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Is Bangladesh entering the Era of Malaria Elimination?

On World Malaria Day 2022, Kasturi Haldar, Editor-in-Chief of PLOS Pathogens, Neil Lobo at the University of Notre Dame, and Mohammad Shafiul Alam and Wasif Ali Khan from the International Center of Diarrheal Diseases, Bangladesh (icddr, b), comment on advances in malaria control and elimination in Bangladesh and its geopolitical location in the worldwide spread of drug resistant malaria. 

There has been historic reduction of malaria (>93%) in Bangladesh from 2008-2020 (http://www.nmcp.gov.bd/  brac 2020). Of the malaria that remains, 90% occurs in three districts (Khagrachhari, Rangamati and Bandarban) of the Chittagong Hill Tracts (CHT; Fig. 1; red). Another 10 districts are low endemic: these include the Chittagong and Cox’s Bazar (Fig. 1 ochre) as well as eight north eastern districts (Fig. 1 cyan).  The National Malaria Elimination Program (NMEP) in partnership with an NGO consortium led by BRAC (the world’s largest NGO, indigenous to the country) spearheads the elimination agenda.  The principal strategy is phased elimination (Fig. 1), while preventing re-introduction in malaria-free areas as well as the emergence of resistance to artemisinins/artemisinin combination therapies (ACTs), drugs that are key for reducing the global burden of malaria. It is of concern that artemisinin resistance (ART-R) has emerged east of the CHTs in Myanmar and the Mekong region as well as westward in India.  

A phase-wise Malaria elimination target map from Bangladesh by 2030.
Fig 1. Phased Malaria elimination Bangladesh 2010-2030. (data courtesy, National Malaria Elimination Program, Govt of Bangladesh)
Image credit

https://doi.org/10.1155/2019/6780258

Since evidence-based data are needed to continually support the national elimination program, Bangladesh has invested in advanced research to address the threats of emerging drug and insecticide resistance.  A major advance in the hilltops was the first measurements of clinical clearance of parasites from patients after they start ACT treatment  (Nima et al 2022;  the gold standard to measure ART-R). Equally important were the first culture adaptation of local parasites in Bangladesh, measurement of  in vitro ART-R and  developing a comprehensive model for monitoring drug resistance in Bangladesh and other malaria-endemic countries (Nima et al 2022). The detection of spread of insecticide resistance (Alam et al 2020) guides spatial and temporal dimensions of vector intervention strategies to empower more focal and directed strategies to purge transmission ‘hot-spots’ and thereby secure malaria elimination.

Graph of the Annual Parasitological Index of Bandarban suburbs showing decreasing API/1000 population
Fig 2. Annual Parasitological Index of Bandarban Suburbs, 2012-2021, data courtesy National Malaria Elimination Program, Govt of Bangladesh

Despite Bangladesh’s great strides, we must anticipate expected and unexpected barriers in the path to elimination (defined as three consecutive years of zero locally-acquired P. falciparum malaria). In Bandarban district, individual Upazillas (sub districts) of Alikadam and Thanchi showed elevation of malaria from 2020 to 2021 (4.5% and 7% respectively; although the overall district-level malaria rose only by 1.5%; Fig. 2).  Pandemics such as Covid 19 may profoundly influence surveillance and response, but nonetheless, in 2020 P. falciparum malaria decreased in Bandarban (Fig. 2).  Since malaria is a vector borne disease, climate  is expected to be  important and this well correlated to the increased API seen in 2019  (Nima et al 2022). However, climate mitigation may have mixed effects  as suggested by modeling studies (Carlson et al 2022).

On World Malaria Day in the 51st year of its independence, we celebrate Bangladesh’s stellar progress and resolute determination to enter the era of malaria elimination.    

Kasturi Haldar, Ph.D. Editor-in-Chief, PLOS Pathogens, is the Julius Nieuwland Chair of Biological Sciences and Parsons-Quinn Director of the Boler-Parseghian Center for Rare and Neglected Diseases, University of Notre Dame. 

Neil Lobo is Research Professor of Biological Sciences, University of Notre Dame Eck Institute for Global Health, 

Mohammed Shafiul Alam, Ph.D. is Scientist, Emerging Infections & Parasitology Laboratory, Infectious Diseases Division, icddr, b, Dhaka, Bangladesh.

Wasif Ali Khan MBBS, MHS is Scientist, Infectious Diseases Division, icddr, b; Dhaka, Bangladesh.

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