- Email: [email protected]
Malaria prevention and control in Bhutan: Successes and challenges
Acta Tropica 117 (2011) 225–228
Contents lists available at ScienceDirect
Acta Tropica journal homepage: www.elsevier.com/locate/actatropica
Short communication
Malaria prevention and control in Bhutan: Successes and challenges Tashi Tobgay a,∗ , Cristina E. Torres b,1 , Kesara Na-Bangchang c,2 a
Ministry of Health, P.O. Box: 726, Kawajangsa, Thimphu, Bhutan WHO-TDR Clinical Coordination and Training Center, Faculty of Allied Health Sciences, Thammasat University (Rangsit Campus), Klongluang, Pathumthani 12121, Thailand c Graduate Program in Biomedical Sciences, WHO-TDR Clinical Coordination and Training Center, Faculty of Allied Health Sciences, Thammasat University (Rangsit Campus), Klongluang, Pathumthani12121, Thailand b
a r t i c l e
i n f o
Article history: Received 24 September 2010 Received in revised form 6 November 2010 Accepted 16 November 2010 Available online 27 November 2010 Keywords: Malaria Prevention Control Bhutan
a b s t r a c t This paper highlights on the current malaria situations in Bhutan and its challenges for future prevention and control strategies. In Bhutan, malaria affects more than half of the entire population, mostly residing in the southern districts bordering with Indian states of Assam and West Bengal. Over the past ten years, due to concerted efforts, the morbidity and mortality due to malaria has significantly declined. These preventive and control measures focused on the mass distribution of long lasting insecticidal treated nets, focal indoor residual spray and use of artemisinin-based combination therapies. However, considerable challenge lies ahead and research is needed to generate local evidence for sustainable elimination of malaria from Bhutan. The article should be of value and interest to planners, malaria programs and for future researchers on malaria in Bhutan. © 2010 Elsevier B.V. All rights reserved.
Bhutan started the modern health care system in 1961 (Berkeley, 1969; Ward and Jackson, 1965). Since then, the Bhutan health system has evolved into a complex structure that has addressed its health issues to improve its health indicators including malaria prevention and control (GNH Commission, 2009; Ulrika Enemark et al., 2007; World Health Organization, 2008b). Health care in Bhutan is delivered through a three tiered system consisting of the primary, secondary and tertiary levels that provide preventive, promotive and curative services. These services are provided through 29 hospitals, 178 basic health units (BHU) and 654 outreach clinics. These health facilities are scattered in all twenty districts and 201 gewogs (sub-districts), providing services to 634,982 people who are sparsely located across 38,394 km2 (National Statistical Bureau, 2007). Health care including supply of medicines and referral outside the country is provided free by the government and there are no private hospitals or clinics (Ministry of Health, 2009). Historically, malaria was a dreaded disease in Bhutan, which was prevalent mostly in the southern parts of country and in the deep valleys (Berkeley, 1979). A pre-eradication survey conducted in 1962, found that malaria parasite prevalence in children ranged from 10.7% to 55.5% in the malaria endemic villages (Vector-borne Disease Control Programme, 2007). Subsequently, malaria eradication programme was established in Bhutan with
∗ Corresponding author. Tel.: +975 2 339853; fax: +975 2 328091. E-mail address: [email protected] (T. Tobgay). 1 Tel.: +66 2 5644440x1800; fax: +66 2 9869207. 2 Tel.: +66 2 9869213x7271; fax: +66 2 9869207. 0001-706X/$ – see front matter © 2010 Elsevier B.V. All rights reserved. doi:10.1016/j.actatropica.2010.11.008
the assistance from the Government of India. Malaria eradication activities included extensive use of indoor residual spray with dichlorodiphenyltrichloroethane (DDT) and establishment malaria centres in Southern districts for active case surveillance. Since then, malaria prevention and control in Bhutan was strengthened and expanded to curtail the high incidence (Rajagopal, 1985). Currently, malaria transmission is perennial in seven southern districts bordering with India and seasonal transmission during summer months occurs in nine other districts (Fig. 1). Over 70% of the cases occurred in three districts of Sarpang, Samdrup Jongkhar and Samtsi which borders with Indian states of West Bengal and Assam. Plasmodium vivax and Plasmodium falciparum are the malaria parasite species prevalent in Bhutan. The vector species found in Bhutan through recent surveys are Anopheles psedowillmori, Anopheles willmori, Anopheles maculates, Anopheles fluviatilis, Anopheles dirus and Anopheles vagus (Vector-borne Disease Control Programme, 2007). However, we have not found any reports confirming the malaria vector in Bhutan. Over the past ten years, there was significant reduction of malaria cases in Bhutan both in terms of mortality and morbidity (Vector-borne Disease Control Programme, 2007). In 1999, there were 12,591 reported malaria cases with 53 deaths as compared to only 329 reported cases with 2 deaths in 2008. The case reduction was achieved despite maintaining the annual blood examination rate of over 10% of the population at risk. There is approximately equal distribution of P. falciparum and P. vivax cases over the years. The case fatality has remained constant at over 5 per 1000 P. falciparum cases, despite reduction in absolute death due to
226
T. Tobgay et al. / Acta Tropica 117 (2011) 225–228
Fig. 1. Malaria transmission areas of Bhutan.
