insights into the provision of health care in North East India.

INTRODUCTION: The Megha Health Insurance Scheme (MHIS) was launched in 2013 in the North-East Indian state of Meghalaya to reduce household out-of-pocket expenditure on health and provide access to high-quality essential healthcare. Despite substantial expansion of the MHIS since the scheme's inception, there is a lack of comprehensive documentation and evaluation of the scheme's performance against its Universal Health Care (UHC) objectives. METHODS: We analysed six years of enrolment and claims data (2013-2018) covering three phases of the scheme to understand the pattern of enrolment, utilisation and care provision under the MHIS during this period. De-identified data files included information on age, sex, district of residence, the district of provider hospital, type of hospital, date of admission, status at discharge, claimed category of care, package codes, and amount claimed. Descriptive statistics were generated to investigate key trends in enrolment, service utilisation, and Government health spending under the MHIS. RESULTS: Approximately 55% of the eligible population are currently enrolled in MHIS. Enrolment increased consistently from phase I through III and remained broadly stable across districts, gender, age group and occupation categories, with a small decline in males 19-60 years. Claims were disproportionately skewed towards private provision; 57% of all claims accrued to the 18 empanelled private hospitals and 39% to the 159 public sector facilities. The package 'General Ward Unspecified' was responsible for the highest volume of claims and highest financial dispensation across all three phases of the scheme. This likely indicates substantial administrative error and is potentially masking both true burden of disease and accurate financial provision for care under the MHIS. Anti-rabies injections for dog/cat bite contributed to 11% of total claims under MHIS III, and 1.6% of all claims under MHIS II. This warrants investigation to better understand the burden of animal bites on the Meghalayan population and inform the implementation of cost-effective strategies to reduce this burden. CONCLUSIONS: This paper describes the first analysis of health insurance enrolment and claims data in the state of Meghalaya. The analysis has generated an important evidence base to inform future MHIS enrolment and care provision policies as the scheme expands to provide Universal Health Coverage to the state's entire population.

Risk factors associated with gall bladder cancer in high incidence areas in India: a systematic review protocol.

INTRODUCTION: Gall bladder cancer (GBC) is a lethal form of malignancy of the gastrointestinal tract with a unique geographical distribution. Cases are aggregated in the river basins of Ganga-Brahmaputra, in the north, east and north-east India, collectively termed as the 'high-risk' zone for GBC. Although some studies report high prevalence of typhoid infection linking with high burden of GBC in these regions, there is no systematic review of the factors associated with GBC in the high incidence areas. To address this gap, we are conducting a systematic review to identify and organise the factors associated with GBC in the high-risk zone of India. METHODS AND ANALYSIS: A systematic review of all observational studies that report a quantitative relationship between at least one risk factor for GBC among adults (>18 years) in the high-risk zone in India will be conducted. The databases PubMed-MEDLINE, CINAHL, EMBASE, Web of Science, Scopus, OpenGrey and Google Scholar published in English and after 1990 will be searched. This review will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses recommendations. The primary outcome is GBC. If data permit, meta-analysis will be performed. Two independent reviewers will independently screen the articles, extract the data and assess the methodological quality of the studies. ETHICS AND DISSEMINATION: As this will be a systematic review without human participants' involvement, there will be no requirement for ethics approval. Findings will be disseminated widely through peer-reviewed publication and media, for example, conferences and symposia. PROSPERO REGISTRATION NUMBER: CRD42021256673.

Household and individual level risk factors associated with declining malaria incidence in Meghalaya, India: implications for malaria elimination in low-endemic settings.

BACKGROUND: A detailed analysis of household and individual level Plasmodium infection patterns in two low-endemic districts of Meghalaya was undertaken to better understand the epidemiology of malaria in northeast India. METHODS: Socio-demographic and behavioural information from residents (aged 1-69 years) of households were collected through pre-tested, questionnaire conducted in 2018 and 2019. Blood samples collected from participants were tested for Plasmodium falciparum and/or Plasmodium vivax infection using rapid diagnostic test, microscopy and PCR. Plasma samples from a subset of participants were analysed for antibodies against thirteen P. falciparum and four P. vivax antigens. Associations between household and individual level risk factors, and Plasmodium infections were evaluated using multilevel logistic regression models. RESULTS: A total of 2753 individuals from 827 households were enrolled in 2018, and 834 individuals from 222 households were enrolled in 2019. Of them, 33 (1.2%) were positive by PCR for P. falciparum in 2018 and none were positive for P. vivax. In 2019, no PCR-positive individuals were detected. All, but one, infections were asymptomatic; all 33 infections were sub-microscopic. Reported history of malaria in the past 12 months (OR = 8.84) and history of travel in the past 14 days (OR = 10.06) were significantly associated with Plasmodium infection. A significant trend of increased seropositivity with age was noted for all 17 antigens. Although adults (≥ 18 years) consistently had the highest seropositivity rates, a sizeable proportion of under-five children were also found to be seropositive. Almost all individuals (99.4%) reported sleeping under an insecticide-treated bed-net, and household indoor residual spray coverage in the 12 months preceding the survey was low (23%). Most participants correctly identified common signs and symptoms of malaria, i.e., fever (96.4%), headache (71.2%), chills (83.2%) and body-ache (61.8%). Almost all participants (94.3%) used government-provided services for treatment of malaria. CONCLUSION: This study explored the epidemiology of malaria in two communities in Meghalaya, India, in the context of declining transmission. The presence of widespread asymptomatic infections and seropositivity among under-five children suggest that low-level Plasmodium transmission persists in this region. Implications of the study findings for malaria elimination efforts in low-transmission settings are discussed.

