DepartmentofPublicHealth,MinistryofHealth

VectorborneDisease ControlProgramme
ProgrammeProfile

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Vector-borne Disease ControlProgramme

MALARIA Background: Malaria programme in Bhutan was started in 1964 as National Malaria Eradication Programme (NMEP). The main prevention and control strategy, then, was active surveillance, case management, and vector control by Indoor Residual Spraying (IRS) with DDT. Later was renamed as National Malaria Control Programme (NMCP). Since 2003 the programme has been functioning under the name of Vector-borne Disease Control Programme(VDCP) and also looks after other mosquito borne diseases. The prevalent vector borne diseases in Bhutan are malaria, dengue. Visceral leishmaniasis (Kala azar)and Japanese encephalitis. Malaria cases have been reported since 1965. The first dengue outbreak in Bhutan was reported in July 2004. In July 2007 about 12 (kala azar) cases have been documented from the Eastern dzongkhags of Tashigang, Tashiyangtse and Mongar. A few sporadic cases of Japanese encephalitis have been treated in the referral hospitals in the last few years. Malaria Prevention and control strategies: Since 1965 till 1994 Malaria control strategy was focused on Indoor residual Spraying (IRS) with DDT. A major programme decision was taken at that point and the chemical for Indoor Residual Spray (IRS) was changed from DDT to deltamethrine and since then IRS remained the main vector control strategy in Bhutan till 1997. As significant reduction in malaria was achieved in 1998 IRS was completely phased out and replaced by Insecticide Treated Bed Nets (ITBN) in phased manner till 2003. In 2004 focal IRS was also done for one round as the coverage with Insecticide treated nets was very low. The programme as well as the communities faced several challenges and difficulties as the bed nets had to be re impregnated twice a year at 6 monthly intervals as a result of which significant malaria control could not be achieved in spite of all efforts. In 2006 with support from Global Fund the malaria prevention and control strategies have been scaled up and newer tools (new drug Artemether-Lumefantrine and Long Lasting Insecticide-treated Nets) highly recommended for prevention and control globally were introduced. Scaled up interventions in Bhutan resulted in significant decline in malaria cases in Bhutan 10th FYP Goal and Objectives:

The 10th five year goal is to reduce malaria morbidity and mortality by 75% by 2013 from the 2005 baseline and thus contribute to MDG Goal 6;Target 8 have halted by 2015 and begun to reverse the incidence of malaria and other major diseases, The main objectives are: 1. To increase coverage of malaria prevention among population at risk 2. To increase access to early diagnosis and prompt treatment 3. To strengthen technical and managerial capacity of the malaria control programme and establish a mechanism for multisectoral involvement 4. To increase IEC coverage with focus on behavioural change impact. The 10th FYP will mainly focus on: 2

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1. StrengtheningInstituteandHumanresourcedevelopment 2. Improvingcommunityparticipation 3. ScaleupmalariapreventionthroughIntegrated vector management (IVM) through use of Long Lasting Insecticide Treated Bed Nets (LLINs) and Focal Indoor Residual Spray (IRS) and bioenvironmental management 4. StrengthenEDPTwithfocusonhardtoreachareas 5. RevampSurveillanceandstrengthenmonitoringandevaluation Country malaria status 1994 was the year when the highest number of malaria cases was reported in the country with 39,852 confirmed cases. The malaria trend is now declining in all the dzongkhags. The Annual Parasite Index has reduced from 104/1000 population in 1994 to 2/1000 in 2007. The Slide Positivity Rate (SPR) has reduced from 20% in 1994 to 2% in 2007. Plasmodium falciparum malaria is 48% of the cases in 2007.The annual Blood examination rate (ABER) is 11% in 2007. Number of deaths has declined from 48 in 1994 to 2 in 2007. In the last five years the case fatality rate has been maintained below 1%.