Table 1 Malaria indices from 1999 to 2009 (0). Year
BSC
T + VE
T.Pf
ABER
API
SPR
Death
CFR
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
79,589 76,445 65,974 74,696 61,246 54,892 60,152 66,079 51,446 47,268 62,341
12591 5935 5982 6511 3806 2670 1825 1868 793 329 972
6654 2738 3177 3496 1680 1090 954 905 379 180 559
19 18 15 17 14 12 13 14 11 10 13
32 14 14 15 8 6 4 4 2 0.7 2
17 8 9 9 6 5 3 3 1 0.7 2
22 15 14 11 15 5 5 6 2 2 4
3.3 5.5 4.4 3.1 8.9 4.6 5.2 6.6 5.3 11.1 7.2
Note: BSC: blood slide collection, T + VE: total positive for malaria, TPf: total positive for Plasmodium falciparum including mixed Plasmodium falciparum and Plasmodium vivax cases; ABER: annual blood examination rate, API: annual parasite incidence, SPR: slide positivity rate, Pf: Plasmodium falciparum; CFR: case fatality rate.
malaria (Table 1). The plausible explanation to this could be due to late diagnosis and treatments considering the geographical terrain or the health facilities are not equipped to manage severe malaria cases or there is delayed referral to the higher health facilities. The incidence of malaria is high within the age groups of 15–49 years, with infections more prevalent in males than females (Fig. 2). The main reasons for such gender and age variations could be due to occupational risk as men usually has to go to forest to collect firewood; guard their field at night and travels across the borders for business. Bhutan used dichlorodiphenyltrichloroethane (DDT) for indoor residual spray till 1995. From 1995 onwards, considering the safety and the people’s acceptance, the chemical was changed to deltamethrin 2.5% WP at a dosage of 25 mg/m2 (World Health Organization, 2007a). Currently IRS is considered in focal areas based on the following criteria:
a. Annual parasite incidence above 5 per 1000 population for the past 3 years. b. Slide positivity rate of above 3% for the past 3 years. c. P. falciparum rate above 50% for the past 3 years. d. Death due to malaria occurred in that village within past 3 years. Indoor residual spray is carried out annually in selected areas before the onset of the high transmission season (July to September). In 2009, 17,000 household were sprayed twice a year (Vector-borne Disease Control Programme, 2010). In 2006, with the assistance of The Global Fund for HIV/AIDS, TB and Malaria (GFATM), Long Lasting Insecticidal Nets (LLIN) and artemisinin-based combination therapies (artemether/lumefantrine) were introduced. A total of 110,722 nets have been distributed during 2006–2008 and over 90,000 LLINs were distributed in 2010. The nets were distributed according to the family size and on average; each household receives about 2 nets (Vector-borne Disease Control Programme, 2010). Bhutan has sustained the LLIN coverage over 90% of households in perennial transmission areas (The Global Fund, 2009). Treatment with anti-malarial drugs is only given after confirmatory diagnosis by either rapid diagnostic test or by microscopy. The treatment regimen consists of artemether/lumefantrine for uncomplicated P. falciparum malaria, artemether injection and quinine injection reserved for severe P. falciparum malaria. Chloroquine with primaquine is used for the treatment of P. vivax infection. In addition, all the P. falciparum cases are admitted in the health facility to provide directly observed treatment and to monitor the progress. Further, environmental management to reduce the breeding sites and potential breeding sites are regularly done in collaboration with communities. Integrated vector management has been initiated in 2009 in one community and community action groups were formed to monitor the breeding sites within the community. This initiative has received good response from the community and the programme has plans to expand to other districts.
