MALARIA in Nepal: Epidemiology and Strategies for Elimination by 2025

MALARIA
Presenter: Dipsikha Aryal
MPH 2021
BPKIHS
12/7/2021 3:04 PM 1

Outline of Presentation
1) Introduction
2) Global Scenario
3) SEAR Scenario
4) Scenario of Nepal
5) Key Strategies
6) Achievements
7) Take home message
8) References
12/7/2021 3:04 PM 2

Introduction
 Malaria (protozoan disease) caused by parasite called plasmodium.
In the year 1880 LAVERAN discovered plasmodium is responsible for malarial diseases.
In the year 1894 and 1897 MASON gave information about transmission of malaria, but it was
confirmed by the experiment of SIR RONALD ROSS.
12/7/2021 3:04 PM 3

Introduction…contd
The 5 Plasmodium species known to cause malaria in humans are P falciparum, P vivax, P
ovale, P malariae, and P knowlesi.
Malaria is transmitted by the bite of infected female Anopheles mosquito.
Malaria spreads when a mosquito becomes infected with the disease after biting an infected
person, and the infected mosquito then bites a noninfected person. The malaria parasites enter that
person's bloodstream and travel to the liver. When the parasites mature, they leave the liver and
infect red blood cells.
It is preventable and curable.
12/7/2021 3:04 PM 4

Epidemiology of Malaria
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Key Determinants of Transmission
 Human Ecological and environmental factors
Climate change and topographical factors
Presence or abundance of key vector species and vulnerability in terms of human population
movement
Land use pattern
Socio-economic factors
Larval and adult habitat of vectors
12/7/2021 3:04 PM 7

Global Trend in the burden of Malaria
Globally, there were an estimated 229 million malaria cases in 2019 in 87 malaria endemic
countries, declining from 238 million in 2000. At the Global technical strategy for malaria
2016–2030 (GTS) baseline of 2015, there were 218 million estimated malaria cases.
The proportion of cases due to Plasmodium vivax reduced from about 7% in 2000 to 3% in 2019.
 Malaria case incidence (i.e. cases per 1000 population at risk) reduced from 80 in 2000 to 58 in
2015 and 57 in 2019 globally. Between 2000 and 2015, global malaria case incidence declined by
27%, and between 2015 and 2019 it declined by less than 2%, indicating a slowing of the rate of
decline since 2015.
12/7/2021 3:04 PM 8

Global Burden… contd
 Twenty-nine countries accounted for 95% of malaria cases globally. Nigeria (27%), the
Democratic Republic of the Congo (12%), Uganda (5%), Mozambique (4%) and Niger (3%)
accounted for about 51% of all cases globally.
 The World Health Organization (WHO) African Region, with an estimated 215 million cases in
2019, accounted for about 94% of cases.
 Although there were fewer malaria cases in 2000 (204 million) than in 2019 in the WHO
African Region, malaria case incidence reduced from 363 to 225 cases per 1000 population at risk
in this period, reflecting the complexity of interpreting changing disease transmission in a rapidly
increasing population. The population living in the WHO African Region increased from about
665 million in 2000 to 1.1 billion in 2019.
12/7/2021 3:04 PM 9

The WHO South-East Asia Region accounted for about 3% of the burden of malaria cases
globally. Malaria cases reduced by 73%, from 23 million in 2000 to about 6.3 million in 2019.
Malaria case incidence in this region reduced by 78%, from about 18 cases per 1000 population at
risk in 2000 to about four cases in 2019.
 India contributed to the largest absolute reductions in the WHO South-East Asia Region, from
about 20 million cases in 2000 to about 5.6 million in 2019. Sri Lanka was certified malaria free
in 2015, and Timor-Leste reported zero malaria cases in 2018 and 2019.
Malaria cases in the WHO Eastern Mediterranean Region reduced by 26%, from about 7 million
cases in 2000 to about 5 million in 2019. About a quarter of the cases in 2019 were due to P.
vivax, mainly in Afghanistan and Pakistan.
12/7/2021 3:04 PM 10

 Over the period 2000–2019, malaria case incidence in the WHO Eastern Mediterranean
Region declined from 20 to 10. Sudan is the leading contributor to malaria in this region,
accounting for about 46% of cases. The Islamic Republic of Iran had no indigenous malaria cases
in 2018 and 2019.
 The WHO Western Pacific Region had an estimated 1.7 million cases in 2019, a decrease of
43% from the 3 million cases in 2000. Over the same period, malaria case incidence reduced from
five to two cases per 1000 population at risk. Papua New Guinea accounted for nearly 80% of all
cases in this region in 2019. China has had no indigenous malaria cases since 2017. Malaysia
had no cases of human malaria in 2018 and 2019.
12/7/2021 3:04 PM 11