Epidemiology In 2007 Samdrup Jongkhar Dzongkhag reported the highest number of cases in the country contributing 35% of the total cases. Next was Sarpang Dzongkhag with about 32 % of the cases. Whereas malaria trend is declining in the perennial transmission dzongkhags the number of malaria cases reported from the dzongkhags that have seasonal transmission is showing an increasing trend from 5% in 2002 to 18 % in 2007.(Table 1) About 10 % of total malaria cases is from across the border. 90% of the cases are above the age of 15. Above 60 % of the malaria cases are males as compared to females. Malaria in infants is below 1% and >75% of the malaria cases in the country is in the above 15 age group.(table 2)

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Table1MalariacaseinPercentage(%)infiveendemicDzongkhagsandotherdzongkhagsfrom1998 to2007
Dzongkhag Sarpang S/Jongkhar Samtse Chukha Zhemgang Other Dzongkhags 1998 41 46 5 2 2 4 1999 41 37 8 6 4 4 2000 43 34 8 4 5 6 2001 51 26 14 3 2 4 2002 49 23 17 5 1 5 2003 36 18 28 12 1 5 2004 34 14 38 7 1 6 2005 36 28 19 6 2 9 2006 30 33 13 11 2 11 2007 32 35 7 7 0.4 18

Table2Agewise&sexwisedistributionofmalariacasesinBhutan(20032007)
Age 2003 2004 2005 2006 2007

Tot al (%)

Tot al (%)

Tota l (%)

Tota l (%)

Tota l (%)

<1

15

10

25 (0.7)

12

12 (0.5)

7 (0.4)

12 (0.6)

4 (0.5)

1-5

120

94

214 (7)

85

66

151 (6)

55

55

110 (6)

55

47

102 (5)

17

10

27 (3)

5-15

580

367

947 (26)

357

292

649 (24)

197

177

374 (21)

212

152

364 (20)

82

69

151 (19)

15-49

1315

949

2264 (59)

1000

552

1552 (58)

743

371

1114

848

350

1198 (64)

359

156

515 (65)

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>50 280 76 356 (9) Total 2310 (60%) 1496 (40%) 3806 1646 (62%) 1024 (38%) 192 114 306 (12) 2670 1136 (62%) 689 (38%) 136 84 220 (12) 1825 1256 (67%) 612 (33%) 132 60 192 (10) 1868 518 (65 %) 275 (35 %) 57 39 96 (12) 793

Source: Annual Malaria Report 2007

Review of the 9FYP 9 FYP Program /Policy Objectives/Strategies Reduce malaria disease burden and help enhance socio-economic development process of the people living in malaria endemic areas. Specific Objectives are as follows: 1. Reduce malaria mortality to less than 25% as compared to 2001, 2. Ensure Early Diagnosis and Prompt Treatment (EDPT) facilities in all malaria transmission areas, 3. Intensify malaria IEC campaigns, and create basic awareness on prevention and control of malaria in over 95% of the population in endemic areas, 4. Ensure Insecticide Treated Bed Net (ITBN) program implemented status with coverage of over 90% of rural population, 5. Strengthen Entomological and Drug Research Units with the required facilities and skills to meet the growing research needs of the program, 6. Initiate inter-sector collaborative control activities in endemic Dzongkhags, 7. Strengthen Dzongkhags implementation capacity for decentralized malaria control activities. Strategies 1. Provision of microscopy diagnostic facility and anti-malarial drugs in all health centers in the endemic areas for facilitating EDPT. 2. Decentralization of malaria microscopy and case management refresher courses. 3. Selective and comprehensive use of insecticides for control of adult and larval vectors as determined by the endemicity and intensity of transmission areas, and susceptibility status. 4. Awareness creation about primary prevention and control of malaria in the communities through enhanced IEC advocacy program, and community participation in the control program with primary focus to make ITBN program self-sustainable.

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5. Initiation of inter-sector collaborative efforts in the malaria control program through introduction of mosquito proof engineering designs, and environmental management, especially the sectors involved in the major construction projects. 6. Use of epidemiological and other parameters to predict epidemic, and institution of rapid response mechanism to manage epidemics. 7. Capacity development both in terms of infrastructure and human resource by strengthening research units with equipment, furniture and appropriate expertise for carrying out operational researches. 8. Intensify research activities on drug sensitivity studies in all high risk endemic Dzongkhags and sustain and strengthen entomological surveillance system.