T. Tobgay et al. / Acta Tropica 117 (2011) 225–228
227
Fig. 2. %Malaria cases by age group and gender.
Despite success, various challenges lay ahead posing tremendous threat to the elimination of malaria from Bhutan. Bhutan has one of the toughest geographical terrains and most of the villages are entrenched into deep valleys and forests lying far away from health facilities. The malaria reports are based on health facility reports and so far, there is no survey conducted in Bhutan to explore the true malaria burden. As per WHO statistics, the predicted cases for Bhutan for year 2006 were 15,879 malaria cases with 19 deaths. This predicated cases were nearly 10 times higher than reported cases for year 2006 which was 1868 malaria cases and only 6 deaths (World Health Organization, 2008b). In addition, high percentage of P. falciparum cases and consequently high cases fatality rate is a worrisome trend. Prevalence surveys need to be conducted to understand the real malaria burden in Bhutan and it would be vital for remodeling future preventions and control activities (Rajakaruna et al., 2010). Lack of trained and qualified human resources has always been a constraint in Bhutan. For example, there is only one entomologist in the Ministry of Health. The human resource requirement is more justified as the programme moves into the elimination phase where intensified surveillance and better case management is imperative (World Health Organization, 2007b). The Royal Institute of Health Sciences, the only health related institute of the country, provides pre-services training such as diploma courses for nurses, paramedic health workers and other technicians. Currently, Bhutan has no medical college. Therefore, most of the available trained technical professionals and medical doctors are trained in neighboring countries of India, Bangladesh, Nepal, Thailand and other developed countries such as Australia, UK and USA. However, Bhutan is in a process of establishing the Bhutan Institute of Medical Sciences which will train medical doctors and other health related professionals. In addition, there is also a plan to establish a research centre for tropical and zoonotic diseases in the next five year plan which starts from 2013. Malaria is endemic in southern Bhutan that shares a porous border with the Indian state of Assam and West Bengal. With exception to the few urban areas where there is road connections and thriving business, most of the other border areas are forested. In these Indian administered forested areas; there are settlements of the tribal communities with no proper health facilities. Some of these tribal people often seek medical care from the health facilities of Bhutan lying across the border areas. The number of malaria
cases from across the border who seek treatment in Bhutan constitutes over 10% of the total malaria cases (Vector-borne Disease Control Programme, 2008). Therefore, cross border activities need to be studied and instituted as a component of malaria elimination programs in Bhutan. Despite considerable achievements in malaria prevention and control, its success is hardly researched and published literature on Bhutan malaria situations is very scarce. WHO recommends that, for any interventions to be effective and sustainable, it has to be based within the socio-cultural and political context of the individual country. This mandates generation of local knowledge and evidences (World Health Organization, 2008a). Unfortunately, Bhutan is far behind in the field of research and development. Hence, to document the past experiences and to guide the future directions, research in Bhutan is of paramount importance. In conclusion, fast tracking the malaria prevention and control in Bhutan to the elimination phase requires thorough consideration and mitigation of current challenges. The cross border malaria dynamics needs enhanced monitoring and research. Further, the current preventive and control measures should be strengthened with improved community involvement without lessening political and international support. Only then will Bhutan will be able to eliminate malaria in a sustainable manner. Conflict of interest The authors have no conflict of interest. Acknowledgments The study is funded by UNICEF/UNDP/World Bank/WHO Special programme for Research and Training in Tropical Diseases (TDR). Gratitude to The Commission on Higher Education, Ministry of Education of Thailand and Royal Government of Bhutan for the institutional support. References Berkeley, J.S., 1969. Medical practice in Bhutan. Practitioner 203, 791–797. Berkeley, J.S., 1979. Primary medical care in Bhutan. J. Roy. Coll. Gen. Pract. 29, 530–533.