CRISPR-Cas12a-Based Detection of SARS-CoV-2 Harboring the E484K Mutation.

The novel respiratory virus SARS-CoV-2 is rapidly evolving across the world with the potential of increasing its transmission and the induced disease. Here, we applied the CRISPR-Cas12a system to detect, without the need of sequencing, SARS-CoV-2 genomes harboring the E484K mutation, first identified in the Beta variant and catalogued as an escape mutation. The E484K mutation creates a canonical protospacer adjacent motif for Cas12a recognition in the resulting DNA amplicon, which was exploited to obtain a differential readout. We analyzed a series of fecal samples from hospitalized patients in Valencia (Spain), finding one infection with SARS-CoV-2 harboring the E484K mutation, which was then confirmed by sequencing. Overall, these results suggest that CRISPR diagnostics can be a useful tool in epidemiology to monitor the spread of escape mutations.

Lack of evidence for infectious SARS-CoV-2 in feces and sewage.

The SARS-CoV-2 can be excreted in feces and can reach sewage systems. Determining the presence of infective viral particles in feces and sewage is necessary to take adequate control measures and to elucidate new routes of transmission. Here, we have developed a sample concentration methodology that allows us to maintain viral infectivity. Feces of COVID-19 patients and wastewater samples have been analyzed both by molecular methods and cell culture. Our results show no evidence of infective viral particles, suggesting that fecal-oral transmission is not a primary route. However, larger-scale efforts are needed, especially with the emergence of new viral variants.

Spatial and temporal village-level prevalence of Plasmodium infection and associated risk factors in two districts of Meghalaya, India.

BACKGROUND: Despite declining incidence over the past decade, malaria remains an important health burden in India. This study aimed to assess the village-level temporal patterns of Plasmodium infection in two districts of the north-eastern state of Meghalaya and evaluate risk factors that might explain these patterns. METHODS: Primary Health Centre passive malaria case data from 2014 to 2018 were analysed to characterize village-specific annual incidence and temporal trends. Active malaria case detection was undertaken in 2018 and 2019 to detect Plasmodium infections using PCR. A questionnaire collected socio-demographic, environmental, and behavioural data, and households were spatially mapped via GPS. Adult mosquitoes were sampled at a subset of subjects' houses, and Anopheles were identified by PCR and sequencing. Risk factors for Plasmodium infection were evaluated using bivariate and multivariate logistic regression analysis, and spatial cluster analysis was undertaken. RESULTS: The annual malaria incidence from PHC-based passive surveillance datasets in 2014-2018 was heterogenous but declining across villages in both districts. Active surveillance in 2018 enrolled 1468 individuals from 468 households (West Jaintia Hills) and 1274 individuals from 359 households (West Khasi Hills). Plasmodium falciparum prevalence per 100 people varied from 0 to 4.1% in the nine villages of West Jaintia Hills, and from 0 to 10.6% in the 12 villages of West Khasi Hills. Significant clustering of P. falciparum infections [observed = 11, expected = 2.15, Relative Risk (RR) = 12.65; p < 0.001] was observed in West Khasi Hills. A total of 13 Anopheles species were found at 53 houses in five villages, with Anopheles jeyporiensis being the most abundant. Risk of infection increased with presence of mosquitoes and electricity in the households [Odds Ratio (OR) = 1.19 and 1.11], respectively. Households with reported animals had reduced infection risk (OR = 0.91). CONCLUSION: Malaria incidence during 2014-2018 declined in all study villages covered by the passive surveillance data, a period that includes the first widespread insecticide-treated net campaign. The survey data from 2018 revealed a significant association between Plasmodium infection and certain household characteristics. Since species of Plasmodium-competent mosquito vectors continue to be abundant, malaria resurgence remains a threat, and control efforts should continue.

Ayurveda and medicalisation today: The loss of important knowledge and practice in health?