In the WHO Region of the Americas, malaria cases reduced by 40% (from 1.5 million to 0.9
million) and case incidence by 57% (from 14 to 6). The region’s progress in recent years has
suffered from the major increase in malaria in Venezuela (Bolivarian Republic of), which had
about 35,500 cases in 2000, rising to over 4,67000 by 2019. Brazil, Colombia and Venezuela
(Bolivarian Republic of) account for over 86% of all cases in this region.
Since 2015, the WHO European Region has been free of malaria
12/7/2021 3:04 PM 12

Global Malaria Death
Globally, malaria deaths have reduced steadily over the period 2000–2019, from 7,36000 in
2000 to 409000 in 2019. The percentage of total malaria deaths among children aged under 5
years was 84% in 2000 and 67% in 2019. The global estimate of deaths in 2015, the GTS
baseline, was about 453000.
 Globally, the malaria mortality rate (i.e. deaths per 100000 population at risk) reduced from
about 25 in 2000 to 12 in 2015 and 10 in 2019, with the slowing of the rate of decline in the latter
years.
About 95% of malaria deaths globally were in 31 countries. Nigeria (23%), the Democratic
Republic of the Congo (11%), the United Republic of Tanzania (5%), Mozambique (4%), Niger
(4%) and Burkina Faso (4%) accounted for about 51% of all malaria deaths globally in 2019.
12/7/2021 3:04 PM 13

Malaria death…contd
Malaria deaths in the WHO African Region reduced by 44%, from 6,80000 in 2000 to 3,86000
in 2019, and the malaria mortality rate reduced by 67% over the same period, from 121 to 40
deaths per 100 000 population at risk.
 In the WHO South-East Asia Region, malaria deaths reduced by 74%, from about 35000 in
2000 to 9000 in 2019.
India accounted for about 86% of all malaria deaths in the WHO South-East Asia Region
12/7/2021 3:04 PM 14

Malaria in South East Asia
 Malaria is a serious and persistent threat to public health in many parts of Asia. The South-East
Asia Region is the Region with the second highest estimated malaria burden globally. In the
South-East Asia Region, WHO’s response to malaria is led by experts grouped in the Malaria
Unit based in WHO’s South-East Asia Regional Office in New Delhi, India.
 1.6 billion people are at risk
750,000 cases reported
165 malaria death (2018)
12/7/2021 3:04 PM 16

SEAR…contd
As per the World Malaria Report released in 2018 WHO South-East Asia Region had an
estimated 8 million cases and 11,600 malaria deaths – 69% and 70% less as compared with 2010.
This is the largest decline among all six WHO Regions.
Two countries in the Region - Maldives and Sri Lanka – have been certified malaria free, and
two more, Timor-Leste and Bhutan, are close to elimination target.
Despite being the highest burden country of the Region, India reduced its reported cases by half
as compared with 2017. Bangladesh and Thailand also reported substantial decline in reported
cases.
All countries in the Region are on target to achieve a more than 40% reduction in case incidence
by 2020, and all have strategic plans for malaria elimination by 2030.
12/7/2021 3:04 PM 17

Scenario of Malaria in Nepal
 Malaria is endemic in the southern plain of Nepal which shares a border with India. More than
80% cases of malaria in Nepal are caused by Plasmodium vivax.
Malaria control project was first initiated in Nepal in 1954 with the support from USAID (then
USOM). The objective of the project was to study malaria mainly in Terai belt of central Nepal.
In 1958, national malaria eradication program, was launched with the objective of eradicating
malaria from the country within a stipulated time period.
 Due to various reasons the eradication concept was reverted to control program in 1978.
Following the call of WHO to revamp the malaria control programs in 1998, Roll Back Malaria
(RBM) initiative was launched to address the perennial problem of malaria in hard-core forests,
foot hills, inner Terai and valley areas of the hills, where more than 70 percent of the total malaria
cases of the country prevail.
12/7/2021 3:04 PM 19