228
T. Tobgay et al. / Acta Tropica 117 (2011) 225–228
GNH Commission, 2009. Tenth Five year Plan (2008–2013), vol. ii Main document. GNH Commission, Thimphu. Ministry of Health, 2009. MoH: General Synopsis and History. MoH. National Statistical Bureau, 2007. Bhutan Living Standard Survey: 2007 Report. Rajakaruna, R., Alifrangis, M., Amerasinghe, P., Konradsen, F., 2010. Pre-elimination stage of malaria in Sri Lanka: assessing the level of hidden parasites in the population. Malaria Journal 9, 25. Rajagopal, R., 1985. Studies on malaria in Bhutan. Journal of Communicable Diseases 17 (4), 278–286. The Global Fund, 2009. Bhutan: Grant Performance Report. The Global Fund for HIV/AIDS, TB and Malaria, Geneva. Ulrika Enemark, Bjorn Melgaard, Esben Sonderstrup, 2007. Health Sector Review. Ministry of Health, Thimphu, Bhutan. Vector-borne Disease Control Program, 2007. Annual Malaria Report. Vector-borne Disease Control Program. Department of Public Health, Bhutan.
Vector-borne Disease Control Program, 2008. Annual Malaria Report. Vector-borne Disease Control Program. Department of Public Health, Bhutan. Vector-borne Disease Control Program, 2010. Program Report. Vector-borne Disease Control Program. Department of Public Health, Bhutan. Ward, M., Jackson, F., 1965. Medicine in Bhutan. The Lancet 285, 811–813. World Health Organization, 2007a. Bhutan Malaria Control Programme Review. World Health Organization, South East Regional Office, New Delhi, India. World Health Organization, 2007b. Malaria Elimination: A Field Manual for Low and Moderate Endemic Countries. World Health Organization, Geneva, Switzerland. World Health Organization, 2008a. Global Malaria Control and Elimination: Report of a Technical Review. World Health Organization, Geneva, Switzerland. World Health Organization, 2008b. World Malaria Report 2008. World Health Organization, Geneva, Switzerland.
Contents lists available at ScienceDirect
Acta Tropica journal homepage: www.elsevier.com/locate/actatropica
Short communication
Malaria prevention and control in Bhutan: Successes and challenges Tashi Tobgay a,∗ , Cristina E. Torres b,1 , Kesara Na-Bangchang c,2 a
Ministry of Health, P.O. Box: 726, Kawajangsa, Thimphu, Bhutan WHO-TDR Clinical Coordination and Training Center, Faculty of Allied Health Sciences, Thammasat University (Rangsit Campus), Klongluang, Pathumthani 12121, Thailand c Graduate Program in Biomedical Sciences, WHO-TDR Clinical Coordination and Training Center, Faculty of Allied Health Sciences, Thammasat University (Rangsit Campus), Klongluang, Pathumthani12121, Thailand b
a r t i c l e
i n f o
Article history: Received 24 September 2010 Received in revised form 6 November 2010 Accepted 16 November 2010 Available online 27 November 2010 Keywords: Malaria Prevention Control Bhutan
a b s t r a c t This paper highlights on the current malaria situations in Bhutan and its challenges for future prevention and control strategies. In Bhutan, malaria affects more than half of the entire population, mostly residing in the southern districts bordering with Indian states of Assam and West Bengal. Over the past ten years, due to concerted efforts, the morbidity and mortality due to malaria has significantly declined. These preventive and control measures focused on the mass distribution of long lasting insecticidal treated nets, focal indoor residual spray and use of artemisinin-based combination therapies. However, considerable challenge lies ahead and research is needed to generate local evidence for sustainable elimination of malaria from Bhutan. The article should be of value and interest to planners, malaria programs and for future researchers on malaria in Bhutan. © 2010 Elsevier B.V. All rights reserved.