Malaria Status at the end of the 9FYP (Table 3 &4)

By end of the 9FYP,malaria cases and malaria deaths reduced by 88% and 82% respectively as compared to the beginning of the 9FYP. 94.5%of households in the targeted areas (i.e. endemic-areas ) owns at least one Insecticide treated bed net (ITN) or Long Lasting Insecticide treated Nets (LLIN) and atleast 38.2%of households in seasonal transmission areas own at least one ITN /LLIN. 100% patients are receiving anti-malaria drugs as per the treatment guideline(both old and new guideline). 75% of the Pf malaria cases have been treated as uncomplicated falciparum malaria and received an appropriate drug that is Artemether-Lumefanthrine combination drug and the rest were treated as severe malaria.The case fatality rate due to malaria remains below 1%. Table 3: Malaria indicators in the beginning of the 9FYP and at the end of the 9FYP

2002 2003 2004 2005 2006 2007 (statusattheendof9FYP)

Malaria Cases
6511

Malaria Deaths
11

ABER
17

SPR
9

API
15

CFR%
0.3

PF%
54

3806

15

14

0.9

44

2670

12

0.9

41

1825

13

0.5

52

1868

14

0.7

48

793

11

0.5

48

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Source: VDCP

Table 4: Dzongkhag wise malaria cases and malaria transmission indicated by Annual Parasite Incidence (API) per 1000 population at the start and end of 9FYP. 2002
Dzongkhag Malaria cases 3179 1527 1110 307 77 64 0 38 5 15 121 3 52 0 7 0 6 0 0 0 API 81 40 19 4 4 4 0 1 0 1 2 0 1 0 1 0 0 0 0 0

2003
Malaria cases 1362 686 1078 470 37 19 0 15 0 31 53 2 27 0 4 2 19 1 0 0 API 34 18 19 7 2 1 0 0 0 2 1 0 1 0 0 0 1 0 0 0

2004
Malaria cases 910 374 1018 191 42 22 4 28 5 18 4 3 24 0 5 1 18 2 1 0 API 22 10 17 3 2 1 0 1 0 1 0 0 1 0 0 0 1 0 0 0

2005
Malaria cases 656 506 344 167 33 23 2 14 8 0 11 0 8 2 4 3 14 30 0 0 API 16 13 6 2 2 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0

2006
Malaria cases 570 618 248 199 39 59 8 9 2 4 5 0 19 1 11 2 11 63 0 0 API 14 15 4 3 2 3 0 0 0 0 0 0 0 0 1 0 0 1 0 0

2007
Malaria cases 286 306 59 55 3 13 3 6 4 1 9 3 10 3 3 5 4 20 0 0 API 7 8 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Sarpang S/jongkhar Samtse Chukha Zhemgang Tsirang Dagana Wangdue Punakha Trongsa Trashigang Trashiyangtse Mongar Lhuntse Pemagatshel Bumthang Paro Thimphu Haa Gasa

Data Source :VDCP

FUNDING for VDCP Malaria Programme is supported finically by four major agencies namely: Royal Government of Bhutan, World Health Organization (WHO), Government of India (GOI) and Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria (GFATM). Bhutan received a grant of USD 1.73 million from GFATM in the 4thround, extending over the five years. The GFATM project implementation that started in April 2005 provided an opportunity to enhance the programme activities; improve the access to early diagnosis and prompt treatment; reduce transmission through supply of LLINs and IRS; and improve human resource capacity. In addition to GFATM, the 7