Scenario of Nepal
The high risk of acquiring the disease is attributed to the abundance of vector mosquitoes,
mobile and vulnerable population, relative inaccessibility of the area, suitable temperature,
environmental and socio-economic factors.
 Currently Nepal has headed into elimination in 2025 with activities rolled out across all the 77
districts of the country including the high, moderate, low and no risk districts.
 A total of 1,97,084 people (0.7%) live in high-risk wards. Similarly, 9,34,931 people (3.2%) live
in moderate risk wards, 1,10,92,688 people (37.9%) live in low risk wards and 1,70,24,477 (58.2
%) live under no risk wards.
12/7/2021 3:04 PM 20

Vector Bionomics
 Plasmodium vivax is the predominant species in Nepal followed by Plasmodium falciparum is the
other important species. While the relative proportion of P. vivax cases have been increasing from
71% in 2010 to 95% in 2018, the proportion of P falciparum is correspondingly on the decline from
around 29% in 2010 to 5% in 2018. P. malariae and P. ovale are sometimes detected among patients
returning from Africa.
Malaria is transmitted by bite of a female Anopheles mosquito. The mosquitoes that transmit
malaria breed in relatively clean water and the immature stages thrive better in water at temperatures
ranging from 23-36°C. Anopheles fluviatilis is now the primary malaria vector in Nepal, Anopheles
annularis and Anopheles maculatus complex are the secondary malaria vectors.
12/7/2021 3:04 PM 21

Trend of Malaria cases in Nepal
3241
2857
2092
1674
1352
991
1128 1187
1065
619
2000
1550
1100
974
671
506 492 557
440
102
1241 1307
992
700 681
485
636 630 625
517
0
500
1000
1500
2000
2500
3000
3500
2067/68 2068/69 2069/70 2070/71 2071/72 2072/73 2073/74 2074/75 2075/76 2076/77
Total
Indigenous
Imported
12/7/2021 3:04 PM 23

Trend of malaria cases: PV and PF
509
1314
428
312 274
162 148
82 58 56
2732
1543
1664
1325
1078
829
980
1105
1007
563
0
500
1000
1500
2000
2500
3000
2067/68 2068/69 2069/70 2070/71 2071/72 2072/73 2073/74 2074/75 2075/76 2076/77
P falciparum P. Vivax
12/7/2021 3:04 PM 24

Case Definition
A confirmed malaria case is a case in which the presence of parasites or antigens in the
peripheral blood have been demonstrated, with or without symptoms.
A malaria case (uncomplicated) is symptomatic malaria parasitaemia without signs of severity or
evidence of vital organ dysfunction.
A malaria case (severe) is symptomatic malaria parasitaemia with signs of severity or evidence of
vital organ dysfunction, which includes: – Prostration (inability to sit), altered consciousness,
lethargy or coma – Difficulty in breathing – Severe anaemia (Haemoglobin < 7mg/dl) –
Generalized convulsions/ fits – Inability to drink/vomiting – Dark or limited production of urine –
Jaundice
12/7/2021 3:04 PM 27

Parasitologically confirmed
malaria infection
Due to
mosquito
borne
transmission
Acquired
outside
country
Imported
Acquired
locally
Indigenous
Any case without
evidence of direct
link to imported
case
Not due to
mosquito borne
transmission
Induced e.g. due
to blood
transfusion
congenital malaria
Case Classification
12/7/2021 3:04 PM 28

How does imported malaria impact indigenous
infection?
Imported Case
Local Mosquitoes Infected
Secondary cases
More mosquitoes infected
Further
generations of
cases
Introduced case
Indigenous cases
12/7/2021 3:04 PM 29

Malaria Surveillance System
1. Malaria Disease Information System (MDIS) (case notification within 24 hours of case
detection).
2. District Health Information System 2 (DHIS-2) (aggregate, monthly data).
3. Early Warning and Reporting System (EWARS-weekly reporting).
12/7/2021 3:04 PM 30

Case Detected in HF
Notify within 24 hours – SMS via MDIS / inform Focal Person, send slide for Lab test
P .Vivax case, G6PD test done - Non –reactive: Treat as per NMTP Chloroquine 3 days
+Primaquine 14 days
Preliminary case classification done: Index case: Locally acquired
Conduct Case based surveillance in the area within 72 hours from case diagnosis- Inform district
focal person – Local HF team along with FCHV
Case confirmed and case classification verified with completion of CIF
Conduct RACD - test all members of index household and treat positive case, send slide for Q/A
If the case is indigenous; Test 50 HHs or area within a radius of 1 -2 km, surrounding in all directions
to index house members who have fever or history of fever of last 14 days and treat positive cases,
send slide for Q/A.
Fill CIF of all positive cases
32

