Monday, November 08, 2010

Progress of Activity Malaria Control in Timor Leste 2007-2009

Progress of Activity Malaria Control in Timor Leste 2007-2009
In Timor Leste, Malaria is a major public health problem and the leading cause of morbidity and mortality with approximately 200,000 clinical and confirmed malaria cases and about 20 to 60 deaths per year. The disease burden and economic loss due to the disease is enormous. Between 20 to 40% of all outpatients and 30% of all hospital admissions present from symptomatic malaria. Malaria incidence is quite high among the under 5 years of age children group, which represents nearly 37-34% of the total cases Table 3).
Our vision is to achieve MDG goals by 2015 in making malaria no longer a cause of mortality and a barrier to socio-economic developmental growth in Timor-Leste.
Our mission is to enable sustained delivery and use of most effective prevention and treatment for those affected most by malaria.
Overall Goal:
Over overall of National Malaria Control  is to reduce the burden of malaria in Timor Leste.
Malaria Control Strategy:
In line with the Global Malaria Control Strategy, adopted in 1992 by a Ministerial Conference on malaria held in Amsterdam, and subsequently endorsed by the World Health Assembly and the UN General Assembly in 1993 and in line with WHO-SEARO scale up strategy, Timor-Leste malaria control strategy is based on 4 imperative:

  • Provide early diagnosis and prompt treatment of malaria
  • Distributing LLIN to high risk group
  • Providing integrated Vector Control
  • Establishing epidemic preparedness and Response

Overall Objectives:
a) To reduce malaria mortality by 30% of the level in 2006 by 2012.
b) To reduce malaria morbidity by 30% of the level in 2006 by 2012.
c) To reduce malaria morbidity among pregnant women and children under five years by 50% of the level in 2006 by 2012.
d) To reduce malaria prevalence among the population at risk by 25% of the level in 2008 by 2012.
Situation analysis:
The number of clinical malaria malaria cases reported in the country decreased from 243,695  to 114,670 from2006 to 2009 (Fig. 1). The contributory factors for reduction of malaria cases in the country were emphasis on introduction of Artimisinine Combination Therapy (ACT) for treatment of P. falciparum malaria cases, use of Rapid Diagnostic Test (RDTs) for P. falciparum diagnosis and distribution of Long Lasting Insecticide (LLINS) to the high risk areas.  However, there was no drastic reduction of malaria can not been seen in the number of P. falciparum cases due to increase of RDTs which diagnose P. falciparum  in the health posts without malaria microscopy..
A total of 143,594 and 114,670 malaria cases were reported in 2008 and 2009 respectively. P. falciparum and P. vivax are the major parasite species in the country and P. falciparum accounted for 73% of the confirmed malaria cases from 2006 to 2008. Incidence rate of malaria cases reported in 2008 and 2009 are 133 and 103 per thousand populations respectively (Table 1).

Clinically diagnosed cases
Microscopically and RDT  confirmed cases
P. falciparum cases
P. vivax cases
Incidence (1000 pop.)

There is a 50% reduction of malaria in 2009 compared to 2007. The probable reasons for this could be: (a) Introduction of ACT for treatment of P. falciparum cases (b) increased coverage and reporting of health services due to use of Rapid Diagnostic Test (RDT) kits in the rural Community Health Centers and Health Posts where there were no malaria microscopy facilities available (c). stratification of the malaria risk areas according to malaria incidence and strengthening of LLINs distribution in malaria high risk areas (d) recruitment of 71 officers as  malaria focal points at regional, district and national level funded by GF round 7 and strengthening of monitoring and evaluation  . Malaria incidence is quite high among the under 5 years of age children group (276 per 1000 population) which represents nearly 36% of the total cases.  No of high risk malaria sub districts  decreased from 18 to 12 sub districts districts  (Fig 2 and fig 3).

Table 1: Number of clinically and microscopically and RDT (Rapid Diagnostic Test kits which detect P. falciparum malaria ) confirmed malaria cases and deaths due to malaria from 2007-2008 

Due to interplay of ecological and climatic conditions, receptivity to malaria transmission is high in southern shore region, moderate in northern shore region and low in mountainous region (Fig 2) .

