Malaria is one of the major public health problems in Bangladesh. Out of 64 districts in the country 13 border districts in the east and northeast facing the eastern states of India and a small territory of Myanmar are in high endemic malaria zones, reporting about 98% of the total malaria cases every year.
2. Malaria is one of the major public health
problems in Bangladesh. Out of 64 districts in
the country 13 border districts in the east
and northeast facing the eastern states of
India and a small territory of Myanmar are in
high endemic malaria zones, reporting about
98% of the total malaria cases every year.
3. Malaria is caused by the plasmodium parasite. The parasite can be
spread to humans through the bites of infected mosquitoes.
There are many different types of plasmodium parasite, but only five
types cause malaria in humans. These are:
Plasmodium falciparum – mainly found in Africa, it is the most common
type of malaria parasite and is responsible for most malaria deaths
worldwide.
Plasmodium vivax – mainly found in Asia and South America. This
parasite causes milder symptoms than Plasmodium falciparum, but it
can stay in the liver for up to three years, which can result in relapses.
Plasmodium ovale – fairly uncommon and usually found in West Africa. It
can remain in your liver for several years without producing symptoms.
Plasmodium malariae – this is quite rare and usually only found in Africa.
Plasmodium knowlesi – this is very rare and found in parts of South East
Asia.
4. Was first known as AGUE or MARSH FEVER
•Italian: “aria cattiva ”= bad air; “mal aria”= bad air.
Malaria may have contributed to the decline of the
Roman Empire and was so pervasive in Rome that it was
known as the "Roman fever“. Several regions in ancient
Rome were considered at-risk for the disease because
of the favourable conditions present for malaria vectors.
•2700 BCE: The NeiChing (Chinese Canon of Medicine)
discussed malaria symptoms and the relationship
between fevers and enlarged spleens.
•Hippocrates from studies in Egypt was first to make
connection between nearness of stagnant bodies of
water and occurrence of fevers in local population.
•Romans also associated marshes with fever and
pioneered efforts to drain swamps.
5. Symptoms of malaria typically develop within 10 days to four
weeks following the infection. In some patients, symptoms may
not develop for several months. Some malarial parasites can enter
the body but will be dormant for long periods of time. Common
symptoms of malaria include:
shaking chills that are moderate to severe
high fever
profuse sweating
headache
nausea
vomiting
diarrhea
anemia
muscle pain
convulsions
coma
bloody stools
6. Malaria is a major public health problem in
some parts of Bangladesh, particularly in 13
districts in the north-east & south-east
areaswhich border India and Myanmar. In
2013 the prevalence rate of malaria was
found to be 0.7% in these districts. About
80% of the total cases are reported from the
three Chittagong Hill Tract (CHT) districts
(Rangamati, Khagrachari and Banderban)
including Chittagong and the coastal
district Cox’s Bazar.
7.
8. Total population of the three CHT districts is 1.6
million. The indigenous population constitutes about
50% of the total population in these districts. The
tribal hamlets are in clusters in the remote hills and
foothills and some are hard-to-reach due to lack of
communication.
Most of the houses are thatched built with indigenous
material e.g. bamboo, wood etc. and these houses
seldom have any protection against the vector
mosquitoes and thus peoples are vulnerable to
malaria infection.
There are also higher risk of malaria transmission in
the border areas, due to cross-border
movement/migration across international boundaries
with eastern states of India and part of Myanmar.
9. Four districts (Mymensingh, Netrakona, Sherpur and
Kurigram) with eight endemic upazilas have low
transmission of malaria and have shown <5% malaria
positivity rates (RDT and Microscopy) over last three
years. These districts currently may be considered for
adopting pre-elimination strategies. The NMCP should
have phased targets of elimination for these districts
and gradually expanding to the other moderate
endemic areas in near future. There is significant
progress in malaria control in Bangladesh during the
period from 2008 to 2013 showing a progressive
decline in total cases and deaths.
10.
11. Malaria transmission in Bangladesh is a complex
phenomenon due to the presence of multiple vectors
each playing unique role for their vector bionomics
and susceptibility to insecticides that should be taken
into account in vector control.