Malaria Diagnosis
Screen for malaria to the following persons: SPR
◦ Classical Symptomatic Patients- who have typical s/s of malaria with/without travel history
to endemic zone
◦ Every PUO patients- Pyrexia of unknown origin
◦ Roaming cases
In general, 2 diagnostic tools available in Nepal:
RDT- antigen based, WHO pre-qualified.
Microscopy- the “GOLD STANDARD’’ diagnostic method
12/7/2021 3:04 PM 34

Laboratory test
Microscopy
 Giemsa stained Thick & Thin Smear
 Acridine orange stained Thin Smear
 Quantitative Buffy Coat Assay (QBC)
Rapid Diagnostic Test (Antigen Detection )
 PfHRP-II (Plasmodium falciparum Histidine Rich Protein)
 pLDH (specific iso-types) -(Parasite lactate dehydrogenase)
 Aldolase (pan Specific)
Molecular biology tests
 Polymerase Chain Reaction (PCR)
12/7/2021 3:04 PM 35

Malaria Treatment
12/7/2021 3:04 PM 36

Treatment…contd
12/7/2021 3:04 PM 37

Activities towards Malaria Elimination
12/7/2021 3:04 PM 38

National Malaria Eradication Program
1925- major
Philips(IMS)
–Malaria
Burden in
Makawanpur
and Chitwan
valley
1954-insect
borne disease
control
program
1956-58
Rapti valley
malaria
control
program
1958- Malaria
eradication
program –
First national
public health
program
Malaria
control
program
1978
WHO global
malaria control
strategy 1992
Revised WHO
global malaria
control strategy
2000 & regional
malaria control
strategy 2007
Malaria
elimination
2014-2025
(Evolution)
12/7/2021 3:04 PM 39

Nepal Malaria Strategic Plan For Elimination
(2014-2025)
The objectives of malaria control programs range from reducing the disease burden and
maintaining it at a reasonably low level, to eliminating the disease from a defined geographical
area, and ultimately to eradicating the disease globally. These levels of control are defined as
follows,
• Malaria control: reducing the disease burden to a level at which it is no longer a public health
problem
• Malaria elimination: interrupting local mosquito-borne malaria transmission in a defined
geographical area, i.e. zero incidence of locally contracted cases, although imported cases will
continue to occur. Continued intervention measures are required.
• Malaria eradication: permanent reduction to zero of the worldwide incidence of malaria
infection.
12/7/2021 3:04 PM 40

Vision: Malaria-free Nepal by 2025
Mission: To empower the health staff and the communities at risk of malaria to contribute towards
the vision of malaria-free Nepal by 2025.
Goals:
• To sustain zero death due to malaria from 2012 onwards;
• To reduce the incidence of indigenous malaria cases by 90% by 2018 (relative to 2012);
• To reduce no. of VDCs having indigenous malaria cases by 70% by 2018 (relative to 2012);
• To receive WHO certification of malaria free status by 2025.
12/7/2021 3:04 PM 41

Strategic Objectives
1) To strengthen strategic information for decision making towards malaria elimination.
2) To further reduce malaria transmission and eliminate the foci.
3) To improve quality of and access to early diagnosis and effective treatment of malaria.
4) To sustain support from the political leadership and the communities towards malaria
elimination.
5) To strengthens programmatic technical and managerial capacities towards malaria elimination.
12/7/2021 3:04 PM 42

Global Technical Strategy for Malaria 2016-2030
12/7/2021 3:04 PM 43

Major activities in year 2076/77
68,528 LLIN was distributed as mass distribution and 89,189 LLINs were distributed through
continuous distribution to people leaving in active foci, malaria risk groups, army police, pregnant
women at their first ANC visits.
Conducted the ward-level micro-stratification of malaria cases in 77 districts.
Continuation of case-based surveillance system as key intervention, including web-based
recording and reporting system for districts. The MDIS is now fully operational.
Orientated district and peripheral level health workers on case-based surveillance and response.
Conducted private sector engagement activities; health worker orientation on malaria diagnosis
and treatment, recording and reporting to DHIS2 on correctly and timely manner.
Approved private sector engagement and Lab plan Carried out detailed foci investigation at 61
sites.
12/7/2021 3:04 PM 44