Fig.2: Micro stratification of the sub districts according to malaria incidence (1000 population)

Fig 3: Micro stratification of sub districts according to malaria incidence from April 2009 to March 2010

Table 3: Number of malaria cases and malaria incidence reported according to the age groups, year 2007 to 2009
Age group
Total number of malaria cases (%)
Incidence (per 1000 population)
0-5 years
77,947  (37%)

>5 years
135,539 (63%)


0-5 years
51,500 (36%)
>5 years
92,094 (64%)

0-5 years
39,674 (34%)

>5 years
74,996  (66%)


Entomological Investigations:
Entomological surveys carried out in the country revealed that there are 10  anopheline species in the country. An. barbirostris and An. subpictus were incriminated as primary and secondary vectors. These vectors show early biting behaviour (6:00 AM to 12:00 PM) and rest indoors. Therefore, Insecticide treated bed nets alone by the people except children under 5 years of age may not be very effective, as the peak biting time of the vector does not coincide with the sleeping time of the people. These result provide evidence for using for integrated approach for vector control including LLINs, indoor residual spraying, environmental management, use of larvivorous fish , larvicides  and personnel protection.

Insecticide susceptibility test which was carried out using vectors An. subpictus and An. barbirostris revealed that these species susceptible to deltmethrin, permethrin, fenitothion, cyflothrin, DDT, malathion and lambdacyahalothrin .

 Larval surveys carried out in the country revealed that An. subpictus and an. barbirostris found breeding high densities in the slow moving or stagnant water pools with vegetation which create were created during the rainy season.

Vector Control:
Distribution of LLINs to children under 5 years and pregnant mothers is the major vector control method use in the country. Indoor Residual Spraying (IRS) was carried out in small scale in the IDP camps. Even though IRS was effective according to the behavior of vector, IRS  could not carry out in large scale due to shortage of funds. Pyriproxyfen , Insect Growth Hormone was applied in the malaria vector breeding places in high risk malaria areas in Dili districts. Larvivorous fish, Apolochilus panchax is available in most of the permanent water bodies which malaria vectors can be transmitted. Malaria and other mosquito breeding places reduction with community participation and intersectoral collaboration was carried out in every Friday morning starting from World Malaria Day in 2009.
The malaria control programme has now received a grant support under the Global fund Round 7 grant of USD 6,168,687 for the initial two years starting from 1st of April 2009. This fund has being supported the MoH to strengthen the human resources, logistics, technical and managerial capacity and to expand malaria control interventions including adequate availability of ACT and other antimalarials, RDT at the health facilities without malaria microscopy, distribution of Long Lasting Insecticide Treated Nets (LLINs) to children under 5 years and pregnant mothers and small scale Indoor Residual Spraying (IRS) in malaria epidemic areas.
a. Poor capacity of the health system with poor access to diagnosis and treatment. Therefore malaria patients in the remote areas are out of reach by health services 
b. Strengthening of diagnosis and treatment
c. Poor community participation and intersectoral collaboration for malaria control
d. The coverage of Long Lasting Insecticide treated nets is poor. 195,000 LLINS which was procured through GF round 7 will be distributed by Ministry of Health with assistance from Community Health Volunteers. Distribution of LLINs also a challenge for the MOH.
e. Shortage of funds to carry out Indoor residual spraying in the malaria epidemic areas.
f. The surveillance systems need to be improved and therefore epidemics are missed in the early stages 
g. There are 75 temporary officers and drivers  recruited to strengthen the malaria control activities at national and district level; namely 5 regional malaria officers, 13 district malaria officers, 27 sub-district malaria officers (high risk malaria areas), 2 vector control assistants , entomology team consists of 2 entomology assistants and 6 insect collectors , 3 analysts for quality control of malaria microscopy, 5 drivers at national and 13 drivers in 13 districts. Only the programme manager is permanent staff. It is important to recruit these officers and drivers to recruit as permanent staff for the sustainability of a successful National Malaria Control Programme in the country MS01

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