There are four primary vectors (An philippinensis An
minimus, An sundaicus and An baimai/An dirus),
three secondary vectors (An vagus, An annularis and
An aconitus) and at least two suspected vectors (An
maculatus and An willmori)) with potential role in
transmission in various parts of the country. These
primary vectors of malaria were detected and
confirmed since the malaria eradication period.
12.
13. Bangladesh has a tropical monsoon climate. The average rainfall varies from
119 to 348 cm.The alluvial soil of Bangladesh is continuously enriched by
heavy silt-deposits during the rainyseason. The total forest area covers
about 8 percent of the land area. With the Global Climate Change
Bangladesh is likely to be more affected and there might be increased
prevalence of vector borne diseases.
Most malaria cases are reported in three administrative regions (divisions) of
Bangladesh .Mosquitoes are very sensitive to moisture and temperature, and
their activities can be monitored by weather conditions. Three weather
parameters are important for mosquito activity and malaria epidemiology:
temperature, humidity, and rainfall. Temperature and humidity in
Bangladesh are relatively stable from year to year. However, annual rainfall
fluctuates between 2,000 and 3,000 mm.
Two seasons are defined in the annual cycle: a warm, wet season from April
to October, and a cool, dry season from November to March. During the
cool, dry season, mosquitoes are less active and the number of malaria cases
is small. This number increases considerably during the warm, wet season.
14. Historically, the malaria control programme in
Bangladesh had four phases:
Malaria Eradication Programme (in early
1960s;
Malaria Control Programme (1977-1994);
Revised Malaria Control Strategies (RMCS-
1994); and
Continuation of RMCS with updated
strategies until today.
15. Figure: Malaria Programme in Bangladesh-Milestone Activities
Current activities are part of the existing National Strategic Plan (2008-
2015) which envisaged 60% reduction of malaria morbidity and mortality
(compared to baseline 2005) by 2015. Malaria National Strategic Plan
(2015-2020 ) is being introduced to achieve ‘zero indigenous
transmission’ and ‘zero death’ aiming malaria elimination in Bangladesh
by 2020.
16. Figure: Mortality of Anophele Species to LLINs & ITNs
The LLIN namely BestNet (manufactured by Netprotect) supplied in 2013.
Deltamethrin treated Polyethylene net and normal net dipped with K-O-TAB 1-2-3
(only Durgapur of Netrokona) were tested.
The mortality rate for selected were found 36% (polyester) & 31% (Normal net)
dipped with K O TAB-123 in Durgapur.
17. What is LLIN and ITN?
An insecticide-treated net (ITN) is a net (usually a bed
net), designed to block mosquitoes physically, that has
been treated with safe, residual insecticide for the
purpose of killing and repelling mosquitoes, which carry
malaria.
A long-lasting insecticide-treated net (LLIN) is an ITN
designed to remain effective for multiple years without
retreatment. The insecticide is cleverly bound within the
fibres that make up the netting and is 'slow released' over
a 4-5 year period.
K-O Tab 1-2-3 is a 'dip-it-yourself' long-lasting
formulation with time-limited interim recommendation
from WHO for treatment of washed white and coloured
polyester nets for up to 15 washes.
18. Statistic: HEED Bangladesh signed in agreement with
GFATM one of the principle recipients BRAC in May,
2008 to implement Malaria Control Project in Jaintapur
Upazila in Sylhet district with a view to contribute in
reducing malaria burden nationally by June, 2015.
What HEED BD did is:
1. LLIN: Total distributed
15500 and replaced
15500
2. ITN with KO tab123: Total
bed net treated 19082 in
2011
3. House-to-house
education for promotion
and use of LLINs/ITNs
20. The NMCP had the GFATM
support since 2007 and
there was an increase in
number of cases due to
scaling up of interventions;
introduction of RDR for
diagnosis, and ACT for
treatment of P. falciparum
cases. Thereafter, a steady
decline is noted from 84,690
cases in 2008 to 26,891
cases in 2013, having a
68.2% reduction in case
incidence. The total deaths
came down to 15 in 2013 as
against 154 in 2008 showing
90.2 % reduction.