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programme receives regular technical support from WHO. Furthermore, the Government of India has supported the programme from its inception and during the 9th five-year plan Nu 40 million was committed extending over a period of five years. The funds from the government of India are utilized mainly to procure insecticides. Challenges: In spite of all efforts border malaria poses a challenge and set back to the malaria control programme in Bhutan. Community participation in malaria and vector borne diseases is inadequate and needs strengthening. Inter sectoral collaboration for malaria prevention control is lacking and developmental activities (like forestry, fishery, irrigation, construction and mines to name a few)on one hand set up to uplift the socio-economic status of the people has detrimental effects on health of people living in malaria receptive areas. Malaria being a multi faceted disease transmitted by mosquito vectors that do not recognize boundaries and is a very environment sensitive parasitic disease. People in non transmission areas can get malaria when they travel to areas where there is transmission and can cause morbidity even in the absence of vectors. Reduced transmission for some years in high transmission areas is a challenge in itself because the immunity level in the populations is reduced therefore risk of severe complicated malaria increases and malaria mortality To reduce malaria case load to a level it is no more a public health problem, good viable disease surveillance and vector surveillance system should be strengthened and for that adequate number of skilled human resource at the community level will be required. Other emerging diseases like dengue, kala azar and Japanese encephalitis are also over stretching VDCP budget. Capacity in terms of technical expertise is still an issue.

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DENGUE Dengue is the fastest emerging arborviral infection. Its epidemiology is evolving rapidly, with increased frequency of outbreaks and expansion to new geographical areas that were previously unaffected. The mortality is highest during the initial period of the outbreak/epidemic. The progressive worsening of dengue is attributed to unplanned urban development, poor water storage and unsatisfactory sanitary conditions. It is an integral part of urbanization because of the creation of breeding habitats. It is a domesticated species that breeds in artificial containers. The high population density of the vector increases the opportunities for transmission of dengue. Dengue fever and the potentially lethal haemorrhagic form of dengue are a fast growing public health problem worldwide (50 million cases with 500,000 manifesting shock and/or haemorrhage each year), and particularly important in the Americas and Asia. Dengue and dengue haemorrhagic fever (DEN/DHF) have been known in the South East Asia Region since the 1950s, but the incidence of classical dengue is known from reports in the literature for at least 200 years. Dengue and DHF are highly endemic in Thailand, Indonesia and Myanmar and, until recently, they were of moderate concern in India and Sri Lanka. As of 2007, among the 11 countries In South East Asia Region of WHO, 10 of them now report dengue cases to WHO. Dengue was reported for the first time in Bhutan in July 2004 and 2579 suspected dengue cases were reported in the outbreak in 2004. From 2005 to 2007, 11 to 122 suspected cases were reported. In 2008 till September 44 suspected dengue cases were reported from Phuntsholing and JDWNRH, Thimphu. The case fatality rate however is very high in 2008 as compared to previous years which indicate the need for intensifying the dengue cases diagnosis and management. Dengue virus serotype 1, 2 and 3 have been found in the blood samples collected in Bhutan from 2004 to 2006. The dengue virus strains in Bhutan are similar to those circulating regionally and may have been introduced or reintroduced from these neighboring areas. The fact that there were more primary dengue infections than secondary infections for all 3 years and the relatively advanced mean age of patients suggests that dengue virus has entered Bhutan relatively recently. Vector surveillance findings have shown that the dengue vectors are there in almost all the districts in Bhutan except a few northern districts.

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Reported dengue cases

3000 2500 2000 1500 1000 500 0

Bhutan : reported suspected dengue cases and CFR (2004-2008(till September) 9.1 2579

4.1 0.0 11
2005

0.0
2004

1.7 116
2006

122
2007

44
2008

10.0 9.0 8.0 7.0 6.0 5.0 4.0 3.0 2.0 1.0 0.0

Cases

CFR

Components of the dengue prevention and control strategy (1) Dengue surveillance (2) Integrated vector management (3) Case management (4) Social mobilization (5) Outbreak response communication (6) Operational Research Challenges Since clinical signs are non specific and diagnosis requires specialized laboratory support, surveillance of dengue is a major challenge. Dengue is a disease that comes into focus during an epidemic and the interest on it as well as the commitment to combat it declines after the epidemic is brought under control. Its control requires a high level of sustained government and public commitment, strengthening of the public health infrastructure, intersectoral and intercountry collaboration and community mobilization. The occurrence of dengue in one country is a threat to other countries and the spread of dengue intensified due to proliferating trade and travel. Therefore, dengue cannot be controlled if efforts are limited to one country.

Case Fatality Rate

10