The death toll from two of the world’s most
severe infectious diseases – malaria and
tuberculosis (TB) – has declined significantly
in most of the Asia-Pacific region but is still
high in several countries. Overall, the Asian
and Pacific region has made significant
progress towards achieving Millennium
Development Goal 6 (MDG-6) targets to halt
and begin to reverse incidence of malaria and
TB.
Malaria
Malaria is one of the most devastating of the
communicable disease threats in the world, with
78 million cases and almost 118,000 deaths
reported in 2009. It is also an important parasitic
disease in the Asia-Pacific region with more than
5 million cases and 4,000 deaths.
Although the malaria cases per 100,000
population, in the Asia-Pacific region rose
between 1990 and 2005, between 2005 and
2009, these cases were nearly halved and deaths
caused by malaria were reduced by more than
10% – a remarkable accomplishment for the
region. Nonetheless, malaria disease remains
worrisome in some countries. The annual rate in
Papua New Guinea was 20,137 per 100,000
population in 2009. Other countries with very
high cases per 100,000 population in 2009 were
the Solomon Islands (16,071), Timor-Leste
(9,566) and Vanuatu (6,178). Additionally,
malaria in many countries is grossly
underreported.
Malaria was reported to have caused 4,226 deaths
in Asia and the Pacific in 2009, which composes
only 3.6% of all deaths from malaria globally.
Africa had the largest share of malaria deaths –
96% of total deaths worldwide in 2009.
Although India reported the highest number of
malaria cases in the region, Papua New Guinea
was a close second despite the much smaller total
population; both countries had more than
1 million cases in 2009. Next were Myanmar and
Indonesia with more than 500,000 cases each in
2009. India also reported the highest number of
deaths from malaria, over 1,000; followed by
Myanmar, Indonesia and Papua New Guinea.
The combined total of malaria deaths in those
four countries was 85% of the regional total.
South and South-West Asia is the subregion with
the largest proportion of cases, accounting for
44% of the regional total. South-East Asia and
the Pacific come second, each with a 28% share
of the total. In terms of deaths, conversely, South-
East Asia accounts for the largest share, at 55%
of all malaria deaths in the region, whereas South
and South-West Asia accounts for 29% and the
Pacific 16%.
Overall, Asia and the Pacific reported an increase
in malaria cases between 1995 and 2000. The
spike in rates was most dramatic in Papua New
Guinea, Solomon Islands and Vanuatu.
With increasing resources and improvements in
detection, diagnosis and treatment as well as
vector control, public health interventions
continue to reduce malaria in most endemic
countries. For example, the Solomon Islands
reported cases of 89,778 per 100,000 population
in 2000 that had declined to 16,071 by 2009.
Papua New Guinea reported a lower yet still
substantive decrease, from 29,813 to 20,137 over
the same period. Bhutan, the Lao People’s
Democratic Republic and Sri Lanka had malaria
cases exceeding 1,000 per 100,000 in 2000 which
had decreased by over one half to less than 500
per 100,000 in 2009 in all three countries.
While the number of malaria cases increased in
some Asia and the Pacific countries from 1990
to 2005, the number of deaths from malaria
declined for most countries over that same time
frame. This improvement can be partially
attributed to success in diagnosing cases and
providing appropriate treatment.
Figure I.20 – Malaria cases in most affected
countries of Asia and the Pacific, 1990 to 2009
Figure I.21 – Deaths from malaria in most
affected countries of Asia and the Pacific, 1996
to 2009 
Combating Antimalarial Drug Resistance in Cambodia
Antimicrobial resistance
The development of resistance to antimicrobial medicines in the malaria parasite is a concern that may impact
malaria related deaths in the future. This concern has received international attention as the theme for World Health
Day 2011.
Antimalarial drug resistance
Resistance to anti-malarial drugs signifies the ability of a parasite strain to survive and/or multiply despite the
administration and absorption of antimalarial medicine in recommended dosages. Resistance to earlier generations
of antimalarial medicines such as chloroquine and sulfadoxine-pyrimethamine is widespread in most endemic
countries. Infections show delays in recovery after the start of treatment, indicating resistance. The evidence is
worrying that resistance to artemisinin has arisen along the Cambodian – Thai border. Artemisinin is one of the
most effective drugs at present against malaria. The loss of its efficacy owing to resistance would present an enormous
challenge to malaria control and elimination – locally and regionally – and a huge setback for global efforts to
combat the threat.
Combating resistance
Confronting the possibility of such a catastrophe, WHO, the health ministries of Cambodia and Thailand, and
others have developed and implemented a containment strategy. The initiative is funded by the Bill and Melinda
Gates Foundation and aims to contain and ultimately eliminate the spread of the artemisinin-resistant parasite from
the border area. To halt the spread of antimicrobial resistance, a six-point policy package was developed.
Intensified vector control through 100% coverage of the entire population with long-lasting insecticide-impregnated
bed nets.
Improved early diagnosis and treatment in remote rural areas through services of well-equipped and well-trained
malaria workers in all villages farther than 5 km from a public health facility.
Used innovative high-technology equipment in screening and treatment of 2,800 villages in the targeted zone (Pailin
province) to detect cases.
Used a real-time electronic surveillance and mapping system that can detect cases among residents and cross-border
migrants.
Established additional health posts and clinics along the border to treat high-risk groups.
Implemented 28-day follow-up of all detected malaria cases.
The project has received accolades from experts in the field. According to Dr. Yok Sovann of the Pailin Provincial
Health Department, in 2009 “Krachab [village] had the highest number of malaria cases in Pailin province. Now,
among the 100 fever cases we have just tested using malaria rapid diagnostic tests, none had malaria. Previously, at
least 15 to 50 patients died of malaria in Pailin health facilities every year. But now, in late 2009 and 2010, there
have been no malaria deaths. I think this is partly due to the activities of the containment project.”1 Through the
project, malaria drugs and rapid diagnostic tests are supplied on time, and health staff have gained knowledge and
skills in effective malaria management.
