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Indonesia is seeking to eliminate malaria island by island as it works toward national malaria elimination by 2030.

Overview Indonesia, a large archipelago, is the fourth most popu-lous country in the world. Indonesia has a long history of research and ingenuity in malaria control. The country has experienced a 53 percent decrease in confirmed malaria cases between 2005 and 2010, from 437,323 cases to 229,819 cases.1 Four species of malaria parasites infect humans in Indonesia: Plasmodium falciparum, P. vivax, P. malariae, and P. ovale; P. falciparum accounts for 53 percent of infections.1 P. falciparum and P. vivax mixed infections are very common, while P. malariae and P. ovale infections are rare. The malaria disease burden and parasite distribution in Indonesia is geographically asymmetrical, as most cases are found in the eastern part of the nation. Drug-resistant P. falciparum is a major issue in Indonesian Papua and other eastern provinces; drug resistance is starting to become a challenge in treating P. vivax as well.2 A fifth species, P. knowlesi, has been discov-ered in Indonesian Borneo, yet no large-scale surveys of this parasite have been conducted in Indonesia to date.3, 4

Indonesia has at least 24 species of malaria vectors includ-ing Anopheles balabacensis, Farauti Complex, An. koliensis, Punctulatus Complex, Maculatus Group, and Sundaicus Complex.5, 6 A recently decentralized health care system, along with a high diversity of vectors, environments, and cultures, makes controlling malaria in Indonesia especially challenging.

Indonesia is a country partner of the Asia Pacific Malaria Elimination Network (APMEN), a diverse network com-posed of 12 Asia Pacific countries, as well as leaders and experts from key multilateral and academic agencies.7, 8 Although Indonesia faces numerous challenges in eliminat-ing malaria, it has renewed its malaria control strategy and elimination goals with the help of foreign assistance and regional collaboration, and is currently aiming for national elimination by 2030.6, 9

229,819

432

44

0.95

19

Reported cases of malaria(53% P. falciparum)

Deaths from malaria

% of population at risk(total population: 234 million)

Annual parasite incidence (cases/1,000 total population/year)

% Slide positivity rate

At a Glance1*

*2010 statistics

Progress Toward EliminationMalaria in Indonesia was described by Dutch settlers in the 1600s as a major health scourge, but was likely present well before their arrival. In 1924, the central malaria bureau was formed as a subdivision of the public health service, and was the beginning of the Indonesian governments formal cru-sade against malaria. For the next few decades, environmen-tal modification techniques including new irrigation schemes, removing algae from fishponds, and educating communities on local vector control, basic diagnosis, and transmission were used to decrease vector breeding habitats.14

Political turmoil during the Japanese invasion from 1942 to 1945 and the ensuing revolution for independence against the Dutch colonialists from 1945 to 1949 undermined much of the countrys malaria control measures during this time. After this period of fighting, malaria control efforts such as indoor residual spraying (IRS) with DDT were scaled up. This led to a significant reduction in transmission and major economic benefits in highly endemic areas as workers health and pro-ductivity increased.2 Mass chloroquine treatment was success-fully used in western Papua, however, its continual use was the cause of current resistance patterns seen in this region.15

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Eliminating malaria in INDONESIA

In 1959, in accordance with the World Health Assemblys shift to eradication, Indonesia shifted its malaria control program to an elimination-focused program. The national malaria eradication service (NMES) aimed to eliminate malaria in Indonesia by 1970. Over 9,000 tons of DDT were used on the islands of Java and Bali from 1959 to 1963. Insecticide resis-tance developed, and minimum targets for elimination were never met.16 The feasibility of elimination became less likely, and a combination of political and financial constraints along with an attempted violent coup dtat in 1965 weakened and eventually discontinued the malaria program activities.17

As the malaria program gradually shifted back to a control strategy, the islands were stratified into two groups with sepa-rate strategies. The islands of Java and Bali, where most of the population is concentrated, had a case detection strategy focused on active and passive case detection, mass fever sur-veys, and migration surveillance. In contrast, the less populous outer islands only used passive case detection and conducted malaria surveys.2 From 1969 to 1999, the malaria burden was significantly reduced on Java and Bali, but the disease burden on the outer islands remained heavy due to the intrinsic chal-lenges of treating a sparsely populated, vast geographical region with limited transportation and infrastructure.

Malaria Transmission Limits

0 1,000 2,000 3,000 Kilometres 0 1,000 2,000 3,000 Kilometres

Plasmodium falciparum Plasmodium vivax

Water

P. vivax free

Unstable transmission (API

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The East Asian economic crisis of 1997 and subsequent fall of an authoritarian regime led to several years of political and economic instability exacerbated by a massive shift from a centralized to a decentralized government system. Accord-ingly, the Indonesian public health care system experienced major logistical and financial setbacks. With limited resources available, implementing and maintaining consistent and ac-curate malaria surveillance has been a challenge.

