Towards Malaria Elimination in Indonesia

Executive Board Meeting, ACT MALARIA

Dr. Rita Kusriastuti, M.ScDirector of VBDC, DG DC&EH, MOH INDONESIA

VIENTIENE, 16 – 18th March 2009

Indonesia : COUNTRY IN BRIEF

Jakarta

• 220 million people• 1.9 million square km• 33 provinces• 471 districts• 17,000 islands (transportation includes flight, road, boat)• cultural diversity• since 2003 shifting to decentralized system

7 hours flight

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S

N

EW

Endemisitas rendahsedangtinggi

Kasus Positif di Jawa Bali# 1 Dot = 5

Kasus di Bukan Jawa Bali# 1 Dot = 20

MALARIA INCIDENCE IN INDONESIA2005

PETA ENDEMIS MALARIA DI INDONESIATAHUN 2007

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Low ModerateFree1 dot = 50 Kasus

1 dot = 250 kasusHigh

0 0-1 1-5 5-49 50-100 > 100API o/oo

0

500,000

1,000,000

1,500,000

2,000,000

2,500,000

3,000,000

3,500,000

Malaria Klinis 3,178,212 2,737,927 2,660,674 2,482,906 2,335,585 2,113,265 2,167,028 1,774,845 1,624,930

Spesimen Darah Diperiksa 1,880,418 1,604,573 1,440,302 1,224,232 1,109,801 982,828 1,246,324 930,029 1,145,087

Kasus Positif 256993 267,592 273,793 223,074 268,852 315,394 347,597 311,789 266,277

2000 2001 2002 2003 2004 2005 2006 2007 2008

Malaria Cases in Indonesia 2000Malaria Cases in Indonesia 2000--20082008

1

1

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7

89

10

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1 4

1 515

16

1 6

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18 19

202 0

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2121

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2 2

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PENYEBA RA N V EK TOR MA LA RIA DI INDONESIA 2008VECTOR MALARIA IN INDONESIA

Keterangan : 1. An.aconitus 6. An. flavirostris 11. An. ludlowi 16.An.sinensis 2. An.balabacensis 7. An. koliensis 12. An.maculates 17. An. .subpictus3. An.bancrofti 8. An.letifer 13. An.minimus 18 An.sundaicus 4. An.barbirostris 9. An.leucosphyrus 14.An.nigerrimus 19. An. vagus 5. An.farauti 10. An.karwari 15. An.punctulatus 20. An. umbrosus21. An.tesellatus 22. An.parangensis 23.An. kochi 24.An.ludlowi 25.An.annullaris

OBJECTIVES : Indonesia

1.1. By the year 2010 be able By the year 2010 be able to decreaseto decrease all HCI all HCI areas (villages with malaria positive areas (villages with malaria positive ≥≥ 5 per 5 per 1000 pop) 1000 pop) by 50 %by 50 %

2.2. In year 2010 all districts and cities able to In year 2010 all districts and cities able to conduct conduct confirmationconfirmation of malaria suspected cases of malaria suspected cases and 100% treat withand 100% treat with ACTACT

3. In year 2010 all Indonesia’s endemic areas conduct intensification and integration in malaria control.

4. By the year 2010 begin elimination of malaria in stepwise by Islands

OBJECTIVES :ELIMINATION

1. Elimination in DKI, Bali, Batam: 2010

2. Elimination in Jawa and Aceh : 2015

3. Elimination in Sumatra, NTB, Kalimantan, Sulawesi: 2020

4.Elimination in Papua, WestPapua, Maluku,, NTT, North Maluku : 2030

Malaria Figure by Islands 2007

-

100,000

200,000

300,000

400,000

500,000

600,000

700,000

Sumatera Jaw a-Bali Kalimantan Sulaw esi Maluku-NusaTenggara

Papua

Islands

Clinical

BSE

Positive

Pf + Mix

P v

Indonesia : Steps towardsElimination

2000

3 yrs3 yrs

2000-2030

Indonesia : Elimination

CONTROL PHASE :-No or limited confirmation activities, limited microscopist.- Diagnosis :Clinical Malaria-Predominantly Plasmodium falciparum-Weak in surveillance , outbreak often occur and late in control it - prevalence still high, SPR > 5 %

-PRE ELIMINATION- Good confirmation activities-Good surveillance activities, towards the zero transmission (indigenous)-API < 1 / 1000 population at village level

Intervention towards Elimination

• Confirmation of all malaria cases by quality malaria microscopy

• Full coverage by effective antimalarial drugs given free of charge

• Total coverage by IRS the main prevention measure in active foci (coverage >85%)

• Use LLN as prevention and vector control• Strong malaria information system covering all health

facilities including community surveillance• Surveillance system to classify all cases and all foci with

their present functional status (in real time) • Active case detection• Geographical reconnaissance

ACTIVITIES

TrainingsTrainingsActive case detection (MBS. MFS).Active case detection (MBS. MFS).

