BHUTAN - Eliminating malaria in


                                Eliminating malaria in
Bhutan has experienced a 97 percent decrease in reported malaria cases
between 2000 and 2011, and is aiming to obtain World Health Organization
malaria-free certification by 2020.

Bhutan is a small, landlocked country with a small popula-                At a Glance1
tion and mountainous terrain. Bhutan has achieved a drastic               194 Reported cases of malaria
decline in malaria; cases peaked at nearly 40,000 in 1994 and                 (47% P. vivax)
dropped to only 194 confirmed cases in 2011.1 In 2011,
47 percent of malaria cases in Bhutan were Plasmodium vivax,
                                                                             1 Death from malaria
45 percent were P. falciparum, and the remaining were mixed                 75 % of population at risk
infections.2 Anopheles sinensis and An. aconitus are the                       (total population: 0.7million)
vectors primarily responsible for malaria transmission, with,
                                                                         0.27 Annual parasite incidence
An. annularis, An. barbirostris, and An. maculatus acting as
                                                                              (cases/1,000 total population/year)
secondary vectors.3
                                                                           0.4 % Slide positivity rate
Four districts in Bhutan have zero risk of malaria transmis-
sion, nine have seasonal transmission risk, which is historically
May through September, and seven districts in the south             Source: World Health Organization, World Malaria Report 2012
along India’s border have perennial transmission risk.4, 5 The
groups most at-risk of malaria are males, specifically farmers,
students and migrant workers, due to the various occupa-
                                                                    Progress Toward Elimination
tional factors of traveling to India for business or working in     Bhutan’s National Malaria Eradication Programme was es-
the fields or forests.2, 5 In 2009, 94 percent of the total cases   tablished in the early 1960s with the support of the govern-
were from perennial-transmission districts.5 Sarpang District,      ment of India through the procurement of insecticides. IRS
a perennial-transmission district in the south that borders         with DDT was introduced in 1962 at a time when the malaria
India’s northern state of Assam, recorded the majority of           burden was low, with only 518 reported cases.2 Through case
imported cases between 2000 and 2010 and had the highest            management and vector control, annual parasite incidence
number of local cases in seven out of the last 10 years.2           decreased from 5.5 percent in 1965 to only 1.2 percent in
                                                                    1968.14 Active case detection was initiated in 1969. However,
The government of Bhutan sustains two vector control mea-
                                                                    despite this effort, the percentage of cases due to
sures: long-lasting insecticide treated bed nets (LLINs) and
                                                                    P. falciparum rose dramatically from 12 percent of cases in
indoor residual spraying (IRS) in the perennial-transmission
                                                                    1968 to 57 percent of cases by 1975.14 An abundance of the
districts. In addition, the country provides early diagnosis
                                                                    An. maculatus vector was suspected to be the reason for the
and prompt treatment with artemisinin-based combination
                                                                    dramatic increase.14
therapy (ACT).6 Bhutan is a country partner of the Asia Pacific
Malaria Elimination Network (APMEN), a network composed             The number of total malaria cases from 1976 to 1983
of 14 Asia Pacific countries and other stakeholders working         fluctuated between 3,500 and 5,000, but in 1984 reached
to eliminate malaria in the region.7, 8 With continued support      more than 18,000.15 P. falciparum resistance to chloroquine
from the Global Fund, and improvements in cross-border              was first reported in 1984, and by 1996 P. falciparum totaled
collaboration with India, Bhutan will reach its goals to elimi-     63 percent of all malaria cases in the southern districts of
nate malaria by 2016 and obtain World Health Organization           Sarpang and Samdrup Jongkhar.16 P. falciparum resistance to
(WHO) malaria-free certification by 2020.9

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                                      					                                                                      Eliminating malaria in BHUTAN

Malaria Transmission Limits
Plasmodium falciparum                                                        Plasmodium vivax

  0                100               200 Kilometres                             0                   100           200 Kilometres

       Water                                                                        Water
       P. falciparum free                                                           P. vivax free
       Unstable transmission (API

                                         					                                                               Eliminating malaria in BHUTAN

  Reported Malaria Cases
Number of cases

                                                                                                               793 329 972 436 194
                   5,000                                                                                      cases cases cases cases cases
                           1990   1992   1994    1996      1998       2000        2002       2004      2006        2008          2010
  Cases have decreased significantly between 1994 and 2011 from nearly 40,000 to less than 200.
 Source: World Health Organization, World Malaria Report 2012