Bhutan started the modern health care system in 1961 (Berkeley, 1969; Ward and Jackson, 1965). Since then, the Bhutan health system has evolved into a complex structure that has addressed its health issues to improve its health indicators including malaria prevention and control (GNH Commission, 2009; Ulrika Enemark et al., 2007; World Health Organization, 2008b). Health care in Bhutan is delivered through a three tiered system consisting of the primary, secondary and tertiary levels that provide preventive, promotive and curative services. These services are provided through 29 hospitals, 178 basic health units (BHU) and 654 outreach clinics. These health facilities are scattered in all twenty districts and 201 gewogs (sub-districts), providing services to 634,982 people who are sparsely located across 38,394 km2 (National Statistical Bureau, 2007). Health care including supply of medicines and referral outside the country is provided free by the government and there are no private hospitals or clinics (Ministry of Health, 2009). Historically, malaria was a dreaded disease in Bhutan, which was prevalent mostly in the southern parts of country and in the deep valleys (Berkeley, 1979). A pre-eradication survey conducted in 1962, found that malaria parasite prevalence in children ranged from 10.7% to 55.5% in the malaria endemic villages (Vector-borne Disease Control Programme, 2007). Subsequently, malaria eradication programme was established in Bhutan with
∗ Corresponding author. Tel.: +975 2 339853; fax: +975 2 328091. E-mail address: [email protected] (T. Tobgay). 1 Tel.: +66 2 5644440x1800; fax: +66 2 9869207. 2 Tel.: +66 2 9869213x7271; fax: +66 2 9869207. 0001-706X/$ – see front matter © 2010 Elsevier B.V. All rights reserved. doi:10.1016/j.actatropica.2010.11.008
the assistance from the Government of India. Malaria eradication activities included extensive use of indoor residual spray with dichlorodiphenyltrichloroethane (DDT) and establishment malaria centres in Southern districts for active case surveillance. Since then, malaria prevention and control in Bhutan was strengthened and expanded to curtail the high incidence (Rajagopal, 1985). Currently, malaria transmission is perennial in seven southern districts bordering with India and seasonal transmission during summer months occurs in nine other districts (Fig. 1). Over 70% of the cases occurred in three districts of Sarpang, Samdrup Jongkhar and Samtsi which borders with Indian states of West Bengal and Assam. Plasmodium vivax and Plasmodium falciparum are the malaria parasite species prevalent in Bhutan. The vector species found in Bhutan through recent surveys are Anopheles psedowillmori, Anopheles willmori, Anopheles maculates, Anopheles fluviatilis, Anopheles dirus and Anopheles vagus (Vector-borne Disease Control Programme, 2007). However, we have not found any reports confirming the malaria vector in Bhutan. Over the past ten years, there was significant reduction of malaria cases in Bhutan both in terms of mortality and morbidity (Vector-borne Disease Control Programme, 2007). In 1999, there were 12,591 reported malaria cases with 53 deaths as compared to only 329 reported cases with 2 deaths in 2008. The case reduction was achieved despite maintaining the annual blood examination rate of over 10% of the population at risk. There is approximately equal distribution of P. falciparum and P. vivax cases over the years. The case fatality has remained constant at over 5 per 1000 P. falciparum cases, despite reduction in absolute death due to
226
T. Tobgay et al. / Acta Tropica 117 (2011) 225–228
Fig. 1. Malaria transmission areas of Bhutan.
Table 1 Malaria indices from 1999 to 2009 (0). Year
BSC
T + VE
T.Pf
ABER
API
SPR
Death
CFR
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
79,589 76,445 65,974 74,696 61,246 54,892 60,152 66,079 51,446 47,268 62,341
12591 5935 5982 6511 3806 2670 1825 1868 793 329 972
6654 2738 3177 3496 1680 1090 954 905 379 180 559
19 18 15 17 14 12 13 14 11 10 13
32 14 14 15 8 6 4 4 2 0.7 2
17 8 9 9 6 5 3 3 1 0.7 2
22 15 14 11 15 5 5 6 2 2 4
3.3 5.5 4.4 3.1 8.9 4.6 5.2 6.6 5.3 11.1 7.2
Note: BSC: blood slide collection, T + VE: total positive for malaria, TPf: total positive for Plasmodium falciparum including mixed Plasmodium falciparum and Plasmodium vivax cases; ABER: annual blood examination rate, API: annual parasite incidence, SPR: slide positivity rate, Pf: Plasmodium falciparum; CFR: case fatality rate.
