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Metrics details. Malaria has been targeted for elimination from Indonesia by , with varying timelines for specific geographical areas based on disease endemicity. The regional deadline for malaria elimination for Java island, given the steady decrease of malaria cases, was the end of This study documents factors that affect incidence and spatial distribution of malaria in Purworejo, such as geomorphology, topography, health system issues, and identifies potential constraints and challenges to achieve the elimination stage, such as inter-districts coordination, decentralization policy and allocation of financial resources for the programme. Historical malaria data from to were collected through secondary data, in-depth interviews and focus group discussions during study year —

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Metrics details. Malaria has been targeted for elimination from Indonesia by , with varying timelines for specific geographical areas based on disease endemicity. The regional deadline for malaria elimination for Java island, given the steady decrease of malaria cases, was the end of This study documents factors that affect incidence and spatial distribution of malaria in Purworejo, such as geomorphology, topography, health system issues, and identifies potential constraints and challenges to achieve the elimination stage, such as inter-districts coordination, decentralization policy and allocation of financial resources for the programme.

Historical malaria data from to were collected through secondary data, in-depth interviews and focus group discussions during study year — Malaria cases were mapped using the village-centroid shape file to visualize its distribution with geomorphologic characteristics overlay and spatial distribution of malaria. API in each village in Purworejo and its surrounding districts from to was stratified into high, middle or low case incidence to show the spatiotemporal mapping pattern.

The spatiotemporal pattern of malaria cases in Purworejo and the adjacent districts demonstrate repeated concentrated occurrences of malaria in specific areas from to District health system issues, i. A new malaria elimination approach that fits the local disease transmission, intervention and political system is required. These changes include timely measurements of malaria transmission, revision of the decentralized government system and optimizing the use of the district capitation fund followed by an effective technical implementation of the intervention strategy.

The WHO Global Malaria Eradication Programme collapsed in the s, resulting in an increase of malaria in many regions which had previously experienced significant control [ 1 ]. However, during the past decade scale-up of interventions against malaria, including insecticides-treated nets ITNs , indoor residual spray IRS , rapid diagnostics testing RDT , and artemesinin-based combination therapy ACT , has led to significant declines in malaria globally.

A parallel research agenda has been developed to facilitate discovery, development and implementation of novel interventions to facilitate malaria elimination.

Malaria was first formally reported in Indonesia in Almost the entire population of Indonesia was at risk before the National Malaria Control Programme was founded in [ 2 ]. This was followed by the Malaria Control Phase — and Indonesia Roll Back Malaria Campaign to present which focuses on malaria case detection and surveillance and integrated activities as recommended by WHO [ 5 ]. Although there have been fluctuations in global malaria support efforts, thanks to strong national commitment, some countries are successful in their progress toward malaria elimination, including Indonesia.

Although the decline in malaria was not always steady due to political turmoil in and sudden implementation of decentralization policy in , an overall temporal decline has been observed.

In , the total number of suspected malaria cases was 2. However, this success is not distributed evenly throughout Indonesia, with the eastern part of the country remaining malaria-endemic and the large islands of Sulawesi, Kalimantan and Sumatra having higher incidence than Java [ 8 , 9 ]. The Indonesian National Malaria Programme aspires to eliminate malaria from the country by [ 11 ].

Thus, if this trend continues, malaria elimination is expected in Java and Bali by The transmission dynamics of malaria are determined by the local environment, vector species bionomics, human behaviour, and parasite biology.

The island of Java is the centre of economic growth in Indonesia as evidenced by a high Gross Domestic Product relative to outer islands [ 13 ].

Population mobility-related issues such as transmigration due to cultural activity, jobs, etc. Purworejo is a district in the Province of Central Java. Purworejo is a part of the Menoreh Hills and is endemic for malaria transmission [ 14 ]. During, API in Purworejo was reduced around 2—11 per 1, [ 14 ]. However, a drastic surge occurred in , when the API in Purworejo reached The API was 2. In , it was estimated that ,, people in Indonesia were at risk of malaria [ 16 ]. The API values in provinces outside Java varied between 0.