The current malaria elimination program in Indonesia was stimulated in 2000 by the start of the Roll Back Malaria Initia-tive. The Indonesian Ministry of Health launched its initiative Gebrak Malaria, or Crush Malaria, in April 2000, which focused on malaria control in endemic areas. In April 2009, the Indonesian Ministry of Health launched a formal set of elimination targets, implementing a spatially progressive ap-proach to elimination across all islands from west to east with the national goal of elimination by 2030.6, 9

GOALS: 1. Eliminate malaria in low-transmission provinces (Java, Bali, and Batam) by 20156

2. Eliminate malaria in intermediate- and variable-transmission provinces (Kalimantan, Sulawesi, and Sumatra) by 20209

3. Achieve the pre-elimination stage in all remaining malaria-endemic provinces by 20209

4. National malaria elimination by 20309

Reported Malaria Cases

Although confirmed cases have risen due to increased availability of, and training in, laboratory confirmation, the number of clinically diagnosed cases has actually decreased over the last decade, which suggests an overall decrease in cases.

Source: World Health Organization, World Malaria Report 2011

0

50,000

100,000

150,000

200,000

250,000

300,000

350,000

400,000

450,000

500,000

1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010

Num

ber of ca

ses

GNI per capita (US$) $2,500

Country income classification Lower middle

Total health expenditure per capita (US$) $55

Total expenditure on health as % of GDP 2.4

Private health expenditure as % total health expenditure

48

Eligibility for External Funding1012

Economic Indicators13

The Global Fund to Fight AIDS, Tuberculosis and Malaria

Yes

U.S. Governments Presidents Malaria Initiative No

World Bank International Development Association No

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Challenges to Eliminating MalariaMulti-island countryThe Indonesian archipelago consists of over 17,000 islands spread out over 1.9 million square kilometers.2 Although only 6,000 of these islands are inhabited, the challenges associ-ated with malaria control in the worlds fourth most populous nation are significant. Ethnic and linguistic diversity, an ex-tremely mobile population, a tropical climate, a lack of infra-structure, logistical challenges to delivering health services, and frequent natural disasters contribute to the challenge of eliminating malaria in Indonesia.

Accurate surveillance and treatmentThe majority of malaria cases are still diagnosed clinically in most Indonesian provinces outside of the highly populated urban centers.18 Lack of equipment and trained laboratory personnel have made it difficult to scale up laboratory diag-nostics in remote areas. Drug resistance is also a formidable

problem, and many first- and second-line drugs are becom-ing ineffective in endemic areas.2, 19, 20

Information, education, and communicationNumerous gaps in communication and education exist among the various provinces of Indonesia. Although cam-paigns for education, mass insecticide-treated net distribu-tion, and IRS have been conducted with some success, many Indonesians living in endemic areas still do not see malaria as a serious disease and have little knowledge of its diagno-sis, treatment, and prevention.21, 22

ConclusionDespite numerous economic, political, and environmental setbacks, Indonesia has made progress in malaria control over the last few decades. Increased scale-up of diagnostics, treatment, and education of citizens and health care provid-ers should provide the catalyst Indonesia needs to move from control to pre-elimination and ultimately achieve its national goal of elimination by 2030.

Sources1. WHO. World Malaria Report 2011. Geneva: World Health Organization; 2011.2. Elyazar I, Hay S, Baird JK. Malaria Distribution, Prevalence, Drug Resistance and Control in Indonesia. Advances in Parasitology. 2011; 74:

41175.3. Singh B, Kim Sung L, Matusop A, Radhakrishnan A, Shamsul SS, Cox-Singh J, et al. A large focus of naturally acquired Plasmodium

knowlesi infections in human beings. Lancet. 2004; 363(9414): 101724.4. White NJ. Plasmodium knowlesi: the fifth human malaria parasite. Clin Infect Dis. 2008 ; 46(2): 1723.5. Sinka ME, Bangs MJ, Manguin S, Chareonviriyaphap T, Patil AP, Temperley WH, 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: 89.6. Kusriastuti R. Intensified & Integrated Malaria Control: Towards Malaria Elimination in Indonesia. ACT Malaria Executive Board and Part-

ners Meeting; 2010 March 1517th, 2010; Luang Prabang, Lao PDR; 2010.7. APMEN. Asia Pacific Malaria Elimination Network. [Available from: www.apmen.org]8. Hsiang MS, Abeyasinghe R, Whittaker M, Feachem RG. Malaria elimination in Asia-Pacific: an under-told story. Lancet. 2010; 375(9726):

