Early malaria resurgence in pre-elimination areas in Kokap Subdistrict, Kulon Progo, Indonesia

Abstract

BackgroundIndonesia is among those countries committed to malaria eradication, with a continuously decreasing incidence of malaria. However, at district level the situation is different. This study presents a case of malaria resurgence Kokap Subdistrict of the Kulon Progo District in Yogyakarta Province, Java after five years of low endemicity. This study also aims to describe the community perceptions and health services delivery situation that contribute to this case.MethodsAll malaria cases (2007–2011) in Kulon Progo District were stratified to annual parasite incidence (API). Two-hundred and twenty-six cases during an outbreak (May 2011 to April 2012) were geocoded by household addresses using a geographic information system (GIS) technique and clusters were identified by SaTScan software analysis (Arc GIS 10.1). Purposive random sampling was conducted on respondents living inside the clusters to identify community perceptions and behaviour related to malaria. Interviews were conducted with malaria health officers to understand the challenges of malaria surveillance and control.ResultsAfter experiencing three consecutive years with API less than 1 per thousand, malaria in Kokap subdistrict increased almost ten times higher than API in the district level and five times higher than national API. Malaria cases were found in all five villages in 2012. One primary and two secondary malaria clusters in Hargotirto and Kalirejo villages were identified during the 2011–2012 outbreak. Most of the respondents were positively aware with malaria signs and activities of health workers to prevent malaria, although some social economic activities could not be hindered. Return transmigrants or migrant workers entering to their villages, reduced numbers of village malaria workers and a surge in malaria cases in the neighbouring district contributed to the resurgence.ConclusionCommunity perception, awareness and participation could constitute a solid foundation for malaria elimination in Kokap. However, decreasing number of village malaria workers and ineffective communication between primary health centres (PHCs) within boundary areas with similar malaria problems needs attention. Decentralization policy was allegedly the reason for the less integrated malaria control between districts, especially in the cross border areas. Malaria resurgence needs attention particularly when it occurs in an area that is entering the elimination phase.

Health-Seeking Behavior of People in Indonesia: A Narrative Review

“…Quantitative studies provide evidence of factors determining people's behavior, but are limited in their ability to explore the wider narrative of reasons for choosing specific care, which can be explored in qualitative studies. There were also 10 studies that applied mixed methods design [29,43,44,58,61,70,71,92,93,95]. For example, Brooks et al [29] explored secondary data from the Indonesian Demographic and Health Survey to quantify the effect of the insurance program on maternity services, and explored barriers of the services utilization qualitatively [29].…”

“…These practices have been passed down for generations, and this embedded culture cannot be ignored. They are commonly used for treating most diseases, including malaria [25,44,61,69], tuberculosis [21,39,51,59,67,72], leprosy [46], rheumatoid arthritis [76], cancer [28,38,45], hypertension [93], stroke [56], and diabetes [95]. Traditional remedies are also used for promoting health and preventing disease.…”

“…Traditional remedies are also used for promoting health and preventing disease. For example, women took traditional herbal drinks to stay healthy during pregnancy and breastfeeding [26,49], and some people took bitter-tasting plants to prevent malaria [44,62,69,85,90].…”

Using health facility-based serological surveillance to predict receptive areas at risk of malaria outbreaks in elimination areas

“…These findings are consistent with findings from previous studies in the area suggesting that malaria infection is expected to be less common among children compared to adults most likely due to a different level of behavioural risk (night outdoor activities and forest-related jobs such as loggers, coconut/palm tapper, fruit farmer, etc.) which leads to higher exposure among males and adults [7,10,31,35]. Interestingly, higher exposure was also associated with bed net use.…”

“…Previous studies in Indonesia suggest that the current diagnostic sensitivity (microscopy and rapid diagnostic test (RDT)) and timeliness of transmission measurement are not sufficient to describe and predict decreasing numbers of cases and potential outbreaks in low transmission areas striving for elimination [31][32][33]. The risk of outbreaks is high where there are larger numbers of migrants or travellers [31,[34][35][36] and/or where residents with asymptomatic infections are not actively seeking treatment for malaria [37][38][39][40][41][42][43][44][45]. Therefore, surveillance systems need to be improved to better locate and target infections and further reduce transmission [32,46].…”