According to the WHO, about 8.5 million people are at risk of malaria in Nepal. However, over the last decade, the country has made substantial progress in fighting the disease. Malaria declined significantly from over 30,000 cases in 2010 to less than 4,000 cases in 2017 and Nepal is currently implementing an acceleration to elimination programme.1 There were less than 10 reported deaths in 2017 from 75 districts in the country, while the other 35 districts have reported zero malaria cases between 2010 and 2013.2 Nepal has also been identified by WHO as one of 21 countries with the potential to eliminate malaria by 2020.3
Despite this steep decrease over the longer term, recently there has been a significant increase (by over 20%) from 2016 to 2017.1 This is likely due to the open border with India and limited financial and human resources.5
Plasmodium vivax malaria and P. falciparum malaria are the dominant forms of malaria in the country.3 P. vivax represents about 70% of all malaria cases while P. falciparum cases make up the rest. More than half of the malaria cases are imported.3
Cross-border collaborations are ongoing between the two countries to address the issue.2
Four anopheles mosquito species are considered to be the major malaria vectors in the country, i.e. An. annularis, An. fluviatilis, An. minimus and An. maculatus.2
There are three main ecological zones in Nepal: Mountain, Hill and Terai; these run from west to east and are intersected by rivers flowing from the north to the south. Malaria cases are reported all year round with heightened transmission following the monsoon and peaking in July.2
There is substantial population movement across Nepal’s border with India. Thus, a key issue in the country, in relation to malaria transmission, is migrant workers who visit malaria-endemic states in India and then subsequently contribute to malaria transmission in Nepal.
Vision and goals
The vision of Nepal’s malaria elimination programme is to be malaria-free by 2025. To achieve this vision, the following goals have been set-out.2
Sustain zero death due to malaria from 2012 onwards;
Decrease the incidence of indigenous cases by 90% by 2018 (in comparison to 2012’s levels);
Reduce the number of village development committees (VDCs) having indigenous malaria cases by 70% by 2018 (baseline: 2012 level);
To receive WHO certification of malaria-free status by 2025.
The country’s programme uses microstratification (tools that divide the country into smaller sub group to guide interventions, mapping out areas of disease burden, receptivity and vulnerability.
Key actions the country has adopted to reach the stipulated goals include improving the coverage and quality of indoor residual spraying (IRS), introducing long lasting insecticide treated nets (LLINs), and increasing access to rapid malaria diagnosis (RDTs) as well as artemisinin-based combination treatments (ACTs).2
Malaria surveillance is conducted via a network of government health facilities; although active case detection or community-based surveillance systems are limited. At district and peripheral health facilities, epidemic preparedness and response mechanisms are in place to detect and control potential malaria epidemics and Rapid Response Teams are present at the regional, district and community levels. Malaria diagnosis and treatment are free in government health facilities. Health Management Information Systems does not cover unsecured areas and private sector health facilities. 2
Treatment policy for P. vivax
P. vivax malaria is treated with chloroquine and primaquine for 14 days. The dosage of primaquine for radical treatment of P. vivax is 0.25 mg/Kg (14 days). 1
Recently, it has been recommended that a single dose of primaquine be given in P. falciparum cases along with ACT. 2 In instances where there are no laboratory services, the guidance is that suspected cases be tested with an RDT and then treated with chloroquine or artemether lumefantrine.2
G6PD testing policy
G6PD testing before treatment with primaquine is recommended in national treatment guidelines.1
G6PD deficiency prevalence
G6PD deficiency prevalence is generally between 6 and 12 %.4