Title Progress and challenges to control malaria in a remote area of Chittagonghill tracts , Bangladesh

Background: Malaria is endemic in 13 eastern districts where the overall infection prevalence is 3.97%. In 2006, Bangladesh received US$ 36.9 million from the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) to support the national malaria control programme of Bangladesh. Objectives: The objective of this study was to i) clarify factors associated with treatment seeking behaviours of malaria ii) distribution of LLIN, and iii) re-treatment of ITN in remote area of a CHT district of Bangladesh two years after implementation of national control programme. Methods: All households of Rajasthali sub-district of Rangamati district (households about 5,322, population about 24,097), all BRAC health workers (n = 15), health facilities and drug vendors’ locations were mapped. Distances from households to health facilities, BRAC health workers and drug vendors were calculated. Logistic regression analysis was performed to assess the associations between the choice of the treatment and the distance to various treatment sources, education, occupation and ethnicity. SaTScan was used to detect clustering of treatmentseeking approaches. Findings: LLIN distribution and the re-treatment of ITN exceeded target goals. The most common treatment facility for malaria-associated fever was malaria control programme led by BRAC and government (66.6%) followed by the drug vendor (48.8%). Conclusion: Closeness to health facilities run by the malaria control programme and drug vendors were significantly associated with the choice of treatment. A high proportion of people preferred drug vendors without having a proper diagnosis. Drug vendors are highly patronized and thus there is a need to improve their services for public health good. Otherwise it may cause incomplete treatment, misuse of anti-malarial drugs that will contribute to the risk of drug resistance and jeopardize the present malaria control efforts in Bangladesh. Background Malaria is estimated to be responsible globally for a million deaths every year, and even though 90% of mortality occurs in Africa, it remains a major health threat in South-Asian countries, including Bangladesh. There, it is endemic in 13 eastern districts where the overall infection prevalence is 3.97%. The infections are predominantly Plasmodium falciparum (90.12%) and Plasmodium vivax (5.3%), with 4.5% mixed infections. The overall prevalence in the Chittagong hill tracts (three south-eastern districts) is 11.7%, reaching 36% in a single sub-district, Rajasthali [1]. The malaria control programme in Bangladesh faces formidable challenges, including access to quality healthcare services, inadequately trained personnel, difficulty in travel, a lack of resources and education for the population at risk, and life styles depending on subsistence activities. Health facilities to manage severe malaria also are limited, surveillance is inadequate, and interventions are insufficient [2]. Many studies have described socioeconomic, demographic and environmental risk factors as part of malaria-related knowledge, attitude, and practices studies [3-9] and while bed nets are usually considered a * Correspondence: ubydul@icddrb.org International Center for Diarrhoeal Disease Research Bangladesh, 68 Shaheed Tajuddin Ahmed Sharani, Mohakhali, Dhaka 1212, Bangladesh Haque et al. Malaria Journal 2010, 9:156 http://www.malariajournal.com/content/9/1/156 © 2010 Haque et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. protective measure, they may be used insufficiently [10] or reported as ineffective [11-15]. However, recent studies indicate that insecticide-treated nets (ITN) reduced 48-50% of malaria episodes [16] and are considered one of the most cost-effective health interventions against malaria [11,12]. Baseline information for the implementation of ITN has shown that people were aware of malaria infection, transmission, anti-malarial drugs and malaria control [13]. WHO has recommended full coverage of all people at risk in areas targeted for malaria prevention with long-lasting insecticide-treated nets (LLINs). Especially for endemic areas, LLINs should be delivered to all people and should initially focus on priority target areas [14]. Little is known about treatment-seeking behaviour among indigenous people infected with malaria in Bangladesh. In a baseline survey, treatment-seeking at hospitals was rare, self-treatment was common and people commonly took drugs without consulting a qualified doctor. In five south-eastern districts, 32.3% people preferred to get treatment from drug vendors [3]. The choice of treatment source was related to distance from hospital, disease type, patient’s gender and parent’s education level. People also preferred to receive malaria treatment from the nearest health workers [17]. These results were similar to previous studies [18] indicative of suboptimal treatment regimes. In 2006, Bangladesh received US $ 36.9 million from the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) to support a national malaria control programme that would integrate rapid diagnosis tests (RDTs), new drug regimens (artemisinin-based combination therapy (ACT)), expanded distribution of LLIN, enhanced surveillance, vector surveillance and better documentation of activities. Bangladesh adopted artemether-lumefantrine (AL)(Coartem®) as a first-line treatment of P. falciparum malaria and has sought to provide early diagnosis and prompt treatment to 80% of malaria patients. Other intervention objectives included effective malaria prevention to 80% of the population at risk and to strengthen the malaria epidemiological surveillance system. It was estimated that 40% of the households in high risk areas had nets, 10% of which were insecticide treated. Through this grant, it was expected that 80% of households (1.7 million) would be covered with LLINs. Nets currently present in households would be treated and re-treated twice a year with insecticide [19]. BRAC and the Ministry of Health implemented the national malaria control programme under GFATM and BRAC would be responsible for supplying LLIN to 80% household, as well as deploying health workers in every union to provide RDT and AL at the grass root level. This study was undertaken in Rajasthali, where the highest prevalence of infection had been detected to clarify factors associated with treatment seeking behaviours of malaria, distribution of LLIN, and re-treatment of ITN in remote area of a CHT district of Bangladesh two years after implementation of national control programme. Methods Study area and population The study was conducted in Rajasthali sub-district of Rangamati district situated in the south-eastern part of Bangladesh. The area of this sub-district is 145.04 km [19]. The area is hilly and remote covered with forests and streams and estimated to have highest prevalence of malaria (36%) [1]. The population of Rajasthali is 24,097 living in 5,322 households. Our target was to cover all households in the sub-district. Survey instrument A questionnaire was developed with household id, name, detailed address, treatment-seeking behaviour, preferred hospital, demographic structure, education, occupation and information on possession and type of bed net use. Geographic location recorded with GPS (global positioning system) receivers. GPS also was used to record the position of BRAC health volunteers’ households, all hospitals, health clinics, NGO hospitals and drug vendors in Rajasthali and in adjacent sub-districts outside Rajasthali. The study was conducted between January to April, 2010. Please see the appendix for details (Additional file 1). Data management and cleaning Data were entered in MS Excel 2007 checked for errors or inconsistencies and analysed. The locations (longitude and latitude) of all households were recorded using eTrex Venture single handheld GPS receivers. Administrative boundary data were obtained from the Local Government and Engineering Department (LGED) of the Government of Bangladesh. GPS records were imported in Arc GIS 9.3 software and checked on the polygon boundary map. All errors were checked at field level. Distances between points of interest (distance from households to every health facility) were calculated using planar straight-line distance [20]. Statistical analysis Data was analysed with STATA 10. After characterizations of the frequency distributions, logistic regression analysis was performed to assess the associations between treatment-seeking behaviour and the distance to the place for the treatment, educational level, occupation and ethnicity. All variables were incorporated in multivariate regression model. Odds ratios (ORs) and Haque et al. Malaria Journal 2010, 9:156 http://www.malariajournal.com/content/9/1/156 Page 2 of 7