Malaria Control & Elimination

The Use of Artesunate Combination Therapy (Acts) and Long- Lasting Insecticidal Net (LLIN) in Low Endemic Area to Achieve Malaria Elimination in Indonesia

Abstract

Rita Kusriastuti, Satoto Tri Baskoro, Iwan Dwiprahasto and Hari Kusnanto

Malaria elimination in Indonesia was launched officially as a national program in 2008 following a commitment during the 60th World Health Assembly in 2007. Indonesia’s three major malaria elimination goals include: 1) An annual parasite incidence (API) below 1 per 1000 population 2) Absence of indigenous cases 3) Active surveillance. Another key component of Indonesia’s elimination strategy includes the use of artesunate combination therapy (ACT) in place of chloroquine, because of evidence for widespread resistance. Objective: The objective of this study is to assess the impact of a new policy in malaria treatment using ACT in place of chloroquine together with long-lasting insecticidal net (LLINs) in order to achieve malaria elimination in two low malaria endemic areas (where the API are ranging from 1 - 5 per 1000 population): in Sabang city in Aceh Province, located in the western part of Indonesia and in the Jembrana district, in Bali province located in the eastern part of Indonesia. Method: Epidemiological data were collected from health centers and district health offices from 2008 to 2011 using a standardized reporting form. Both qualitative and quantitative data were collected. In-depth interviews with the authorities, health workers and other key informants such as village malaria volunteers, combined with direct observations were conducted in the two study areas. Result: In combination with LLINs and ACT beginning in 2008 there was decrease in the incidence of malaria in Sabang city from 3.7/1000 population in 2008 to 0.08/1000 population in the 2011, a decrease of almost 50 fold. No indigenous cases were found and a program of active surveillance is in place including surveillance immigrants to and from villages by local volunteers. Similarly in Jembrana district, since the widespread use of ACT and LLINs distribution there was a sharp fall in the incidence from 0.94/1000 population in 2008 to 0.05/1000 population in 2011, decrease of almost 20 fold over 3 years. An absence of indigenous cases reported and an active surveillance is in place by local volunteers. Conclusion: The combination of treatment activity used ACT and prevention used LLINs can reduce malaria even in low endemic. Active surveillance activity was required to ensure the absence of indigenous cases from the area. The model of malaria activities in Sabang city and Jembrana district can be implemented in all low malaria endemic areas in Indonesia in order to obtain the national goal of malaria elimination.