Malaria endemicity map of Indonesia in Inset is Java island, the area in black is the study area, Purworejo. In the year of the commencement of this study the API in Purworejo was 0. Comprehensive assessment of micro-epidemiology [ 17 ] is critical to evaluate preparedness of Purworejo in entering the malaria elimination phase.

This study aims to evaluate factors that affect the incidence and spatial distribution of malaria in Purworejo and its adjacent districts, i. To achieve this goal, historical data of malaria and spatial distribution of malaria from to were collected through secondary data, in-depth interviews and focus group discussions during the study year — Elimination efforts, challenges, constraints, and lessons learned from Purworejo and its surrounding district areas are valuable for public health policy planning on malaria in other endemic areas, either inside or outside Indonesia, with similar characteristics.

It has an area of 1, Elevation varies from 0 to m above sea level. The southern part of Purworejo is bordered by the Indian Ocean. The district consists of 16 sub-districts kecamatan and villages. In , when the study was initiated, Purworejo had a population of , Source: District Health Office of Purworejo, API in each village was stratified using the village as the smallest unit and was mapped spatiotemporally.

Historical data related to health care systems, malaria diagnosis, malaria control activities, ACT, and data regarding cross-border and cross-sector activities, including the malaria control local budget during —, were collected through in-depth interviews, focus group discussions and observation during the study period November —October Focus group discussions FGDs were conducted six times and included 38 informants, i.

These informants included those that work under the PHC, and those that have retired but still serve the community in an unofficial capacity. The in-depth interviews also included 15 informants: the head of PHCs, general practitioners working in PHCs, malaria specialists working at the referral hospital, district pharmacist, district health officer working on either malaria or infectious diseases control and the Head of DHOs of the surrounding districts.

FGDs and in-depth interviews were recorded, transcribed, interpreted, and discussed with the informants and the findings were then confirmed with the DHOs. This study was reviewed and approved by Institutional Review Boards for the ethical conduct of research on human subjects at the Universitas Gadjah Mada, Yogyakarta, Indonesia. Informed consent was collected from informants for interviews and FGDs before their participation in this study.

Purworejo has a varied topography consisting of mountains, hills and plains. This geomorphology is shared with the neighbouring areas in the north, i. The northern region of Purworejo which is also part of South Serayu Hills consists of Halang and Peniron formations dominated by sedimentary rocks.

Erosion from those areas results in transfer of soil to the urban plains. The northeast, east and southeast area of Purworejo share similar geomorphology with Magelang and Kulon Progo districts, known as the Menoreh Hills, dominated by andesite, old andesite and Bemmelen formation Fig.

As a consequence of its rough topography and andesite rock type, these areas have a low porosity that allows the accumulation of stagnant water on rocky outcrops. This occurs in the northern area as well, although the relief is not as rough as the eastern part. Both P. The confirmation of some Anopheles as malaria vectors in Purworejo or its adjacent districts has been reported by others [ 20 , 21 ] as well as vector density studies and seasonal correlations [ 15 , 22 , 23 ].

The vector species found here bite primarily outdoors throughout the night and although primarily zoophilic, some species An. Malaria cases from Purworejo and the adjacent districts were mapped by village with a geomorphologic overlay Fig. This map shows that malaria cases were mostly located in hilly areas, inter-district borders and closer to periodic or intermittent rivers than those within flat, rice-growing areas. Malaria cases from Purworejo and adjacent districts.

Malaria cases were mapped using the village-centroid shape file to visualize its distribution with geomorphologic characteristics overlay. API in each village in Purworejo and its surroundings districts was temporally — stratified by incidence Fig.

In , the number of villages with malaria increased but were more concentrated in northeast and eastern areas at the border with Magelang and Kulon Progo. Although there was a decrease in the number of HCI villages in and , it was followed by a sharp increase both in the total number of villages with malaria and HCI villages in , moving from east to south at the border of Kulon Progo.

