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Malaria control in Bhutan: case study of a country embarking on elimination

Thinley Yangzom1, Cara Smith Gueye2*, Rinzin Namgay1, Gawrie NL Galappaththy3, Krongthong Thimasarn4, Roly Gosling2, Shiva Murugasampillay5 and Vas Dev6

Author Affiliations

1 Vector-Borne Disease Control Programme, Ministry of Health, Royal Government of Bhutan, Post Box 191, Gelephu, Bhutan

2 Global Health Group, University of California, San Francisco, 50 Beale Street, Suite 1200, San Francisco, CA, USA

3 National Malaria Control Programme, Ministry of Health, Public Health Complex, 555/5, Elvitigala Mawatha, Colombo 05, Sri Lanka

4 Malaria Unit, South-East Asia Regional Office of the World Health Organization, World Health House, Indraprastha Estate, Mahatma Gandhi Marg, New Delhi 110 002, India

5 Global Malaria Programme, World Health Organization, Avenue Appia 20, 1211, Geneva 27, Switzerland

6 National Institute of Malaria Research (ICMR), Chachal, VIP Road, Guwahati 781 022, Assam, India

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Malaria Journal 2012, 11:9  doi:10.1186/1475-2875-11-9

Published: 9 January 2012

Abstract

Background

Bhutan has achieved a major reduction in malaria incidence amid multiple challenges. This case study seeks to characterize the Bhutan malaria control programme over the last 10 years.

Methods

A review of the malaria epidemiology, control strategies, and elimination strategies employed in Bhutan was carried out through a literature review of peer-reviewed and grey national and international literature with the addition of reviewing the surveillance and vector control records of the Bhutan Vector-Borne Disease Control Programme (VDCP). Data triangulation was used to identify trends in epidemiology and key strategies and interventions through analysis of the VDCP surveillance and programme records and the literature review. Enabling and challenging factors were identified through analysis of socio-economic and health indicators, corroborated through a review of national and international reports and peer-review articles.

Findings

Confirmed malaria cases in Bhutan declined by 98.7% from 1994 to 2010. The majority of indigenous cases were due to Plasmodium vivax (59.9%) and adult males are most at-risk of malaria. Imported cases, or those in foreign nationals, varied over the years, reaching 21.8% of all confirmed cases in 2006.

Strategies implemented by the VDCP are likely to be related to the decline in cases over the last 10 years. Access to malaria diagnosis in treatment was expanded throughout the country and evidence-based case management, including the introduction of artemisinin-based combination therapy (ACT) for P. falciparum, increasing coverage of high risk areas with Indoor Residual Spraying, insecticide-treated bed nets, and long-lasting insecticidal nets are likely to have contributed to the decline alongside enabling factors such as economic development and increasing access to health services.

Conclusion

Bhutan has made significant strides towards elimination and has adopted a goal of national elimination. A major challenge in the future will be prevention and management of imported malaria infections from neighbouring Indian states. Bhutan plans to implement screening at border points to prevent importation of malaria and to targeted prevention and surveillance efforts towards at-risk Bhutanese and migrant workers in construction sites.

Keywords:
Bhutan; Malaria; Elimination; Control; Migration; Migrant; Diagnosis; Treatment; Surveillance; Vector