Timor Leste-Malaria Situation in SEAR Countries

Malaria Situation in SEAR Countries

Timor-Leste

Bangladesh

Malaria continues to undermine public health. Perennial transmission occurs due to Timor-Leste's favourable climatic conditions with reported cases peaking post-wet season. However, a relatively large number of cases were recorded throughout the year with varying intensity depending upon altitude and vector habitat. Almost the entire population of Timor-Leste is at high risk of malaria.

Four out of the 13 districts (Dili, Viqueque, Cova Lima, and Lautem) report 60% of cases. The number of confirmed cases has increased from 15,212 in 2000 to 48,137 in 2010, while the slide positivity rate increased from 44% to 50% between 2002 and 2008 and finally settled down to 24.6%. The percentage of reported cases attributable to P. falciparum increased from 53% to 75% during 2002 to 2010. These changes may reflect a real increase in malaria or could be at least partly attributable to increased efforts at diagnosis. With increased use of microscopy and RDTs, the parasitological testing rate has increased over the years. The Annual Blood Slide Examination Rate (ABER) increased from 5.6% in 2002 to 8.6% in 2008 and over 17% in 2010 as a result, the percentage of confirmed malaria

Fig.1 : Trends of Confirmed Malaria Cases in Timor Leste, 2002-2010

Malaria Situation in Timor Leste, 2010 : At a Glance
Total population	: 1.15 million
Population in malarious areas	: 1.15 million
Number of lab confirmed malaria cases	: 48,137
P. falciparumproportion	: 75%
Number of probable malaria cases	: 71,321
Number of deaths due to malaria	: 58 (Reported)
Cases treated with ACTs	: 38,828
No. of Ist line anti-malarials doses distributed	: N.A.
No of LLINs distributed	: 166,605
No. of effective LLINs+ITNs (cumulative) availability	: 245,831
No. of population protected with ITNs / LLINs	: 0.49 million
Population protected with IRS	: 89,083
Supported by GFATM in Rd 7 and Rd 10 Over all malaria situation is deteriorating

cases (reported) also increased around 86% (Fig. 1) since 2002 while total malaria cases (probable and confirmed ) decreased from 223 002 cases during 2006 to 119 458 during 2010 showing a decline of 46.4%. The proportion of malaria patients amongst outdoor patients and indoor patients decreased from 16.1% to 8.7% and 1.5% to 0.9% respectively during 2008 t 2010 in Government HFs. Similarly, the malaria deaths declined from 68 in 2006 to 58 in 2010 showing a decrease of 14.7%. The malaria incidence amongst children under 5 is very high However, the trend of these decline is not very systematic and is at times erratic presumably due to weak surveillance system mainly inconsistency and completeness. Distribution of ITNs / LLINs to children under five and pregnant mothers are the main tool for vector control. The same are distributed to pregnant mothers through Ante-natal clinics.

Click on the image to enlarge
Fig.2 : Cumulative availability of LLINs / ITNs in Timor Leste, 2005-2010	Fig.3 : Trends of Distribution of ACTs and malaria Deaths in Timor Leste, 2005-2010

Approximately 50% of the people are covered under the bednet programme. The total availability of effective bednets amongst the population were around 245 831 (Fig. 2). ACT has been adopted by the programme in 2007 and made available through the public sector (Fig. 3). Due to weak infrastructure and lack of trained man power most of the cases are treated clinically only. The quality of malaria microscopy is very poor. The surveillance, data management and data analysis at all levels are very week. The NMCP is mainly financed by Global Fund and the government. Due to limitation of human resources both for quality and quantity, routine diseases surveillance and monitoring activities are very limited.

The total funding for malaria has increased from an average of US $ 1.2 million per annum to US$ 5 million in 2010 (Fig. 4), mainly financed by GFATM , government and UNICEF. The government's contribution has increased dramatically from <5% until 2009, upto 37% in 2010. In 2010, the highest amount was spent on human resources and technical assistance (36%) followed by ITNs (22%) and diagnostics (14%) respectively where as the lowest amount was spent on communication and advocacy (0.3%) followed by planning and administration (1%) and infrastructure and equipments (2%) (Fig. 5).

Click on the image to enlarge
Fig. 4: Availability of funds by Source, 2004-2010	Fig. 5: Expenditure Details by Type in Timor Leste, 2010

Programme goals and targets

To reduce malaria morbidity and mortality until the disease is no longer a public health problem in the country.

Targets	Baseline data in 2005	2010
To reduce the morbidity by 50% of the rate in 2005	51.37 / 1000	25.68/ 1000
To reduce the mortality by 50%of the rate in 2005	8.3/ 100000	4.15/ 100000

Control Strategy

Enhancing case management through early case detection and delivery of effective antimalarial therapies

Utilisation of an integrated vector management programme to prevent and control malaria

Integrating community involvement as a successful way to raise awareness on the prevention and management of malaria

Enhancing components of the health system through capacity building, monitoring and evaluation and community based operational research

Achievement and initiatives

Establishment of Entomology laboratory and entomological surveillance.

Implementation of evidence based Integrated vector control programme.

Best practices and success stories

Use of RDT and ACT to diagnose and treat P. falciparum patients in remote areas.

Stratification of the country according to the incidence of malaria.

Distribution of LLINs according to stratification.

Issues and challenges

Resistance of p. falciparum to chloroquine is problematic with 67% failure rate. It might have contributed to the rise in malaria cases. Emergence of Sulfodoxine-pyremethamine resistance to P. falciparum cases Three cases of drug resistance to quinine were also identified in 2001

Shortage of officers at National and District level for effective implementation of programme

The lack of inter-sectoral action and community participation has contributed to the failure in vector control activities.

Delayed implementation of vector control programmes (IRS) due to lack of mainpower/funding

Poor microscopic diagnosis of malaria parasites and shortage of analysts/microscopists

Increased transmission due to very limited coverage of Insecticide Treated Long Lasting Nets (LLINs) in high risk malaria areas and low utility rate of distributed LLINs nets

Limited or no access to Health institutions with laboratory facilities.

Activities have been too sporadic and fragmented to secure sustained behavioural change.

The Health Care Sector has limited human resources.

Community knowledge, attitude and practice regarding malaria prevention and treatment is relatively low.

Information, education and communication (IEC) has often been too didactic and has failed to reach the targeted audiences.

Failure of existing routine disease surveillance and monitoring system to monitor and evaluate malaria program

Partners and donors

WHO

The Global Fund

AusAid

Care International

ACT malaria