malaria (Table 1). The plausible explanation to this could be due to late diagnosis and treatments considering the geographical terrain or the health facilities are not equipped to manage severe malaria cases or there is delayed referral to the higher health facilities. The incidence of malaria is high within the age groups of 15–49 years, with infections more prevalent in males than females (Fig. 2). The main reasons for such gender and age variations could be due to occupational risk as men usually has to go to forest to collect firewood; guard their field at night and travels across the borders for business. Bhutan used dichlorodiphenyltrichloroethane (DDT) for indoor residual spray till 1995. From 1995 onwards, considering the safety and the people’s acceptance, the chemical was changed to deltamethrin 2.5% WP at a dosage of 25 mg/m2 (World Health Organization, 2007a). Currently IRS is considered in focal areas based on the following criteria:
a. Annual parasite incidence above 5 per 1000 population for the past 3 years. b. Slide positivity rate of above 3% for the past 3 years. c. P. falciparum rate above 50% for the past 3 years. d. Death due to malaria occurred in that village within past 3 years. Indoor residual spray is carried out annually in selected areas before the onset of the high transmission season (July to September). In 2009, 17,000 household were sprayed twice a year (Vector-borne Disease Control Programme, 2010). In 2006, with the assistance of The Global Fund for HIV/AIDS, TB and Malaria (GFATM), Long Lasting Insecticidal Nets (LLIN) and artemisinin-based combination therapies (artemether/lumefantrine) were introduced. A total of 110,722 nets have been distributed during 2006–2008 and over 90,000 LLINs were distributed in 2010. The nets were distributed according to the family size and on average; each household receives about 2 nets (Vector-borne Disease Control Programme, 2010). Bhutan has sustained the LLIN coverage over 90% of households in perennial transmission areas (The Global Fund, 2009). Treatment with anti-malarial drugs is only given after confirmatory diagnosis by either rapid diagnostic test or by microscopy. The treatment regimen consists of artemether/lumefantrine for uncomplicated P. falciparum malaria, artemether injection and quinine injection reserved for severe P. falciparum malaria. Chloroquine with primaquine is used for the treatment of P. vivax infection. In addition, all the P. falciparum cases are admitted in the health facility to provide directly observed treatment and to monitor the progress. Further, environmental management to reduce the breeding sites and potential breeding sites are regularly done in collaboration with communities. Integrated vector management has been initiated in 2009 in one community and community action groups were formed to monitor the breeding sites within the community. This initiative has received good response from the community and the programme has plans to expand to other districts.
T. Tobgay et al. / Acta Tropica 117 (2011) 225–228
227
Fig. 2. %Malaria cases by age group and gender.
Despite success, various challenges lay ahead posing tremendous threat to the elimination of malaria from Bhutan. Bhutan has one of the toughest geographical terrains and most of the villages are entrenched into deep valleys and forests lying far away from health facilities. The malaria reports are based on health facility reports and so far, there is no survey conducted in Bhutan to explore the true malaria burden. As per WHO statistics, the predicted cases for Bhutan for year 2006 were 15,879 malaria cases with 19 deaths. This predicated cases were nearly 10 times higher than reported cases for year 2006 which was 1868 malaria cases and only 6 deaths (World Health Organization, 2008b). In addition, high percentage of P. falciparum cases and consequently high cases fatality rate is a worrisome trend. Prevalence surveys need to be conducted to understand the real malaria burden in Bhutan and it would be vital for remodeling future preventions and control activities (Rajakaruna et al., 2010). Lack of trained and qualified human resources has always been a constraint in Bhutan. For example, there is only one entomologist in the Ministry of Health. The human resource requirement is more justified as the programme moves into the elimination phase where intensified surveillance and better case management is imperative (World Health Organization, 2007b). The Royal Institute of Health Sciences, the only health related institute of the country, provides pre-services training such as diploma courses for nurses, paramedic health workers and other technicians. Currently, Bhutan has no medical college. Therefore, most of the available trained technical professionals and