            GOALS: 1. Zero deaths due to malaria by 20169
                              2. Achieving zero local malaria transmission in Bhutan by 20169
                              3. World Health Organization malaria-free certification by 20209

  districts, with a goal to achieve a 50 percent reduction in
  malaria-related cases and deaths by 2013 compared with
                                                                          Eligibility for External Funding10–12
  2005.2, 18, 19                                                             The Global Fund to Fight AIDS, Tuberculosis and            Yes
 The malaria program has developed a malaria elimination
 strategic plan from 2011 to 2016, which outlines a phased
                                                                             U.S. Government’s President’s Malaria Initiative           No
 approach for eliminating P. falciparum and P. vivax malaria.9
 In the strategic plan, Bhutan plans to develop new part-
                                                                             World Bank International Development Association           Yes
 nerships and coordinate malaria stakeholders, strengthen
 diagnosis, improve delivery of prompt and effective malaria
 treatment, continue coverage with ITNs, scale-up focal IRS
 in high-risk areas, monitor insecticide and drug resistance,
                                                                          Economic Indicators13
 increase training to strengthen health personnel, and encour-
                                                                             GNI per capita (US$)                           $2,130
 age community involvement through activities and outreach
 related to malaria.5, 18 With the introduction of ACTs in 2005,
                                                                             Country income classification                 Lower middle
 P. falciparum has decreased to 45 percent of total cases in
                                                                             Total health expenditure per capita (US$)      $93

                                                                             Total expenditure on health as % of GDP        4

                                                                             Private health expenditure as % total          16
                                                                             health expenditure

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                                     					                                                                   Eliminating malaria in BHUTAN

Challenges to Eliminating                                                  employed at district-level health centers, and border and
                                                                           migrant worker screenings are planned as part of the
Malaria                                                                    elimination strategy.9 Surveillance will be strengthened
Cross-border challenges with India                                         through increased coordination, training, supervision, and
More than 60 percent of the malaria cases in Bhutan come                   mapping equipment and expertise.18
from five districts along the border with India. Assam State in
                                                                           Early diagnosis and prompt treatment
northern India, which borders Sarpang District in southern
                                                                           Long travel distances to health facilities and rugged, moun-
Bhutan, records over 20 percent of malaria-related deaths in
                                                                           tainous terrain often prevent people from promptly seeking
India although it has less than 2.5 percent of the country’s
                                                                           malaria treatment.5 Additionally, many Bhutanese consult
population.21 Imported cases from India were mainly from
                                                                           religious leaders or local healers on malaria treatment before
Sarpang District, as were higher proportions of P. falciparum
                                                                           seeking medical assistance at a health facility.6 In addition to
cases.22 Population movement between these endemic areas
                                                                           these obstacles threatening lives, lack of accessibility to
greatly increases the risk of the spread of malaria in Bhutan.18
                                                                           health services presents a challenge to surveillance if these
Bhutan plans to initiate malaria screening of Indian workers
                                                                           patients are not documented, and poses a risk for outbreaks
at the border by increasing training for malaria diagnosis,
                                                                           and increased transmission if malaria is left untreated. Bhutan
and is considering use of rapid diagnostic tests to increase
                                                                           has a goal to treat all febrile patients within 24 hours of the
the speed of diagnosis.18
                                                                           onset of fever and within one hour of arrival at a health
Surveillance for resistance                                                facility, and these practices are being encouraged through
Bhutan faces a shortage of skilled personnel to conduct                    community education efforts.5
surveillance to monitor efficacy of drugs and vector control
interventions. Bhutan’s elimination plan aims to address                   Conclusion
these gaps in parasitological and entomological surveillance,              Through an increase in communication and collaboration
and outbreak prediction and response.5, 9 Drug resistance is               with neighboring Assam State in India, and continued sup-
predominately confined to five of the perennial-transmission               port from the Global Fund to increase surveillance capacity
districts in southern Bhutan, however, due to high receptivity             and improve early diagnosis and treatment of malaria, Bhu-
and constant inflow of migrants, drug-resistance monitoring                tan will be in a good position to achieve its program goals
is critical.18 Passive parasitological surveillance is currently           and obtain WHO malaria-free certification by 2020.

1.    WHO, World Malaria Report 2012. World Health Organization: Geneva, 2012.
2.    Yangzom, T., et al., Malaria control in Bhutan: case study of a country embarking on elimination. Malar J, 2012. 11: 9.
3.    Sinka, M.E., et al., The dominant Anopheles vectors of human malaria in the Asia-Pacific region: occurrence data, distribution maps and
      bionomic precis. Parasit Vectors, 2011. 4: 89.
4.    SEAR. Malaria Situation in SEAR Countries: Bhutan. 2010; Available from:
5.    Bhutan Ministry of Health, Round 10 Global Fund to Fight AIDS, Tuberculosis and Malaria Concept Note: Sustain and strengthen malaria
      control with cross border control towards malaria pre-elimination. 2010, Bhutan Ministry of Health.
6.    Lhazeen, T., Tobgay, T., Malaria Perceptions and Practices in Bhutan. Southeast Asian J Trop Med Public Health, 2010. 41(2).
      Asia Pacific Malaria Elimination Network. APMEN. Available from:
7.    Hsiang, M. H., Malaria Elimination in Asia-Pacific: an under-told story. Lancet, 2010. 375(9726): 1586–1587.
8.    Asia Pacific Malaria Elimination Network. APMEN. Available from:
9.    VDCP, Bhutan National Strategic Plan 2012–2016. 2011, Vector-borne Disease Control Program: Bhutan.
10.   IDA. International Development Association Eligibility. 2013; Available from:
11.   PMI. U.S. Government’s President’s Malaria Initiative (PMI). 2013; Available from:
12.   The Global Fund to Fight AIDS, Tuberculosis and Malaria. The Global Fund Eligibility List. 2013; Available from: http://www.theglobalfund.
13.   World Bank. World Development Indicators Database. 2013; Available from:
14.   Rajagopal, R., Studies on malaria in Bhutan. J Commun Dis, 1985. 17(4): 278–86.