Table: District-wise Epidemiological data (13 Districts, 2011-2013)
21. Malaria microscopy and RDT are the main tools for
diagnosis in Bangladesh. Microscopy is usually used at
static health facilities (n=83) and new microscopy centers
(n=121) whereas RDT is used at the community level and
in hospitals during odd hours.
Initially P. falciparum specific RDT was used which was
replaced by Pan RDT very recently. RDT started to use in a
mass scale from 2008 under the support of GFATM
funding under round 6. At the community level
‘ShayasthoKarmi’ (health worker) and ‘Shayastho Shebika’
(community volunteer) of NGOs are responsible for
diagnosis and treatment of uncomplicated malaria. The
GoB Health Workers are also responsible for diagnosis and
treatment of uncomplicated malaria using Pan RDT.
22. There has been significant reduction of number
of cases and deaths due to malaria over last few
years. However, the proportion of P. falciparum
malaria has been found to be rather increased
(96%) due to wide scale use of mono-valent Pf-
RDT and limited use of microscopy for diagnosis
of P. vivax. In fact 7,303 cases were diagnosed by
microscopy in 2013 of whom 953 were P. vivax
infection out of total 26,891 reported cases.
Introduction of Pan RDT is an important step as it
would help to diagnose P. vivax cases in the
community and will help to provide treatment as
well.
23. Malaria is an entirely preventable and
treatable disease. The primary objective
of treatment is to ensure the rapid and
complete elimination of the Plasmodium
parasite from the patient’s blood in
order to prevent progression of
uncomplicated malaria to severe disease
or death, and to prevent chronic
infection that leads to malaria-related
anaemia.
24. Treatment of P. falciparum infections
WHO recommends artemisinin-based combination therapies
(ACTs) for the treatment of uncomplicated malaria caused by the
P. falciparum parasite. By combining two active ingredients with
different mechanisms of action, ACTs are the most effective
antimalarial medicines available today.
P. vivax infections
It should be treated with chloroquine in areas where this
medicine remains effective. In areas where chloroquine-resistant
P. vivax has been identified, infections should be treated with an
ACT, preferably one in which the partner medicine has a long
half-life.
Primaquine: 1 tab daily for 14 days in adults (1 tab-
15mg),0.3 mg/kg/daily for 14 days in children. Beside above
mention drugs,WHO recommend others ACTs(eg. artemether
plus lumefantrine, artesunate plus amodiaquine,,) for the
treatment of uncomplicated malaria..
25. Prevention & controls
Prevention of malaria involves protecting yourself against
mosquito bites and taking antimalarial medicines. But public
health officials strongly recommend that young children and
pregnant women avoid traveling to areas where malaria is
common.
To prevent mosquito bites, follow these guidelines:
1. Stay inside when it is dark outside, preferably in a
screened or air-conditioned room.
2. Wear protective clothing (long pants and long-sleeved
shirts).
3. Use flying-insect spray indoors around sleeping areas.
4. Avoid areas where malaria and mosquitoes are present if
you are at higher risk (for example, if you are pregnant,
very young, or very old).
26. All travellers to regions where malaria is
endemic should be thoroughly educated
regarding personal and environmental
measures to provide protection against
mosquito bites. These measures include use
of repellent containing N,N-diethyl-3-
methylbenzamide, use of long sleeves pants
and footwear and or air-conditioned sleeping
areas. The resistance of P. falciparum to
chloroquine is nearly universal.
27. Currently, several antigen and adjuvant
combinations have entered clinical trials,
exposure to natural infection is evaluated.
Vaccination trial done against different stages of
malaria parasite such as pre-erythrotic stage
{antigen-CSP (Circumsporozoite protein), LSA-1
(Liver stage antigen-1)}, Asexual stage {(AMA-1
(Apical membrane antigen-1), Sexual stage
(Pfs25/Pvs25) and multistage antigen but sterile
immunity was not observed in a large proportion.
Vaccine development and field trials are lengthy
and expensive.
