REACHING MALARIA

ELIMINATION IN 2030,
WHERE ARE WE?
Inke Nadia D. Lubis

World Malaria Day 2022 – Ikatan Dokter Anak Indonesia

 Outlines

o Introduction
o Global progress
o National malaria action plan
o Malaria elimination milestones and targets
o Challenges to malaria control and elimination efforts
o How long malaria control should be sustained

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 Introduction
o Creating a world malaria-free world is a bold and important public health and
sustainable development goal
• The WHO tracks global progress towards the goals set out in the Global Technical
Strategy (GTS) for Malaria 2015-2030
o There is tremendous progress in reducing malaria cases and deaths since 2000
• However, stagnation in progress persists since 2016
• Progress has slowed and reversed in higher burden countries
• Low burden countries continue to move closer to elimination
o Between 2000 and 2015, case incidence declined from 80 cases per 1000
population at risk to 58; but slowed dramatically to 56 from 2016 to 2019, and
increase to 59 in 2020

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 Countries with indigenous cases in 2000 and their status by 2020

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 Goals of the Global Technical Strategy for malaria
2016 - 2030

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 In 2016, WHO identified 21 countries that could achieve zero indigenous
cases of malaria within the 2020 timeline

www.fk.usu.ac.id Total malaria cases reduced by 84%

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 Progress towards elimination
2000 2020
o Malaria endemic countries 108 countries 87 countries
o <10,000 indigenous malaria cases 26 countries 47 countries
o <100 indigenous malaria cases 6 countries 26 countries
o Countries achieve elimination 21 countries

Southeast Asian region 2000 2020

o Malaria cases 23 million 5 million (78% reduction)
o Malaria deaths 35,000 9,000 (75% reduction)

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 Indonesia
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 Malaria today
o COVID-19 pandemic has further disrupted the global malaria response
o There were an estimated 14 million more malaria cases and 47,000 more
deaths in 2020 compared to 2019
• Mostly in the Africa region
o GTS 2020 milestone have been missed for morbidity and mortality, without
immediate and dramatic action, the 2030 targets will not be met
• Malaria case incidence at 59 per 1000 population (instead 35 cases per 1000)
• Mortality rate 15.3 per 100,000 population (instead 8.9 per 100,000 pop)
• Of 93 endemic countries, only 32% countries had 40% reduction in cases, 34%
had increased case incidence
o For the Southeast Asian region, all countries except Indonesia and Bhutan met
reduced case incidence and mortality by 40% or more

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 National Malaria Action Plan 2020 – 2024
GOALS:
By 2024, at least 75% of districts in Indonesia achieved malaria elimination
status and no high endemic districts (API >5 ‰)
OBJECTIVES:
1. Reduce burden of API > 1 ‰ from baseline 61 Districts in 2018 to 14
Districts by end 2024
2. To interrupt indigenous malaria transmission from baseline 168
Districts in 2018 to 95 Districts by the end of 2024
3. To prevent re-introduction of malaria from baseline 285 districts in
2018 to 405 Districts by end of 2024

