When we talk about disease control and elimination, Dr Krishna Paudel, Director of Epidemiology and Disease Control Division (EDCD) at Ministry of Health and Population, Nepal says there are two critical aspects – investments from the government’s side complemented by community leadership and engagement.

Nepal has achieved a significant reduction in its malaria burden in recent years; the country reported 117 confirmed indigenous cases in 2019, down from nearly 3900 cases in 2010.

The country is strengthening its surveillance system and using the 1-3-7 approach to eliminate malaria. Effective vector control has resulted in a yearly reduction of indigenous cases of malaria. While, much progress has been made, imported malaria continues to be a major challenge. Both local and border malaria risks are being exacerbated by the current COVID-19 pandemic.

Speaking to APLMA-APMEN, Dr Paudel explained the ways Nepal is fighting malaria, the remaining challenges amidst COVID-19 backdrop, and how surveillance should be prioritized going forward.

Nepal has seen a significant decline in malaria cases over the past few years and is close to elimination. What were some of the strategic efforts that led to this huge success?

In Nepal, we have universal access to diagnosis and effective treatment which is provided free of cost at public health facilities. Rapid diagnostic tests, vector control strategies such as distribution of Long-lasting insecticidal nets (LLINs) and Indoor Residual Spraying have also been implemented. The people’s ability to access malaria tools and commodities majorly contributed to this huge achievement. Moreover, there has been a positive shift in standards of living, education and literacy in the country which has resulted in an improved understanding, greater acceptance and use of protective measures.

Our success lies in our ability to work collectively — the government for implementing the malaria elimination program, non-government entities for supporting the program and the community as well.   

In order to maintain this success however, we need high-level political commitment for continued investment for malaria elimination programmes, complemented by community participation especially when programs are faced with limitations in terms of access to technology, services and commodities.

As Nepal approaches its target to end malaria by 2025, what are some of the remaining last-mile challenges that the country needs to address?

The ongoing pandemic has affected all our malaria efforts. From simply reaching communities (in remote areas) to getting people tested. This has been compounded by hesitancy in testing for febrile illnesses currently for the fear of isolation if tested positive for COVID-19.

Another major challenge is cross-border malaria. Addressing this is a priority for us since more than 80% of reported cases are from border districts. Although we have structures in place to conduct testing at designated entry points, that is not enough as people often travel through different crossings.

Migrant and seasonal Nepali labourers who travel to malaria endemic states in India are at risk of contracting the disease. People from bordering areas such as the lowland region of Terai that lies south of the outer foothills of the Himalayas — who are vulnerable, marginalized and economically disadvantaged — are most affected. Despite control efforts, malaria is now spreading to upper river valley regions in Nepal due to this transit to and from India for seasonal work. So, we do need targeted interventions to address these challenges and reach our elimination goal.

We need to work collaboratively with India in terms of testing, treatment and case reporting across borders. In fact, recently, at SEA Regional Coordination Mechanism Forum (SRCMF) Meeting, countries discussed cross-border issues and recommendations to address it. Hopefully we can develop strong partnerships between countries to deal with this issue.

What are the valuable lessons from Nepal’s malaria control successes that we could apply to beat COVID-19?

As we all know, to combat communicable diseases, surveillance is key —testing, tracing and tracking of every case is very important. This stands true for both malaria and COVID-19. Testing facilities should be available at the community level.

We also have a very good network of community health workers and volunteers who have been working tirelessly despite all the challenges and limitations, particularly in remote areas. In the mountainous Bajura district, access remains an issue as it is not connected by proper roads. Previously we had a malaria outbreak, and transported resources and medical supplies by mules and other domesticated animals. Community health volunteers, community representatives and the local residents as a whole came together to control the outbreak.

Lastly, effective communications are fundamental. When engaging with communities, it is important we use the local language/dialects to ensure they understand and accept protective measures against malaria. This would be useful for COVID-19 and other diseases too. We collaborate with both administrative people and community health workers to prevent language barriers and effectively motivate people to help us achieve the goal of malaria elimination.

Moving forward, what will the Nepal EDCD focus on to make malaria elimination in Nepal a reality?

We are currently working on improving our surveillance activities at the community level especially in areas where we have seen re-introduction of malaria or have detected cases of imported malaria. We are also focusing on strengthening our laboratory network, engaging the community and collaborating with our neighbour India for cross-border activities.

Another important aspect is to engage the private sector in the fight against malaria. When people have fever, they first visit the pharmacy where they are given antibiotics. We engage with large hospitals in the country by conducting orientation programs, trainings, and involving them in our regular surveillance activities. We are trying to include private practitioners and pharmacy outlets in our system, to train them and link them to the public health infrastructure, to improve case reporting from the private sector. With these combined efforts, we can reach the goal of zero malaria.

On a more personal note, how easy has it been for you to adapt from being the Director of a hospital to your new role, Director of EDCD?

During my time at the Primary Healthcare Centre (PHC), I treated children with malaria and adopted the Integrated Management of Childhood Illness approach. Being part of the Epidemiology and Disease Control Division is no different. I provide oversight on many areas — whether it's COVID-19, malaria or even non-communicable diseases like mental health, snake bites etc. I have since been appointed as the spokesperson for the Ministry of Health and Population and have been attending media engagements related to the pandemic.

I’m passionate about making a positive impact on the lives of people. In our COVID-19 battle, for instance, unfortunately we have lost many lives, but we’ve also managed to save thousands at the same time. This is what drives me.

This interview has been edited for length and clarity.