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                                     					                                                                              Eliminating malaria in BHUTAN

15. Bhutan Ministry of Health, Vector-borne Disease Control Programme. 2008.
16. Panduka Wijeyaratne, N.V., Ananda Joshi, Deepika Singh, Sabeena Pandey, An Inventory on Malaria Drug Resistance in Bangladesh, Bhu-
    tan, India, and Nepal. 2004, Office of Health, Infectious Diseases and Nutrition Bureau for Global Health USAID: Washington, D.C.
17. Wijeyaratne, P., et al., An Inventory on Malaria Drug Resistance in Bangladesh, Bhutan, India, and Nepal. 2004, Office of Health, Infectious
    Diseases and Nutrition Bureau for Global Health USAID: Washington, D.C.
18. Bhutan Vector Borne Disease Control Programme, Round 7: Reduce malaria morbidity and mortality by 50% by 2013 compared to 2005.
    2007, The Global Fund to Fight AIDS, Tuberculosis and Malaria.
19. Bhutan Vector Borne Disease Control Programme, Round 4: Enhanced malaria control project. 2004, The Global Fund to Fight AIDS,
    Tuberculosis and Malaria.
20. Lhazeen, K. Update on Malaria Elimination in Bhutan. Presentation at the 2nd Annual Meeting of the Asia Pacific Malaria Elimination Net-
    work (APMEN) 2009. Kandy, Sri Lanka.
21. Talukdar, R.B., This monsoon, Assam takes on malaria. India Together. 2008.
22. Bhutan Ministry of Health, Bhutan Malaria Program Review Toward a Malaria Free Bhutan, in Malaria Program Review Aide Memoire and
    Summary. 2010.

Transmission Limits Maps Sources
Guerra, CA, Gikandi, PW, Tatem, AJ, Noor, AM, Smith, DL, Hay, SI and Snow, RW. (2008). The limits and intensity of Plasmodium falciparum
   transmission: implications for malaria control and elimination worldwide. Public Library of Science Medicine, 5(2): e38.
Guerra, CA, Howes, RE, Patil, AP, Gething, PW, Van Boeckel, TP, Temperley, WH, Kabaria, CW, Tatem, AJ, Manh, BH, Elyazar, IRF, Baird, JK,
   Snow, RW and Hay, SI. (2010). The international limits and population at risk of Plasmodium vivax transmission in 2009. Public Library of
   Science Neglected Tropical Diseases, 4(8): e774.
Thinley Yangzom, Sonam Gyeltshen and Karma Lhazeen, (2010), Vector-Borne Disease Control Programme, Department of Public Health and
    Ministry of Health, Gelephu, Kingdom of Bhutan. (Data years 2007–2010)

About This Briefing
This country briefing was produced through a collaboration of the Global Health Group, in partnership with the Vector-borne
Disease Control Program in Bhutan. Malaria transmission risk maps were provided by the Malaria Atlas Project (MAP).
Funding was provided through a grant to the Global Health Group from the Exxon Mobil Corporation.

The Malaria Elimination Initiative at the Global Health Group of the         The Malaria Atlas Project (MAP) provided the malaria transmission
University of California, San Francisco (www.globalhealthsciences.ucsf.      maps. MAP is committed to disseminating information on malaria risk,
edu/global-health-group) convenes the Malaria Elimination Group              in partnership with malaria endemic countries, to guide malaria control
(, and supports countries actively           and elimination globally. Find MAP online at:
pursuing elimination at the endemic margins of the disease. Funding
for the Malaria Elimination Initiative is provided by the Bill & Melinda

Gates Foundation and Exxon Mobil Corporation.

                                                                             asia pacific malaria elimination network

                                                                             Additional support was provided by the Asia Pacific Malaria Elimination
                                                                             Network (APMEN). Find APMEN online at:

  GLOBAL HEALTH GROUP PROJECT TEAM                     Editor: Allison Phillips | Managing Editor: Chris Cotter | Researcher and Content Developers:
  				                                                 Janelle Downing and Saehee Lee | Graphic Designer: Kerstin Svendsen

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