Says Dr. Duong Socheat, Director of the National Malaria Programme of Cambodia, “Whoever is developing
a fever is immediately diagnosed using a malaria rapid diagnostic test in the hands of trained village malaria workers.
That will lead to proper treatment, in addition to good vector control.”
“When people in the community are less affected by malaria and have less to worry about, they can have greater
freedom to work and get an education and better their lives,” says Dr. Sovann. “I’m very happy with the strong and
close collaboration of all partners in the Containment Project – it has made my work here easier.” |
Tuberculosis (TB)
TB incidence in Asia and the Pacific has declined
in most countries and in the region as a whole,
although some countries still carry a substantial
burden of this communicable disease. An
estimated 5.9 million cases occurred in the region
in 2009, corresponding to an incidence rate of
143 cases per 100,000 population; while the
global rate is 137. The 2009 regional figure
reflects a decline by 8.3% since 1990, when it
stood at 156; in comparison with the regional
rate of 147 in 2000.
The Asia-Pacific region is performing better than
Africa (at 295 per 100,000) but worse than Latin
America and the Caribbean (at 44). However,
with the largest population of all regions, Asia
and the Pacific reports the greatest total incidence
of TB.
Of the subregions, East and North-East Asia
(94 per 100,000), North and Central Asia (116)
and the Pacific (57) are performing better than
the world as a whole, with TB incidence lower
than 137. The South-East Asian rate has been
declining relatively slowly since 1990 (238) with
2009 incidence estimated at 217.
North and Central Asia has recorded an increase
in incidence of tuberculosis since 1990. The
subregion reached a peak of 127 per 100,000 in
2000; since then the rate declined to 116 in 2009. In the Russian Federation, the increase
could have been sparked by the spread of HIV/
AIDS, which has risen from 0.1% of the
population in 1990 to 1.0% in 2009.
HIV/AIDS prevalence has seen smaller increases
in other North and Central Asian countries from
1990 to 2009. TB in those countries may have
increased as a consequence of the break-up of the
former Soviet Union. Lack of drugs, medical services, service providers and inadequate
detection and diagnosis, together with poverty,
malnutrition and poor living standards, may have
contributed to the increase in such countries as
Tajikistan and Turkmenistan.
Figure I.22 – Tuberculosis incidence, North and
Central Asia subregion, 1990 to 2009
Although the incidence of TB in the Pacific
subregion as a whole is very low (57 per 100,000
in 2009), countries such as Kiribati (at 351),
Marshall Islands (207) and Papua New Guinea
(250) are severely affected.
Figure I.23 – Tuberculosis incidence, Asia and
the Pacific, 1990 and 2009
TB incidence in South and South-West Asia has
been stable during the last two decades at 167
per 100,000. It is lower than in South-East Asia;
however, the absolute number of TB incidence
in the former is the highest subregional count,
at 2.9 million, owing to its large population.
The case detection rate (CDR) under DOTS
indicates progress in surveillance activity of TB
control programmes. Late in 2010, WHO
recommended using the CDR in all forms of TB
detection, no longer only in producing estimates
for smear-positive TB. That move reflects the
global effort for universal access to TB care for
all forms of TB, not only the most infectious.
According to the 2009 estimate, the CDR in
Asian and Pacific subregions ranged from 63%
in South-East Asia and South and South-West
Asia to 77% in North-East Asia – all subregions
were higher than the global estimate of 62%.
TB prevalence is defined as the number of cases
of TB at a given point in time per 100,000
population. In 2009, global TB prevalence was
201. The only region, where TB is more
prevalent than in Asia-Pacific, is Africa (392, in
2009). However, during the past two decades, TB
prevalence in Asia and the Pacific declined by
34% (from 331 in 1990 to 220 in 2009),
indicating improved quality and coverage of TB
treatment.
At the subregional level and in reference to 2009
figures, TB was most prevalent in South-East Asia
(344) followed by South and South-West Asia
(269). While Cambodia (693), Myanmar (597)
and the Philippines (520) experienced high
prevalence of TB, all three countries had
managed to nearly halve TB prevalence since 1990. In South and South-West Asia, TB
prevalence was high in 2009 for Bangladesh
(425), Pakistan (373), and Afghanistan (337).
Also for these countries, the decline in TB
prevalence between 1990 and 2009 was
noticeable (at 15%, 34% and 25% respectively).
In contrast to other countries and subregions
in Asia and the Pacific, TB prevalence increased
from 1990 to 2009 in a number of countries in
the North and Central Asian subregion,
including in Armenia, Kyrgyzstan, Tajikistan and
Uzbekistan. The sharpest increase is observable
in Tajikistan, at 118%. The overall declining
trend in TB prevalence for this subregion is
mainly due to positive developments in Georgia
and the Russian Federation. In 2009, the
Democratic People’s Republic of Korea (423)
and Mongolia (323) experienced the highest
prevalence of TB in East and North-East Asia.
For Mongolia the rate of 323 represented a
successful decrease of almost two thirds compared
with the 1990 level. Figure I.24 – North and Central Asian countries
with increasing TB prevalence from 1990 to
2009
Although less visible in the trends in aggregate
prevalence rates for the Pacific subregion, small
island developing countries, including Kiribati,
the Marshall Islands, the Federated States of
Micronesia, Palau, Papua New Guinea, the
Solomon Islands and Tuvalu have been highly
successful in reducing TB prevalence since 1990. Figure I.25 – Pacific countries with declining TB
prevalence from 1990 to 2009
|
Malaria and tuberculosis