1. Ensuring universal 2. Transforming malaria 3. Improve enabling 4. Strengthening the

access to malaria case surveillance as core environment to ensure malaria health system to deliver
elimination achievement
management and intervention of malaria including through BCC and the malaria elimination
prevention
www.fk.usu.ac.id elimination. community engagement. program.
 Key Interventions
Strategy 1
Diagnosis:
1. Increase access to malaria laboratory
examination in all health facilities (public
and private)
2. Improve quality assurance of malaria
diagnosis (microscope and RDT)
Treatment:
1. Increase access of malaria standard
treatment in public and private health
facilities and in the community.
2. Strengthen integrated malaria services
for pregnant mothers and under-five
children within MCH services.
Vector Control:
1. Universal protection of LLINs in malaria
endemic areas.
2. Protection with IRS in selected villages.
3. Improve community-based vector
control, including integrated vector
management with environmental
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modification, larvaciding, or house
Strategy 2
1. Increase malaria case finding
2. Strengthen data systems and
data management
3. Improve epidemiological
investigation (case and foci
investigation)
4. Strengthen early warning
system and emergency response
5. Drug efficacy surveillance
6. Strengthen migration
surveillance
7. Malaria elimination in mobile
migrant populations (MMPs).
8. Improve P. knowlesi
surveillance
9. Improve vector surveillance
including monitoring of vector
resistance and efficacy of LLIN
Strategy 3
1. Increase Central and Local
Government commitment
for acceleration of malaria
elimination and prevention
of reintroduction
2. Strengthen inter sectoral
and inter program
coordination and support for
malaria elimination including
private sectors
3. Behaviour Change
Communication
Strategy 4
1. Strengthen malaria
program management in
context of overall health
system
2. Strengthen management
of sub national malaria
elimination certification.
3. Improve cross border
coordination both within
Indonesia and with
bordering nations (Malaysia,
PNG, Timor Leste).
4. Operational research to
support policy development
and program
implementation
 Specific Strategies Malaria Elimination by Stratification
Acceleration
Objective: Reduce number
of malaria cases
Target: All high endemic
areas (API ≥5 ‰)
Interventions:
Mass LLINs distribution
IRS at village with API >
20‰ and other vector
control interventions based
on local evidence
Scale-up early diagnosis and
prompt treatment
Community empowerment
Integrated ANC and IMCI è
Screen Pregnant women (1st
visit) www.fk.usu.ac.id
and all sick child U5
Intensification
Objective: Clear focus area
Target: Moderate endemic
areas (API 1 - 5 ‰)
Interventions:
LLINs Distribution for high
risk population / at foci
IRS application when
upward trend of malaria
cases detected and other
vector control measures
based on local evidence
Active Case Finding
Community empowerment
Elimination Maintenance
Objective: Interrupt local Objective: Prevent re-
transmission/ No indigenous introduction malaria case
case Target: District that has
Target: Low endemic areas certified malaria elimination
(API <1 ‰) Interventions:
Interventions: Migration surveillance
Epidemiology investigation Epidemiology investigation
and responses : 1-2-5 for all and responses : 1-2-5 for all
positive case positive case
Early diagnosis and prompt Strengthen network for
treatment at all networks early diagnosis and prompt
treatment
Active Case Finding
Surveillance vectors and
Surveillance receptive area
and vector control receptive areas
interventions based on local
evidence
 Malaria Elimination Milestones and Targets
2030
2029
Indonesia certified as
2028
All provinces reach malaria elimination country
2025 the malaria
All districts reach
2019 the malaria elimination
The last year of elimination status
indigenous cases in
300 districts are free of all districts
malaria
5. Papua
2029
& Papua Barat Region

4. Maluku & NTT Region 2028

3. Kalimantan
& Maluku Utara Region
2027

2. Sumatera, Sulawesi,
NTB Region
2025

1. Jawa-Bali Region
2023
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 Regional Subnational Elimination Updated
2021 – 347 District Elimination – as of 31 Dec 2021

Regional Sumatera, Sulawesi, NTB: 181 out of

Regional Kalimantan-North Maluku:
245 distritcs/cities achieved elimination status
37 out of 66 distritcs/cities achieved
(74%)
elimination status (56%)

Regional Papua:
0 out of 42 distritcs/cities achieved
elimination status (0%)

Regional Jawa-Bali:
124 out of 128 distritcs/cities
achieved elimination status
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(97%)
Regional Maluku, NTT:
5 out of 33 distritcs/cities achieved elimination status
(15%)
 Malaria Sub-National Elimination

“Subnational elimination strategy

Stratification 2012 2021 initiated in 2009 and first district received
Certified malaria free 0 347 a certificate was in 2013”
Low endemic 332 127
World Malaria + 33 districts
Moderate endemic 85 16 Days 2022 certified
Commemoration malaria free
High endemic
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(API > 5 ‰) 84 24
 Malaria Control Activities

o Attack vectors to interrupt transmission 50% reduction uncomplicated malaria

• Insecticide treated bed nets (ITNs) 45% reduction severe malaria
17% reduction all-cause mortality
• Indoor residual spraying Cochrane Database Syst Rev 2004;2:CD000363
• Intermittent preventive treatment (IPT)
• In pregnancy (IPTp)
• In children (seasonal malaria chemoprophylaxis)
• In infants (IPTi)
o Identify and treat cases early
• Effective antimalarial (ACT)
• Improved malaria case management (RDTs)

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 Malaria Control Activities

o Attack vectors to interrupt transmission

• Insecticide treated bed nets (TINs)
• Indoor residual spraying 14% reduction uncomplicated malaria
Cochrane Database Syst Rev 2010;2:CD006657
• Intermittent preventive treatment (IPT)
• In pregnancy (IPTp)
• In children (seasonal malaria chemoprophylaxis)
• In infants (IPTi)
o Identify and treat cases early
• Effective antimalarial (ACT)
• Improved malaria case management (RDTs)