15867.9. Intensified Malaria Control Program in Kalimantan and Sulawesi Islands: The Global Fund to Fight AIDS, Tuberculosis and Malaria; 2008.10. World Bank: International Development Association Eligibility. 2012 [Available from: http://web.worldbank.org/WBSITE/EXTERNAL/EXT-

ABOUTUS/IDA/0,,contentMDK:20054572~menuPK:3414210~pagePK:51236175~piPK:437394~theSitePK:73154,00.html]11. U.S. Governments Presidents Malaria Initiative (PMI). 2012 [cited; Available from: http://www.fightingmalaria.gov/countries/index.html]12. The Global Fund to Fight AIDS Tuberculosis and Malaria. The Global Fund Eligibility List. 2012 [Available from: http://www.theglobalfund.

org/en/application/applying/ecfp/eligibility/]13. World Bank. World Development Indicators Database. 2012 [Available from: http://data.worldbank.org/]14. Keiser J, Singer BH, & Utzinger J. Reducing the burden of malaria in different eco-epidemiological settings with environmental manage-

ment: a systematic review. Lancet Infectious Diseases. 2005; 5: 695708.15. Van Dijk W. Mass chemoprophylaxis with chloroquine additional to DDT indoor spraying. Doc Med Geogr Trop. 1958; 10(379384).16. Soerano M, et al. The development and trend insecticide resistance in Anopheles aconitus Donitz and Anopheles sundaicus Rodenwaldt.

Bull World Health Organ. 1965; 32: 1618.17. Takken W, Snellen WB, Verhave JP, Knols BGJ, Atmosoedjono S, Swellengrebel NH, et al. Environmental measures for malaria control in

Indonesiaan historical review on species sanitation: Wageningen Agricultural University Papers; 1990.

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18. Sekartuti T, Sudomo E, Santoso TS, Utami BS. Intensifikasi pemberantasan malaria di empat provinsi Indonesia timur: Survey dasar untuk manajemen kasus, perilaku masyarakat, dan pengendalian vector malaria: Badan Penelitian dan Pengembangan Kesehatan, Departemen Kesehatan Indonesia; 2004.

19. Karyana M, Burdarm L, Yeung S, Kenangalem E, Wariker N, Maristela R, et al. Malaria morbidity in Papua Indonesia, an area with multidrug resistant Plasmodium vivax and Plasmodium falciparum. Malar J. 2008; 7: 148.

20. Ratcliff A, Siswantoro H, Kenangalem E, Maristela R, Wuwung RM, Laihad F, et al. Two fixed-dose artemisinin combinations for drug-resis-tant falciparum and vivax malaria in Papua, Indonesia: an open-label randomised comparison. Lancet. 2007 ; 369(9563): 75765.

21. Sanjana P, Barcus MJ, Bands MJ, Ompusunggu S, Elyazar I, Marwoto H, et al. Survey of community knowledge, attitudes, and practices during a malaria epidemic in Central Java, Indonesia. Am J Trop Med Hyg. 2006; 75: 7839.

22. Pradono J, Kusumawardi N, Lubis N, Hapsari D, Sulistyawati N, Christina C, et al. Survey Kesehatan Rumah Tangga 2004 Volume 3: Badan Penelitian dan Pengembangan Kesehatan, Departemen Kesehatan Indonesia; 2005.

Transmission Limits Maps SourcesGuerra, 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.

Rita Kusriastuti (2009), Directorate of Vector-borne Diseases, Ministry of Health, Jakarta, Republic of Indonesia. (Data years 20052008)

GloBAl HeAlTH GroUP ProjeCT TeAMeditor: Allison Phillips | Managing editor: Chris Cotter | researcher and Content Developer: Jessie de Jarnette | Graphic Designer: Kerstin Svendsen

The Malaria Atlas Project (MAP) provided the malaria transmission maps. MAP is committed to disseminating information on malaria risk, in partnership with malaria endemic countries, to guide malaria control and elimination globally. Find MAP online at: www.map.ox.ac.uk.

The Malaria Elimination Initiative at the Global Health Group of the University of California, San Francisco (www.globalhealthsciences.ucsf.edu/global-health-group) convenes the Malaria Elimination Group (www.malariaeliminationgroup.org), and supports countries actively 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.

About This BriefingThis country briefing was produced through a collaboration of the Global Health Group, in partnership with the National Malaria Control Program in Indonesia. 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.

APMENAdditional support was provided by the Asia Pacific Malaria EliminationNetwork (APMEN). Find APMEN online at: www.apmen.org.

Eliminating malaria in INDONESIA