Activities…contd
Revitalized the malaria microscopy quality assurance system with collaboration between the
Epidemiology and Disease Control Division (EDCD) and VBDRTC, with technical assistance
from WHO.
Orientated district health workers and FCHVs on the government’s malaria elimination initiative
and their role in detecting cases and facilitating early treatment.
Orientated mother groups and school children on malaria prevention and the need for early
diagnosis and prompt treatment.
Conducted quarterly and annual review meetings for district and central level staff. Participants
reviewed data from peripheral facilities and revised it based on suggestions.
Conducted operational research on malaria vector behaviour and insecticide resistance.
Conducted regular vector control (indoor residual spraying) biannually across high and moderate
risk districts.
12/7/2021 3:04 PM 45

Activities…contd
Conducted detailed case based investigation and fever surveys around positive index cases.
Conducted integrated entomological surveillance around twelve different sites of country.
Celebrated World Malaria Day on 25 April.
12/7/2021 3:04 PM 46

Achievements in Malaria
12/7/2021 3:04 PM 47

Achievements by 2076/77
 National Malaria Program had achieved 85% reduction in indigenous malaria cases compared
to 2071/72. Case and Foci investigation are getting momentum; around 97% cases gone through
the case-based investigation.
 In addition, ABER is increasing (2.1%) trend and positivity rate is decreasing (0.25%) trend.
 In 2076/77, altogether 61 suspected foci were investigated. Out of that only 38 foci were active
where local transmission was ongoing. In this year, a total 241 foci were residual non-active and
150 foci were cleared.
12/7/2021 3:04 PM 48

Malaria and COVID-19
As the COVID-19 pandemic spreads rapidly around the globe, there is an urgent need to
aggressively tackle the novel coronavirus while ensuring that other killer diseases, such as
malaria, are not neglected. The WHO Global Malaria Programme is leading a cross-partner effort
to mitigate the negative impact of the coronavirus in malaria-affected countries and, where
possible, contribute towards a successful COVID-19 response.
12/7/2021 3:04 PM 49

Prevention and control of Malaria
 Elimination of mosquito breeding sites
Improvement on health and hygiene
Use of insecticide treated mosquito net
Indoor insecticidal spray
Full sleeves clothing and long trouser
Use of mosquito repellent
Young children and pregnant women should avoid travelling to areas where malaria is common
Chemoprophylaxis
12/7/2021 3:04 PM 51

Challenges
Insecticide resistance and its impact on transmission
Spreading resistance to effective antimalarial drugs
Socio-cultural hindrance in malaria elimination
 Increasing Imported cases
Insufficient funding
Access and availability of services and sensitive surveillance system
Climate change and access to road has also increased malaria cases in hilly reasons as well
Private hospital are also treating cases of malaria but they aren’t reporting in MDIS
12/7/2021 3:04 PM 52

Organizations working for Malaria in Nepal
12/7/2021 3:04 PM 53

Take Home Message
The World Health Organization (WHO) African Region, with an estimated 215 million cases in
2019, accounted for about 94% of cases.
Since 2015, the WHO European Region has been free of malaria
India has highest burden of malaria in SEAR.
Sudurpaschim province has higher prevalence of malaria in Nepal (both indigenous and
imported)
PV and PF are responsible for high number of malaria cases in Nepal.
Nepal has targeted to eliminate malaria by 2025.
National Malaria Program had achieved 85% reduction in indigenous malaria cases compared to
2071/72.
12/7/2021 3:04 PM 57

References
1) World Malaria Report 2020 9789240015791-eng.pdf
2) CDC Division of Parasitic Diseases and Malaria STRATEGIC PRIORITIES
dpdm_strategic_plan.pdf
3) Factsheet of EDCD Factsheet 2021_Provincial Level.pdf
4) Reaching the zero malaria target Factsheet_Central Level.pdf
5) National guideline on Integrated vector management national-guideline-on-integrated-vector-
management-2020-new.pdf
6) National malaria surveillance guidelines 2019 national-malaria-surveillance-guidelines-2019.pdf
7) National malaria treatment protocol 2019 national-malaria-treatment-protocol-2019.pdf
8) DoHS annual report 2076/77 DoHS-Annual-Report-FY-2076-77-for-website.pdf
9) WHO https://www.who.int/health-topics/malaria#tab=tab_1
12/7/2021 3:04 PM 58

Thank you
12/7/2021 3:04 PM 59

MALARIA in Nepal: Epidemiology and Strategies for Elimination by 2025

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