Malaria Situation, Problem, Response and Evaluation in Bangladesh


Introduction

Malaria in Bangladesh continues to be a public health concern and despite extensive efforts by the local and international authorities regarding its control, success in this area has been limited. Islam et al. (2013) have pointed towards the fact that in Southeast Asia, Bangladesh is among the four major malaria endemic countries that has nearly 34% of its population at risk of acquiring malaria. The most frequent causative agent of malaria in Bangladesh is Plasmodium falciparum and malarial prevalence in high endemic areas ranges from 3.1% to 36%. Resistance to a number of older drugs is a common cause of concern in these areas. A multitude of risk factors including poor education, living near water bodies and compromised socio economic status are well established.

In nearly thirteen bordering districts of Bangladesh, Malaria is highly endemic. These areas include the Tripura, Meghalaya, Assam and some neighboring parts of Myanmar. Intense malarial spread in this region has been associated to the geophysical conditions of this area, which is extensively forested and most area is hilly. These conditions coupled with the fact that non-immune population migrates frequently to and from this area makes the risk of transmission further easier throughout the year. WHO (2017) has mentioned that the long-term goal of Bangladesh regarding malaria can be stated as “To reduce malaria morbidity and mortality until the disease is no longer a public health problem in the country”.

Despite significant enhancements in the form of Long Lasting Insecticidal Nets (LLIN) and Insecticide Treated Net coverage, the extension of malarial control programs to distant regions of the country is still a problem (Islam et al. 2013).

Situation

WHO (2017) has pointed out that nearly 98% of malaria cases are reported in the previously mentioned 13 high endemic districts of Bangladesh. The independent (2015) asserts that around 13.25 million people living in these districts are at high risk of acquiring malarial infection. The prevalence rate in 2013 was around 0.7% in these areas. The major bulk of cases (about 80%) are reported from the Chittagong Hill Tracts (CHT) districts, which include the khagrachari, Banderban and Rangamati. The coastal district Cox’s Bazar and Chittagong are also included in the list.

The three CHT districts, Cox’s Bazar and Chittagong have demonstrated a need for intensified malaria control program to achieve elimination targets by 2020. A total of 21,531 cases were reported in 2013 from these districts, which demonstrates the high level of challenge that prevails in these regions. In contrast, the four districts of Mymensingh, Netrakona, Sherpur and Kurigram are already in the pre-elimination phase.

As far as population in the affected areas is concerned, nearly 50% of the population is indigenous; settlers from other areas of the country and from across the border do come to the region and hence contribute to additional burden of the disease. High risk populations include 1) children younger than 5 years, 2) gravid females, 3) travelers from areas where malaria is non-endemic, 4) local people residing in distant areas and returning home after a long time, 5) Jhum cultivators and Tea estates, 6) refugees and 7) people with compromised immune status e.g. AIDS patients.

Diagnosis is largely dependent upon the use of techniques like Malaria microscopy and RDT. RDT finds its application in community settings, whereas microscopy is routinely performed in static health facilities. Recently however, RDT has been replaced by Pan RDT, which has the ability to detect Plasmodium falciparum and non-falciparum malaria. Health workers and community volunteers of NGOs are given the responsibility of diagnosis and treatment.

Problem

The total population of CHT districts is around 1.6 million and since various tribes reside in distant locations and lack communication facilities; they cannot be approached by local health authorities for anti-malarial interventions. The style of house construction in these regions is largely dependent upon materials like bamboo and wood, which renders such housing vulnerable to attack by the vector mosquitos. Since development work in these regions is ongoing, non-immune workers from other regions frequently visit these areas, who are more prone to acquire malarial infection. Since these districts are located in close proximity to the international borders, an additional factor is the cross border movement of non-immune populations to these high endemic areas.

The high-risk groups of population in these areas include the Jhum cultivators, refugees, people living in forests and all those who are unfamiliar to the concept of personal protection from vector mosquitos. Resistance to drugs is a growing concern in Bangladesh and vector prevalence is a persistent threat that can potentially jeopardize elimination efforts at any stage. Therefore, it should be understood that outbreaks could potentially occur which demand rapid responses by concerned authorities and the local community.

Response

The National Malaria Control Program (NMCP) of Bangladesh has a vision to achieve “Malaria-free Bangladesh” and the current goal in this regard is to have achieved “zero indigenous transmission” and “zero” death by the year 2020 (NMCP n.d.). The use and promotion of LLINs has been suggested to be the main tool regarding malarial prevention in Bangladesh.

Kabir et al. (2014) discusses the response of Bangladesh authorities regarding malarial control. The local authorities have responded by distributing long lasting insecticidal nets and by treating ordinary bed nets with insecticides, i.e. Insecticide Treated Net – ITN, to the areas where malaria is endemic. Female community health workers are selected from their areas of residence to ensure local participation in the malaria control program. Since they are selected from their own communities, they provide better involvement with their people. They are tasked with providing home-based care related to the diagnosis and treatment of malaria. Additional areas of responsibility include provision of information related to malaria, its transmission, the proper method of using bed net, symptoms of malaria and about the available facilities for treatment of malaria at the local level.

Since the population remains under considerable influence of religious and political leaders, a variety of sensitization meetings are conducted with such influential to enhance awareness regarding the disease.

The “National Strategic Plan 2015-2020” aims to achieve the goal of malaria elimination-‘zero case and zero death’ by the time it matures. The ultimate purpose is to reach a ‘Malaria free Bangladesh’; a goal that aligns with Bangladesh’s fundamental human right and social justice aims.

