Success in malaria eradication faces new challenges

Malaria is one of the major public health problems in Bangladesh as 13 districts are in the high endemic areas of malaria transmission. Of these districts, the Chittagong Hill Tracts (CHTs), Cox's Bazaar and Chittagong are highly endemic. Sporadic incidence occurs in other parts of the country. Total number of people at risk is 13.25 million in these districts. Of these districts, three are high endemic, one medium endemic and nine are low endemic areas. In those districts, a total of 26,891 people were afflicted with malaria in 2013. Of them 15 died of the disease. Still more than 3.4 million people in four districts are at high risk of malaria although Bangladesh has significantly brought down the number of patients and people at risk. Over 98% of the total cases in the country are reported from 70 endemic upazilas covering 620 unions in 13 endemic districts.
According to a government data, in Bangladesh number of malaria infected people was 59,857 out of whom 227 died in 2007. The number of patients dramatically rose to 84,690 in 2008 but the number of death was down to 154. The number of patients again declined to 63,873 in 2009 with 47 mortality cases. The number further declined to 55,873 with mortality down to 37 in 2010. The downtrend continued with 26,891 patients in 2013 with mortality coming down to 15.  
According to the baseline data of 2008, the rate of malaria-afflicted patients was 776 per hundred thousand population. Bangladesh under the United Nation's millennium development goals (MDGs) targeted to reduce the number of malaria patients to 310 by 2015. The country has succeeded to reduce the number to 202 by 2013. In 2008, mortality rate per hundred thousand population was 1.4 which Bangladesh targeted to reduce to 0.6 by 2015. Bangladesh has reduced the mortality rate to 0.11 per hundred thousand population. This success has come under threat with the intrusion of people from Myanmar and India-afflicted with malaria into Bangladesh. The development has greatly made the target of making Bangladesh malaria-free by 2020 a challenging one. Coordination at the border areas of Bangladesh, India and Myanmar is essential to maintain the success Bangladesh has achieved in controlling and treating malaria.
In 2007, a total of 59,857 laboratory-confirmed cases were reported of which 228 resulted in death. Routine surveillance data shows that the proportion of male and female cases of malaria in Bangladesh is 55 per cent and 45 per cent respectively. The income generating group (>15 years) presents the greatest number of malaria cases. Children and pregnant women also belong to this high-risk category. The poor and marginalised people are also prone to infection and are at an increased risk of fatality.
According to World Health Organisation (WHO) definition, Malaria is a life-threatening disease caused by parasites that are transmitted to people through the bites of infected mosquitoes. Malaria is caused by Plasmodium parasites. The parasites are spread to people through the bites of infected Anopheles mosquitoes, called "malaria vectors", which bite mainly between dusk and dawn.
Malaria is transmitted exclusively through the bites of Anopheles mosquitoes. The intensity of transmission depends on factors related to the parasite, the vector, the human host, and the environment. Malaria is preventable and curable. Non-immune travellers from malaria-free areas are very vulnerable to the disease when they get infected.
Bangladesh has been relentlessly putting its effort to control malaria at both GO-NGO level. The government in partnership with 21 NGOs has been implementing the National Malaria Control Programme (NMCP) in all endemic districts since 2007. The main approach for malaria control is to inform and educate people at community level, promote use of insecticide treated bed nets and increase early diagnosis and prompt treatment of malaria. The largest development organization in the world BRAC through its Shasthya Shebikas and Shasthya Kormis (Health Workers) are responsible for providing diagnostic and treatment services at community level. They also refer patients to the nearest government health facility and pay special attention to pregnant women, children under five kilograms of weight and severe malaria cases. Latest steps include pre-eradication activities in four high endemic districts as mortality has reduced in these districts since 2012. The areas where pre-eradication activities are being carried out are: Haluaghat and Dhobaura upazilas of Mymensigh district, Durgapur and Kalmakanda upazilas of Netrokona district, Jhinaigati and Sribardi upazilas of Sherpur district, and Rajibpur and Roumari upazilas of Kurigram district. The steps also include: malaria detection and treatment in community clinics, disease detection and treatment through special camps in hard-to-reach areas (HTRA), paying the travelling cost to the patients from HTRA, post-mortem of the malaria related death cases, orientation of the private physicians and hotel owners, recording the information of the malaria patients in the government and private medical college hospitals, taking coordinated vector control programme by identifying villages at risk, adequate special arrangement for the high risk community like jhum cultivators and woodcutters, school-based malaria awareness campaign and sending service messages through community radio, cable network, call centre and hotline.
National Malaria Control Programme is a large scale programme of the government involving huge amount of investment of both the government and donors. The Global Fund to Fight Aids, Tuberculosis and Malaria. (GFATM) has allocated US$ 66.21 million for 2007-2015 period while Bangladesh government under its Health Population and Nutrition Sector Development Program (HPNSDP) has allocated US$ 29.7 million for 2011-2016 period and World Health Organisation (WHO) US$ 1.76 million for 2007-2014 period for malaria control programme. People are now receiving quick detection and microscopy services for malaria through 83 government and 121 non-government centres across the country. Still there are some challenges in achieving desired result from the activities. Lack of skilled manpower, poor communication system in hilly areas, strong coordination among the private physicians and organizations and with other ministries including tourism, agriculture and environment still remain as some of the challenges for malaria control programme in Bangladesh.