A similar situation occurred in Kulon Progo, particularly in when the number of malaria-endemic villages decreased but then increased sharply in with one HCI village in [ 24 ]. Spatio-temporal mapping of malaria in Purworejo and its surroundings districts — Malaria cases in Kebumen district seem to bear no relation to those in Purworejo district.

The spatio-temporal pattern of malaria in Purworejo and its surrounding districts supports the fact that malaria has existed in areas that share similar geomorphology regardless of administrative boundaries.

Given that malaria cases often and repeatedly occur in hilly areas but not always in the same villages, the focus of interventions should be widened from the village level to include the neighbouring hilly areas; including only these people in the denominator would reflect a more realistic API calculation, as present calculations based upon administrative boundaries greatly deflate the API value in endemic areas.

In Purworejo, a PHC may serve about 25 villages. Data collected and recapitulated included cases by month, village, number of people with clinical malaria, age, sex, pregnancy status, Plasmodium species, ACT or non-ACT treatment, and indigenous or imported malaria cases.

The proportion of malaria cases caused by P. Number of malaria cases by species in — Indigenously acquired cases were higher than imported malaria cases. Imported cases confirmed by epidemiological investigation—an investigation into the source of these imported cases that confirmed that they were all non-Java in origin—confirmed 35 of a total cases during the — period Source: DHO, Purworejo, — The low number of imported cases reflects the sub-optimal surveillance system.

This was also supported by the fact that in and there were no data on active case monitoring as no VMWs was hired. Since , malaria outbreaks occurred in more than ten locations, including the following villages: Tridadi Banyuasin sub-district in , Kalitapas, Bleber Bener sub-district and Kembaran Banyuasin sub-district in , Ketosari Bener sub-district and Ngrimun Banyuasin sub-district in , Sudorogo Kaligesing sub-district , Kalikalong Loano sub-district , and Kedungpomahan Kemiri sub-district in As well as its adjacent areas, i.

Here, family members who worked as migrant workers or transmigrants outside Java visit home temporarily. As most areas outside of Java are malaria endemic, the return of these people to their villages might spark malaria outbreaks as they might carry Plasmodium gametocytes. Malaria surveillance has been conducted in Purworejo to include monitoring human movement, although this was not supported by sufficient human resources because of lack of financial resources.

Purworejo had 27 PHCs, 64 auxiliary PHCs, one referral hospital, eight private hospitals and clinics, and around midwives. Approximately village midwives are placed in malaria endemic sub-districts. In , 20 of 27 PHCs were reported free of malaria. The district referral hospital, in terms of management, was not under DHO, but local district government.

For the purpose of disease surveillance, it is required to report routine morbidity cases including malaria to the DHO. To support the clinical treatment of malaria at the hospital, DHO allocates anti-malaria drugs to the district hospital. Malaria diagnosis was confirmed microscopically by trained microscopists from the DHO.

A hierarchical system aims to attain correct diagnosis treatment, e. However, routine malaria slide cross-checks could not be performed regularly because there was no allocated budget for sending the slides to Province level.

The referral hospital, private hospitals and clinics did their own malaria identification based on microscopic or RDT in their own laboratories. Although sending slides to the DHO for cross-validation is not an obligation, cross-checking of malaria blood films should be a concern in confirming malaria diagnosis and case management.

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

Erweiterte Suche. Springer Medizin. Wichtige Hinweise. Competing interests The authors received no product or financial support outside of normal operating budgets.

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We assessed the efficacy of artemisinin-based combination therapies for treatment of uncomplicated falciparum malaria, with or without co-infecting Plasmodium spp. Mixed Plasmodium infections were included; P. We retrospectively restricted the analysis to cases with polymerase chain reaction PCR —confirmed parasitemia. Recurrent parasitemia in follow-up was identified by species-specific nested PCR.

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Metrics details. Indonesia 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. Two-hundred and twenty-six cases during an outbreak May to April were geocoded by household addresses using a geographic information system GIS technique and clusters were identified by SaTScan software analysis Arc GIS Purposive random sampling was conducted on respondents living inside the clusters to identify community perceptions and behaviour related to malaria.

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