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Background  Risks of malaria epidemics in relation to El Niño and Southern Oscillation (ENSO) events have been mapped and studied at global level. In India, where malaria is a major public health problem, no such effort has been undertaken that inter-relates El Niño, Indian Summer Monsoon Rainfall (ISMR) and malaria. The present study has been undertaken to find out the relationship between ENSO events, ISMR and intra-annual variability in malaria cases in India, which in turn could help mitigate the malaria outbreaks.    Methods  Correlation coefficients among ‘rainfall index’ (ISMR), ‘+ winter ONI’ (NDJF) and ‘malaria case index’ were calculated using annual state-level data for the last 22 years. The ‘malaria case index’ representing ‘relative change from mean’ was correlated to the 4 month (November–February) average positive Oceanic Niño Index (ONI). The resultant correlations between ‘+ winter ONI’ and ‘malaria case index’ were further analysed on geographical information system platform to generate spatial correlation map.    Results  The correlation between ‘+ winter ONI’ and ‘rainfall index’ shows that there is great disparity in effect of ENSO over ISMR distribution across the country. Correlation between ‘rainfall index’ and ‘malaria case index’ shows that malaria transmission in all geographical regions of India are not equally affected by the ISMR deficit or excess. Correlation between ‘+ winter ONI’ and ‘malaria case index’ was found ranging from −0.5 to + 0.7 (p < 0.05). A positive correlation indicates that increase in El Niño intensity (+ winter ONI) will lead to rise in total malaria cases in the concurrent year in the states of Orissa, Chhattisgarh, Jharkhand, Bihar, Goa, eastern parts of Madhya Pradesh, part of Andhra Pradesh, Uttarakhand and Meghalaya. Whereas, negative correlations were found in the states of Rajasthan, Haryana, Gujarat, part of Tamil Nadu, Manipur, Mizoram and Sikkim indicating the likelihood of outbreaks in La Nina condition.    Conclusions  The generated map, representing spatial correlation between ‘ + winter ONI’ and ‘malaria case index’, indicates positive correlations in eastern part, while negative correlations in western part of India. This study provides plausible guidelines to national programme for planning intervention measures in view of ENSO events. For better resolution, district level study with inclusion of IOD and ‘epochal variation of monsoon rainfall’ factors at micro-level is desired for better forecast of malaria outbreaks in the regions with ‘no correlation’.

El Niño Southern Oscillation as an early warning tool for malaria outbreaks in India