Ayurveda translates as 'life science'. Its knowledge is not limited to medicine, cure or therapy and is for laypersons, households, communities, as well as for physicians. Throughout its evolutionary history, Ayurveda and Local Health Traditions have reciprocally influenced each other. In modern times, the influence of biomedicine on Ayurveda is leading to its medicalisation. Over the past century, the introduction and perspective of biomedicine into India has made the human being an object for positive knowledge, a being who can be understood with scientific reason and can be governed and controlled through medical knowledge. This paper explores how this shift towards medicalisation is affecting the knowledge, teaching, and practice of Ayurveda. It examines the impact and contribution of processes like standardisation, professionalisation, bio-medicalisation and pharmaceuticalisation on Ayurveda education, knowledge, practice and policies. To maintain health and wellbeing Ayurveda's ancient knowledge and practice needs to be applied at individual, community and health care provider levels and not be limited to the medical system. The current over medicalisation of society is a potential threat to human health and well-being. Ayurveda and LHT knowledge can provide essential teachings and practices to counter-balance this current trend through encouraging a population's self-reliance in its health.

Doktor Kot, Doktor Sla - book doctors, plant doctors and the segmentation of the medical market place in Meghalaya, northeast India.

Despite decades of research on India's plural health care market, the practices of many local health traditions outside the allopathic and codified traditions are under-studied. Drawing on interview and observational data, this paper explores the space in which indigenous traditional Khasi healers in Meghalaya state, northeast India, practice. Khasi indigenous healers describe themselves as doktor sla, plant doctors, to distinguish themselves from doktor kot, or book doctors. This distinction operates as a rhetorical resource, utilised to carve a distinct sphere of expertise in relation to the allopathic sector, and to mark claims for the specifically local appropriateness of traditional practices within a shifting market of state-sponsored provision. Khasi healers are a heterogeneous group who treat a wide variety of conditions, including physical ailments which have no obvious correlates in biomedical systems, and musculoskeletal disorders, with which they have recognised expertise. In addition to claiming these discrete strengths, healers also present themselves as accommodating deficiencies in biomedicine, including inherent generic weaknesses of allopathic care as well as specific local gaps in rural health care provision. Thus, the expertise niches of traditional healers have evolved through their interactions with, and the needs of, the community, but also through managing a shifting boundary with biomedical practitioners, who are explicitly sceptical of their efficacy, but tacitly accepting of the ways in which they manage the gaps in biomedical provision. While codified non-biomedical traditions in India have engaged in universalising professionalising projects, in this setting at least, non-codified practitioners have instead utilised discourses of localism.

Malaria in Meghalaya: a systematic literature review and analysis of data from the National Vector-Borne Disease Control Programme.

BACKGROUND: Meghalaya, one of eight states in the northeastern region of India, has been reported to carry a high malaria burden. However, malaria surveillance, epidemiology, and vector studies are sparse, and no reviews combining these topics with malaria prevention and control strategies have been published in recent years. Furthermore, no analysis of surveillance data has been published documenting the changes in epidemiology following the first distribution of long-lasting insecticidal nets (LLINs) statewide in 2016. METHODS: A hybrid approach was used to describe the status of malaria in Meghalaya. First, a literature search was performed using the terms 'malaria' and 'Meghalaya'. Second, data were obtained from the Meghalaya State Malaria Control Programme for 2006-2017 for analysis of trends. Data from 3 years 2015-2017 were analysed further by district and year to assess changes in malaria incidence and distribution following the introduction of LLINs. RESULTS/CONCLUSIONS: Like malaria in mainland India, malaria in Meghalaya is complex, with both Plasmodium falciparum and Plasmodium vivax parasites in circulation, multiple Anopheles vector species, and reports of both unusual and severe malaria syndromes across all age groups. Integrated statewide malaria epidemiology, vector, and prevention and control data for Meghalaya are not readily available, and published studies are largely focused on a single topic or a single district or region of the state. Although malaria prevention and control approaches are available, (e.g. spraying, LLINs, personal repellents), their use and effectiveness is also not well characterized in the literature. Analysis of state malaria control programme data indicates that case incidence and related fatalities in Meghalaya have declined over the last decade. This could be attributed to changes in treatment guidelines and/or statewide distribution of effective prevention methods such as LLINs. Since the distribution of more than 900,000 LLINs in 2016, the malaria caseload has declined significantly in most Meghalaya districts, excluding the remote and geographically isolated South Garo Hills. Additionally, the proportion of adult malaria cases (15+ years of age versus children 0-14 years) in most districts was significantly greater following LLIN distribution, which likely reflects common lifestyle practices in these areas (e.g. adults working during night hours; small children in the households receiving priority for bed net protection). While reduction in malaria case incidence and related deaths is clear, the changes in malaria transmission and clinical manifestation have not been characterized. Routine epidemiology and vector surveillance combined with real-time data reporting are essential for the continued reduction and eventual elimination of malaria in Meghalaya.