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 Malaria Control Activities

o Attack vectors to interrupt transmission

• Insecticide treated bed nets (TINs)
• Indoor residual spraying
• Intermittent preventive treatment (IPT)
• In pregnancy (IPTp)
39% reduction in prevalence of maternal
anaemia
121g increase in birth weight
Cochrance Database Syst Rev 2006(4):CD000169

• In children (seasonal malaria chemoprophylaxis)

• In infants (IPTi)
o Identify and treat cases early
• Effective antimalarial (ACT)
• Improved malaria case management (RDTs)

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 Malaria Control Activities

o Attack vectors to interrupt transmission

• Insecticide treated bed nets (TINs)
• Indoor residual spraying
• Intermittent preventive treatment (IPT)
• In pregnancy (IPTp)
• In children (seasonal malaria chemoprophylaxis)
• In infants (IPTi) During transmission season:
o Identify and treat cases early 82% reduction in malaria episodes
• Effective antimalarial (ACT) 57% reduction in all-cause mortality
Wilson A et al. PLoS One 6(2)
• Improved malaria case management (RDTs)

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 Malaria Control Activities

o Attack vectors to interrupt transmission

• Insecticide treated bed nets (TINs)
• Indoor residual spraying
• Intermittent preventive treatment (IPT)
• In pregnancy (IPTp)
• In children (seasonal malaria chemoprophylaxis)
• In infants (IPTi) 30% reduction in malaria episodes in the
o Identify and treat cases early first year of life
http://www.who.int/malaria/publications/atoz/tefconsultiptiap
• Effective antimalarial (ACT) r2009report.pdf

• Improved malaria case management (RDTs)

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 Malaria Control Activities

o Attack vectors to interrupt transmission

• Insecticide treated bed nets (TINs)
• Indoor residual spraying
• Intermittent preventive treatment (IPT)
• In pregnancy (IPTp)
• In children (seasonal malaria chemoprophylaxis)
• In infants (IPTi)
o Identify and treat cases early
• Effective antimalarial (ACT)
• Improved malaria case management (RDTs)

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 Malaria Control Challenges
Vector Resistance to Insecticides

o Globally, resistance to pyrehtroids – primary insecticide class used in ITNs - is

widespread, being detected in 68% study sites. Resistance to organochlorines,
carbamates and organophosphates reported in 64%, 34% and 28% sites,
respectively
o Of 88 malaria endemic countries, 78 detected resistance to at least one
insecticide class in at least one malaria vector and one collection site
o 29 countries reported resistance to pyrehtroids, organochlorines, carbamates,
and organophosphate across different sites
o 19 countries confirmed resistance to all these four classes

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 Malaria Control Challenges
Resistance to Artemisinin and its Partner Drug

o Artemisinin partial resistance is being monitored using the PfKelch13 markers

associated with decreased sensitivity to artemisinin, and has been reported in
the Greater Mekong Region
o In Indonesia, ACTs remain effective with failure rates less than 5%
o In the African Region, failure using ACT remain below 10%

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 Malaria Control Challenges
Parasite deletions of pfhrp2/3 genes

o Deletions in the parasite’s pfhrp2 and pfhrps3 genes renders parasites

undetectable by RDTs that are based on histidine-rich protein (HRP2)
o 37 countries reported presence of hrp2/3 deletions

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 Challenges to Malaria Elimination Efforts
1. Malaria program is not included in the Minimum Service Standards (SPM)
2. High incidence of cases in Papua
3. Hard to reach population in remote areas and special populations (illegal miner,
loggers, remote indigenous communities)
4. High dependence on donors and reduced local government commitment
5. Implementation of diagnostic services, quality assurance and treatment need
to be improved
6. Cross-programme and multisectoral stakeholders collaboration need to be
improved

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 How long malaria
control should be
sustained?
Wekening malaria control programmes

Cohen JM et al. 2012(11): 122

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 How long malaria
control should be
sustained?
War and other disruptions

Cohen JM et al. 2012(11): 122

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 How long malaria
control should be
sustained?
Relaxation of control program

Cohen JM et al. 2012(11): 122

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 Summary

o In global scale, progress against malaria remains

uneven, despite the pandemic
o Tailored malaria responses are needed to local
settings
o Strengthen health systems – continued progress
against malaria
• Sufficient numbers and competent human
resources
• Political and financial commitment
o Sustanaible efforts

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 Faculty of Medicine, Universitas Sumatera Utara
Jl. Dr. T. Mansyur No. 5, Medan 20155, Indonesia
dean.med@usu.ac.id

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