Case management: diagnosis and treatment.Case management: diagnosis and treatment.Vector control/IVM ( IRS and LLIN).Vector control/IVM ( IRS and LLIN).Village Malaria Posts with Village Mal Village Malaria Posts with Village Mal Cadres.Cadres.Procurement of laboratory facilities Procurement of laboratory facilities (Microscope and RDT) laboratory supplies , (Microscope and RDT) laboratory supplies , LLIN and ACT. LLIN and ACT. Advocacy : RBM forum , partnership NGOAdvocacy : RBM forum , partnership NGO’’s , s , Private, expert organizationPrivate, expert organization

Indonesia: SCALLING UP

Integration and Intensification of Malaria Control ActivitiesIntegration and Intensification of Malaria Control Activities. . -- Mass Blood SurveyMass Blood Survey-- Malaria treatment and bednet distribution to pregnant women.Malaria treatment and bednet distribution to pregnant women.-- Malaria treatment and Bednet distribution during immunization Malaria treatment and Bednet distribution during immunization

program. program. -- Bednet distribution during Mass Drug Administration for FillariaBednet distribution during Mass Drug Administration for Fillariasis sis

control program and conduct mass campaign.control program and conduct mass campaign.-- Establishment of Village Malaria PostsEstablishment of Village Malaria Posts

MALARIA DRUG RESISTENT IN INDONESIA,

1978 - 2005

16

POLICIES POLICIES I.I. DiagnosDiagnosis  must  be  confirm  by is  must  be  confirm  by 

mimiccrosrosccopopee oror Rapid   Diagnostic TestRapid   Diagnostic Test

STOP CLINICAL MALARIA

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POLICIESPOLICIESII.TREATMENTII.TREATMENT

ArtemisininArtemisinin--basedbased Combination TherapyCombination Therapy (ACT)(ACT)

STOP MONOTHERAPY

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III. PIII. PREVENTION : useREVENTION : use LLIN ,LLIN ,IRSIRS ,, repellentrepellentetc.etc.

POLICIESPOLICIES

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IV.IV. Intersectoral collaboaration in RBM Intersectoral collaboaration in RBM forum.forum.

PoliciesPolicies

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V.V. Community participation through Community participation through strengthening the Village Malaria Post strengthening the Village Malaria Post and Village Malaria Cadre/volunteers.and Village Malaria Cadre/volunteers.

PoliciesPolicies

PKK Kabupaten PKK Kabupaten Banjarnegara Banjarnegara Peserta Paduan Peserta Paduan Suara Lagu Suara Lagu ““Gebrak Gebrak MalariaMalaria””

Indonesia : ACHIEVEMENT IN PILOT DISTRICT

• 897 midwives out of 1034 has been trained and equiped in 2007. (86.7%)

• 38,688 new pregnant women out of 49,371 received LLIN when visiting ANC in 2007. (78.8%)

• 16,736 new pregnant women out of 32,786 screened for malaria (51%)

Indonesia: Success Story 1: Integrated Bed Nets Campaign ( MOH –UNICEF )

Intervention : distribution of Long Lasting Insecticide Bed Nets Campaign in Sumatra

Integration with measles, Polio, and Vit A (24 Districts in Sumatra), with Vit A (6 Districts in Sumatra), with Vit A and Sprinkles (Sikka), with filariasis (Keerom and Merauke), purely bednet campaign in NAD.

Indonesia : Success story : Continued

-In total 3,8 million nets were distributed

-Achievement in Sumatra (rapid assessment 1 month after campaign) :

-% HH who has 1 or more ITNs, increased from 2.2% (2/91) before the campaign to 94.5% (86/91) after the campaign. -But the % ITNs that was used/hanged = 44.8% (64/143) -% children under five years of age who slept using ITN increased from 1.9% (2/106) to 51% (54/106) after the campaign

-Figures from other districts were more or less similar

-Benefit for other program was noted and appreciated (high coverage of EPI, nutrition, and mass drug administration of filariasis)

Success story 2 : Vector control program through community mobilization

Intervention : Community based vector control, using PLA (Participatory Learning and Action) approach/Mr. Bangkit (workshop management of vector

control programs, Cambodia, August 2008).Achievement : together with Sub Dit Vector/Mr.Winarno, WHO, PHO, and DHO develop training and activities in the villages in South Halmahera

Indonesia : F U N D I N G

Global Fund 56%

Others 10%

Local Budget

26%

National Budget

8%

Indonesia : F U N D I N G needed

National Bednets Availability 2008-2012

-10,000,00020,000,00030,000,00040,000,00050,000,00060,000,00070,000,00080,000,00090,000,000

Needs (5 yrs ) Actual (3 yrs) Gaps (Needs-Actual)

Plans GF R8 (5 yrs)

Indonesia : Challenges

Lack of access to health facilities in Lack of access to health facilities in very remote areas and hard to reach very remote areas and hard to reach islands.islands.Inequality of health development (Java VS Inequality of health development (Java VS Outer Java). Outer Java). Limitation of adequate Malaria Human Limitation of adequate Malaria Human Resources mostly microscopist & Resources mostly microscopist & entomologistentomologist (Ms.Hasni & Ms(Ms.Hasni & Ms..MelvinawatiMelvinawati,,both both

are participants from strengthening training in Malaria are participants from strengthening training in Malaria microscopy & quality assurance in Philippines, Sept 2008)microscopy & quality assurance in Philippines, Sept 2008)

Environmental changes relates to Environmental changes relates to increasing of mosquito breeding placesincreasing of mosquito breeding placesLimited Operational research Limited Operational research

Indonesia : Challenges

1. Quality of midwives performing RDT needs to be closely evaluated and improved

2. Poor distribution of health workers (midwives) in remote places (in this setting, IPT needed? )

Indonesia : Challenges & opportunities

1. Expansion to 101 district for malaria in pregnancy and 70 district for integration of routine EPI is huge and will need strong technical capacity and strong collaboration to have good quality program.

2. Expansion will need to be continued beyond GF funding.

3. Campaign is effective to reduce malaria in most endemic area, though, expensive.

4. Most malaria endemic area are remote and difficult to reach, logistic and coverage is a challenge

`THANK YOUTerima kasih