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Malaria elimination in Bhutan: opportunities and challenges

Malaria is caused by parasites and transmitted through the bites of mosquitoes. It is one of the most important vector borne diseases in tropical and sub-tropical regions of the world causing significant health problem and remains endemic in 91 countries. In 2016, World Health Organization (WHO) estimated approximately 216 million cases and 445,000 succumbed to malaria.

Historically, the first malaria survey in Bhutan was conducted in 1962 with the assistance of Government of India. Malaria is reported from seven districts in southern Bhutan. Since 2010, the number of cases has dwindled and Bhutan is aiming to eliminate malaria by 2018 in line with the global agenda of malaria elimination by 2030. This achievement would be another milestone in the history of Bhutan’s modern health system following the elimination of leprosy in 1997.

A number of factors have been attributed for this reduction, including wide-scale deployment of malaria control interventions especially insecticide treated bed nets commonly known as long-lasting insecticidal nets (LLINs) and spraying of insecticides on the walls of house often known as indoor residual spraying (IRS), prompt diagnosis and treatment of patients with anti-malarial drugs.

Three rounds of mass LLIN distribution was carried out in 2006, 2010, and 2013 in seven endemic dzongkhags through funding from the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM). Studies have shown that these LLINs are effective in preventing malaria infection when used regularly and properly elsewhere in the world. Similarly, the reduction in malaria cases in Bhutan corresponded with the distribution of LLINs. In addition, two rounds of IRS are implemented in these dzongkhags yearly.

As Bhutan is on the verge of malaria elimination, there are few challenges and opportunities that need immediate attention and consideration. The risk of imported malaria is likely to threaten the elimination efforts and a real risk of re-introduction even after successful elimination of malaria. Given the long and porous border between India and Bhutan, cross-border collaboration and synchronising control and preventive activities need strengthening. In addition, it would be worthwhile to consider a mechanism of screening for malaria, both Bhutanese and foreign nationals traveling from malaria endemics countries.

Second, malaria elimination programme is predominantly funded by international donors, which is not sustainable in the long term. There is an urgent need to explore strategies to ensure sustainable funding for preventive and control measures following elimination in 2018. Current provision of LLINs and IRS should be continued until malaria in the bordering states of India is significantly reduced or eliminated. Continued funding will be required to procure LLINs and continued IRS every six months. Possible ways forward are strategies to initiate public-private partnership through cost sharing and social marketing of LLINs to maintain universal coverage of at-risk populations.

Third, it is imperative that people continue using LLINs even when there are no malaria cases to prevent re-introduction. This will require educating the public and motivating them to use LLINs regularly. In addition, people should be encouraged to seek prompt medical care for fevers at the nearest health centre. This would ensure capturing of any malaria cases and initiation of appropriate treatment.

Lastly, there should be strong and ongoing commitment from the government and public health officials to maintain the same level of support even during the post-elimination period. Maintaining current control and awareness strategies through the post-elimination period until the region is free of malaria should be the aim to achieve a malaria free country.

Contributed by Dr Kinley Wangdi

Australian National  University

Canberra, Australia

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