Statistical Yearbook for Asia and the Pacific 2011
 
People - Health
Malaria and tuberculosis
Data sources: WHO World Malaria Programme, World Malaria Report 2010. WHO Global Health Observatory Database (WHO/GHO).

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

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

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

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

Figure I.25 – Pacific countries with declining TB prevalence from 1990 to 2009


1 WHO, Combating Communicable Diseases: The Work of WHO in the Western Pacific Region”, 1 July 2009 – 30 June 2010. Available from www.wpro.who.int/NR/rdonlyres/05F00135-6E1B-4C8D-814F-8134AF3C3A8B/0/RD10_1_DCC_MVP.pdf.
 
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