28. The National Malaria Control Programme (NMCP),
Bangladesh aims to achieve malaria elimination (‘zero
indigenous transmission’ and ‘zero deaths’) by
ensuring equitable and universal accesses to effective
preventive and curative services to all ‘at risk
population’ through concerted efforts of the GoB,
NGOs, Private sectors, and the community. Achieving
the goal of ‘Malaria Free Bangladesh’ will contribute
to poverty alleviation as the poorest of the poor
segment of the population are largely the victim of
malaria.
By 2020, to have achieved ‘zero indigenous
transmission’ and ‘zero death’ aiming malaria
elimination in Bangladesh.
29. To achieve 100% coverage of ‘at risk’ population
with appropriate malaria preventive interventions
by 2018
To have 100% malaria patients receiving early
and quality diagnosis (RDT or Microscopy) and
effective treatment by 2018
To continue strengthening of programme
management towards elimination by 2020
To continue strengthening of disease and vector
surveillance, Monitoring and Evaluation towards
malaria elimination
To intensify Advocacy, Communication and Social
Mobilization (ACSM) for malaria elimination
30. The National Malaria Control Programme has
received USD 29.70 million from GoB-
HPNSDP during 2011-16 and USD 22.66
million from GF during 2010-15. The NGO-
PR (BRAC and SRs) received USD 16.40 million
and USD 15.21 million from GF, respectively
during the period of 2007-2010-2015. For
the period 2007-2014 the NMCP also
received USD 1.76 million form the WHO
regular biennial programmes for malaria
control activities.
31.
32. Anti-malarial drug resistance:
The South Asian region has made considerable
progress in reducing rates of malaria over the
past 20 years, but last year’s data show that
rates of malaria in Bangladesh are now
increasing. According to the latest statistics, the
total confirmed number of cases of malaria has
risen from 29,518 in 2012, to 26,891 in 2013
and to 57,469 in 2014. Confirmed malaria
deaths increased from 11 in 2012 to 45 deaths
in 2014
33.
34. Add to these threats the fact that there is a widespread and growing
resistance to insecticides, and icddr,b’s, reasons could be many:
1. The increased mobility of Bangladesh’s population, both domestically and
internationally, means that there will also be potentially severe
implications for greater Bangladesh, for the region and for the rest of the
world.
2. The improper administration of drugs is a big problem as well, because
there is no way to ensure that people take the full course of anti-malarial
drugs. They might take one or two doses out of six, but stop after their
fever subsides.
3. When the drugs are not used properly—when the malaria parasite is not
exposed for long enough, or it is exposed to too low concentrations of the
drug—the parasite evolves to protect itself.
4. Detected mutations on the same K13 gene of the Plasmodium falciparum
malaria parasite that is associated with the Cambodian-strain of
artemisinin-resistant malaria.
35. Conclusion
Despite these challenges, the Government of
Bangladesh has pledged to eliminate malaria in
Bangladesh by 2020 and the Asia-Pacific Malaria
Elimination Network (APMEN) is committed to
malaria elimination in the region by 2030. Malaria
is also a priority disease for the Bill & Melinda
Gates Foundation, a main funder of efforts toward
malaria control and elimination. We caught up
with icddr,b Scientist Dr Wasif Ali Khan and
Assistant Scientist Mr. Shafiul Alam to find out
what role icddr,b has to play in achieving these
goals.
36. Reference
1. National Malaria strategic plan 2015-2020
National Malaria Control Programme (NMCP),
Communicable Disease Control Division,
Directorate General of Health Services,
Ministry of Health & Family Welfare.
2. Maksudur Rahman, Hossain Shahid Kamrul Alam, Abu Tayeb, Probir
Kumar Sarker,
Tahera Nazreen, Akhand Tanzih Sultana
Malaria - An update; DS (Child) H J 2011; 27 (2) : 83-87.
3. 3. Dr Ubydul Haque, Hans J Overgaard, Archie C A Clements,
Douglas E Norris, Nazrul Islam, Jahirul Karim, Shyamal Roy, Waziul
Haque, Moktadir Kabir, David L Smith, Gregory E Glass
4. Malaria burden and control in Bangladesh and prospects for
elimination: an epidemiological and economic assessment; The Lancet
Global Health, Volume 2, Issue 2, February 2014, Pages e98–e105.