medical doctors are trained in neighboring countries of India, Bangladesh, Nepal, Thailand and other developed countries such as Australia, UK and USA. However, Bhutan is in a process of establishing the Bhutan Institute of Medical Sciences which will train medical doctors and other health related professionals. In addition, there is also a plan to establish a research centre for tropical and zoonotic diseases in the next five year plan which starts from 2013. Malaria is endemic in southern Bhutan that shares a porous border with the Indian state of Assam and West Bengal. With exception to the few urban areas where there is road connections and thriving business, most of the other border areas are forested. In these Indian administered forested areas; there are settlements of the tribal communities with no proper health facilities. Some of these tribal people often seek medical care from the health facilities of Bhutan lying across the border areas. The number of malaria
cases from across the border who seek treatment in Bhutan constitutes over 10% of the total malaria cases (Vector-borne Disease Control Programme, 2008). Therefore, cross border activities need to be studied and instituted as a component of malaria elimination programs in Bhutan. Despite considerable achievements in malaria prevention and control, its success is hardly researched and published literature on Bhutan malaria situations is very scarce. WHO recommends that, for any interventions to be effective and sustainable, it has to be based within the socio-cultural and political context of the individual country. This mandates generation of local knowledge and evidences (World Health Organization, 2008a). Unfortunately, Bhutan is far behind in the field of research and development. Hence, to document the past experiences and to guide the future directions, research in Bhutan is of paramount importance. In conclusion, fast tracking the malaria prevention and control in Bhutan to the elimination phase requires thorough consideration and mitigation of current challenges. The cross border malaria dynamics needs enhanced monitoring and research. Further, the current preventive and control measures should be strengthened with improved community involvement without lessening political and international support. Only then will Bhutan will be able to eliminate malaria in a sustainable manner. Conflict of interest The authors have no conflict of interest. Acknowledgments The study is funded by UNICEF/UNDP/World Bank/WHO Special programme for Research and Training in Tropical Diseases (TDR). Gratitude to The Commission on Higher Education, Ministry of Education of Thailand and Royal Government of Bhutan for the institutional support. References Berkeley, J.S., 1969. Medical practice in Bhutan. Practitioner 203, 791–797. Berkeley, J.S., 1979. Primary medical care in Bhutan. J. Roy. Coll. Gen. Pract. 29, 530–533.
228
T. Tobgay et al. / Acta Tropica 117 (2011) 225–228
GNH Commission, 2009. Tenth Five year Plan (2008–2013), vol. ii Main document. GNH Commission, Thimphu. Ministry of Health, 2009. MoH: General Synopsis and History. MoH. National Statistical Bureau, 2007. Bhutan Living Standard Survey: 2007 Report. Rajakaruna, R., Alifrangis, M., Amerasinghe, P., Konradsen, F., 2010. Pre-elimination stage of malaria in Sri Lanka: assessing the level of hidden parasites in the population. Malaria Journal 9, 25. Rajagopal, R., 1985. Studies on malaria in Bhutan. Journal of Communicable Diseases 17 (4), 278–286. The Global Fund, 2009. Bhutan: Grant Performance Report. The Global Fund for HIV/AIDS, TB and Malaria, Geneva. Ulrika Enemark, Bjorn Melgaard, Esben Sonderstrup, 2007. Health Sector Review. Ministry of Health, Thimphu, Bhutan. Vector-borne Disease Control Program, 2007. Annual Malaria Report. Vector-borne Disease Control Program. Department of Public Health, Bhutan.
Vector-borne Disease Control Program, 2008. Annual Malaria Report. Vector-borne Disease Control Program. Department of Public Health, Bhutan. Vector-borne Disease Control Program, 2010. Program Report. Vector-borne Disease Control Program. Department of Public Health, Bhutan. Ward, M., Jackson, F., 1965. Medicine in Bhutan. The Lancet 285, 811–813. World Health Organization, 2007a. Bhutan Malaria Control Programme Review. World Health Organization, South East Regional Office, New Delhi, India. World Health Organization, 2007b. Malaria Elimination: A Field Manual for Low and Moderate Endemic Countries. World Health Organization, Geneva, Switzerland. World Health Organization, 2008a. Global Malaria Control and Elimination: Report of a Technical Review. World Health Organization, Geneva, Switzerland. World Health Organization, 2008b. World Malaria Report 2008. World Health Organization, Geneva, Switzerland.