Demographic and Health Survey 2009-10 - Timor-Leste Ministry of ...

MALARIA 13
Malaria remains a leading public health problem in Timor-Leste. Most of the estimated one
million population in the country is at high risk of malaria, with about 80 percent of the cases reported
from just 4 of the 13 districts—Dili, Viqueque, Covalima and Lautem (WHO SEAR, 2010). The
number of confirmed cases has risen from 15,212 in 2000 to 45,973 in 2008. Slide positivity increased
from 44 percent to 50 percent between 2002 and 2008, and the percentage attributed to Plasmodium
falciparum increased from 53 percent to 73 percent over the same period (WHO SEAR, 2010). This
increase may be due to an actual increase in malaria or to the strengthening of diagnostic facilities and
improved monitoring and evaluation. The Ministry of Health (MOH) estimates between 100,000 and
200,000 cases of suspected malaria are reported each year in public health facilities, representing 12
percent of outpatient attendance. Of this figure, about 40,000 are children under age 5. Malaria also
accounts for about four percent of hospital admissions (MOH, 2003).
The existing climatic conditions in Timor-Leste are conducive to the spread of mosquitoes
and the perennial transmission of malaria. The number of reported cases peak during the post-wet
season of November to May (Cooper, et al., 2010). Still, a relatively large number of cases are
recorded throughout the rest of the year. However, because there is relative variation in the
topography of the country, the intensity of transmission varies with altitude, and endemicity is
reduced in the higher altitudes (WHO SEAR, 2010).
Timor-Leste’s efforts to control malaria date back to the pre-independence era when various
strategies were employed at different times. In 1999, the country adopted the Roll Back Malaria
initiative and has since been implementing a combination of curative and preventive interventions.
The National Malaria Control Strategy focuses on early case management and delivery of effective
antimalarial therapies, universal access to long-lasting insecticidal nets (LLINs), selective use of
indoor residual spraying (IRS), and promotion of behavioral change and communication (BCC).
Since 2003, the Global Fund to fight AIDS, Tuberculosis and Malaria (GFATM) has
substantially funded malaria control programs in Timor-Leste (Martins et al., 2009). The NMS
supports the recommendation of WHO’s Roll Back Malaria (RBM) strategy, and in aiming to achieve
the Millennium Development Goals (MDGs), has modified its LLIN distribution program
accordingly, to ensure that there is one LLIN for every two persons considered to be at risk of malaria
(95 percent of the population), thereby providing universal access to LLIN coverage. This is a shift
from the earlier strategy of approximately two nets per household targeted for distribution to
households with children under age 5 and pregnant women, the two most vulnerable groups, and
therefore of primary focus (MOH, 2003). LLINs are distributed to pregnant women through antenatal
clinics in public health facilities. It is reported that approximately 60 percent of the population is
covered under the country’s bed net program (WHO SEAR, 2010).
Case management of malaria is done at hospitals, community health centers (CHCs), and
health posts (HPs) and also during visits to mobile clinics. Since 2007, the antimalaria drug policy has
shifted its focus and adopted artemether-lumefantrine, an artemisinin-based combination therapy
(ACT), as the drug of choice for the treatment of uncomplicated P. falciparum malaria across the
country. This is because of the emergence of chloroquine and sulfadoxine-pyramethamine-resistant
strains of the parasite. Health care providers in both the public and private sectors were trained in the
new protocol for the treatment of malaria, which stipulated that the provision of ACT must be based
on the results of a laboratory examination (microscopy), or a Rapid Diagnostic Test (RDT), where
microscopy was not available. Chloroquine continues to be the drug of choice for the treatment of P.
vivax, the second, but less common, malaria parasite in Timor-Leste.
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