National Malaria Control Programme et al. (2015) have defined 5 objectives of the plan which include, 1) achieving 100% coverage of ‘at risk’ population by 2018, 2) to ensure 100% patients receive early diagnosis and effective treatment by 2018, 3) Strengthening of program to ensure elimination by 2020, 4) strengthening of vector and disease surveillance, monitoring and evaluation towards elimination and 5) intensification of communication, advocacy and social mobilization for total elimination of malaria.

Evaluation

In Bangladesh, a baseline survey to get insight into the prevalence of malaria was conducted in 2007. It was found that around 39.7 per 1000 population was affected by the disease (National Institute of Population Research and Training et al. 2009). A follow up survey to measure malarial prevalence during the post-intervention era was conducted in the endemic areas; the purpose was to get an idea about the effects of interventions and to learn about people’s knowledge regarding malaria. This survey included 70 sub-districts of the high endemic area and lasted from August to November, 2013 (Alam et al. 2016).

Alam et al. (2016) assert that during this survey the unadjusted malarial prevalence was found to be 0.92 per 1000 population. Nearly 77.78% cases were due to Plasmodium falciparum. No specific gender demonstrated increased vulnerability to the disease. The highest prevalence of malaria was found in the Bandarban district of Bangladesh, where it was still around 6.7 per 1000. Children under the age of five years were more likely to acquire the disease; prevalence in this group was 7.37 per 1000.

As far as awareness regarding malaria is concerned, people living in endemic areas demonstrated an improvement in the level of knowledge. Most households (97.76%) were able to demonstrate their understanding regarding the disease. 97.26% were aware of the fact that fever is a cardinal sign of malarial disease. The relationship of mosquito bite and malaria was well understood by about 95% of respondents (Alam et al. 2016).

Regarding the preferred method of prevention, about 90% expressed their inclination towards the use of insecticide-treated bed nets (ITN) as their preferred method. Those living in the CHT areas were better aware that public health facilities and NGO workers were better options regarding malaria treatment. In contrast, the population living in non-CHT areas demonstrated comparatively poor understanding of this aspect. Regarding the provision of free treatment for malaria, 78.78% were aware that it is provided without any cost. Alam et al. (2016) assert that a remarkable increase in the understanding of symptoms of malaria, its transmission, its prevention through the use of nets and mosquito-repellants and preferred treatment options was evident in 2013, as compared to 2007. Overall, Bangladesh has demonstrated a 75% decrease in the incidence of malaria due to its ability to deliver simple interventions discussed earlier. It is therefore safe to assert that this country has made significant progress in the control of malaria and is on its way to achieve its goal during the coming years.

Alam et al. (2016) have mentioned that artemisinin-based combination therapy has demonstrated superior efficacy in the treatment of malaria caused by Plasmodium falciparum. However, with the passage of time, resistance to this regimen is emerging and there is growing concern that beyond a certain point, this therapeutic approach may fail to suffice. Since emergence of resistance has been reported in the neighboring Myanmar and India, Bangladesh is expecting to witness its transmission to its border areas in the near future. This is likely to emerge as a novel challenge for the Bangladeshi health authorities; a prospect that demands timely detection and interventions.

Conclusion

Based on the above discussion, it is logical to conclude that Malaria is a significant health problem in Bangladesh and many thousand individuals are affected by this disease on annual basis. The disease is largely limited to bordering areas of the country and nearly 13 districts are profoundly affected. The government appears to be strongly determined to achieve eradication of malaria; however, this determination is challenged by a number of factors that complicate the scenario. Malaria control during the recent years has witnessed overwhelming success due to effective development and implementation of programs aimed at eliminating malaria from the region. It is hoped that Bangladesh will achieve its aim of malaria control in the near future, efforts for which are already underway.

References

Alam, M.S., Kabir, M.M., Hossain, M.S., Naher, S., Ferdous, N.E.N., Khan, W.A., Mondal, D., Karim, J., Shamsuzzaman, A.K.M., Ahmed, B.N. and Islam, A., 2016. Reduction in malaria prevalence and increase in malaria awareness in endemic districts of Bangladesh. Malaria journal, 15(1), p.552.

Islam, N., Bonovas, S. and Nikolopoulos, G.K., 2013. An epidemiological overview of malaria in Bangladesh. Travel medicine and infectious disease, 11(1), pp.29-36.

Kabir, M.M., Naher, S., Islam, A., Karim, A., Rasid, M.H.O. and Laskar, S.I., 2014. Vector control using LLIN/ITN: reduction of malaria morbidity in Bangladesh. Malaria Journal, 13(1), p.P47.

National Institute of Population Research and Training (NIPORT), Mitra and Associates, and Macro International. 2009. Bangladesh Demographic and Health Survey 2007. Dhaka, Bangladesh and Calverton, Maryland, USA: National Institute of Population Research and Training, Mitra and Associates, and Macro International.

National Malaria Control Programme, Communicable Disease Control, Division Directorate General of Health Services and Ministry of Health & Family Welfare Bangladesh. 2015. Malaria national strategic plan 2015-2020. [Online] Available at: http://static1.1.sqspcdn.com/static/f/471029/25394400/1409707011800/NSP+Malaria+2015-2020+Bangladesh_Full+no+annexes.pdf?token=5NfaJ39GLwj60UHTmnGB3i0Nbaw%3D [Accessed: 24 Feb. 2017].

NMCP. n.d. National Malaria Control Program. [Online] Available at: http://www.nmcp.gov.bd/ [Accessed: 24 Feb. 2017].

The independent. 2015. Malaria situation in Bangladesh. [Online] Available at: http://www.theindependentbd.com/printversion/details/9123 [Accessed: 24 Feb. 2017].

WHO. 2017. Malaria. [Online] Available at: http://www.searo.who.int/bangladesh/areas/malaria/en/ [Accessed: 24 Feb. 2017].


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