Contain This: The Latest in Global Health Security

Bhutan: Malaria Elimination and COVID-19 Vaccination Challenges

December 17, 2021 Indo-Pacific Centre for Health Security: Department of Foreign Affairs and Trade Season 2 Episode 13
Contain This: The Latest in Global Health Security
Bhutan: Malaria Elimination and COVID-19 Vaccination Challenges
Show Notes Transcript

The latest episode in our Indo-Pacific Health Leaders series features Dr Karma Lhazeen, Director of the Department of Medical Services at the Ministry of Health in the Kingdom of Bhutan in conversation with Ambassador Stephanie Williams.

Dr Lhazeen is a tropical medicine specialist, working as a malaria control program manger before becoming chief of the communicable disease division. Since March this year, she has served as the Chair of the Asia Pacific Malaria Elimination Network Vivax Working Group. 

Dr Lhazeen has overseen the national rollout of COVID-19 vaccines in her country and was recently promoted to Director of the Department of Medical Services.

For more information visit the Bhutan's Ministry of Health website.

Plus the website of the Asia Pacific Leaders Malaria Alliance and the Asia Pacific Malaria Elimination Network

Dr Stephanie Williams  

Welcome to Contain This. Today I’m joined by Dr Karma Lhazeen, Director of the Department of Medical Services at the Ministry of Health in the Kingdom of Bhutan.

Dr Lhazeen is a tropical medicine specialist, working as a malaria control program manger before becoming chief of the communicable disease division. Since March this year, she has served as the Chair of the Asia Pacific Malaria Elimination Network Vivax Working Group. 

Dr Lhazeen has overseen the national rollout of COVID-19 vaccines in her country and was recently promoted to Director of the Department of Medical Services.

Dr Lhazeen, could you tell me about Bhutan's story of malaria elimination, in particular, some of the most challenging parts of the last mile?

Dr Karma Lhazeen  00:50

So, for Bhutan if I go into a little bit more detail on how the malaria program evolved in Bhutan. For Bhutanese, malaria as a disease has been known for many centuries, we see it in the old histories, historical documents, and all that people used to fear going to the southern part of the country, which is the endemic area. Five districts are there in Bhutan, which are endemic districts in Bhutan. So it is as far back as few centuries ago, people knew about malaria. But formally, we initiated our malaria control program as a malaria eradication program as far back as in 1964. 

So in 1994, we had the highest number of malaria cases that was ever recorded in the country. So we had almost five digit numbers at that time of 40,000, almost around 40,000 cases. And at the same time, we had about 62 deaths in the country. So that was the highest that we have recorded so far in the country. And in 1995, after that big outbreak of malaria in the south especially, we intensified our control measures, like we introduced deltamethrin indoor residual spray in those high risk districts. After a few years, we also introduced insecticide treated bed nets. So that was, those were the two interventions that we initiated, and we had a drastic reduction of malaria by almost 90% by next two, three years. So from five digits we fell down or came down to four digit numbers. But still, we were struggling with a lot of malaria cases, and Plasmodium falciparum. That was higher than the Plasmodium vivax malaria.  

So, in 2005, we got the opportunity to apply for Global Fund grant, and we were successful. So with that 2005 Global Fund grant, we were able to introduce a lot of better new tools for malaria that were available. So what we did this before, we could not use the rapid diagnostic test kits because of the resources. So we introduced rapid diagnostic kits to diagnose malaria immediately. Then we also introduced the long-lasting insecticide treated bed nets in place of the bed nets that we were trying to promote. And also the best part was that we could introduce the artemisinin combination therapy for blood which was very, very effective in reduction of the Plasmodium falciparum cases.  

By 2009 after three years of introduction of all these, taking all these interventions, we were able to come down to the pre-elimination phase already. And we had an annual parasite incidence rate of less than below one per 1000 population at this population so that certainty had a huge impact on the malaria control program in our country. And initially we were planning to have zero indigenous case by 2018 and get malaria certification by WHO certification by 2021. But somehow we were dealing with Plasmodium vivax malaria, which is a little difficult to treat. Of course, the longer duration of treatment and there is hypnozoites or liver-stage [parasites] that can lead to recurrences. 

So, this way, now, we have reached almost the last mile stage of elimination, and now we have reset our target because in 2018, we could not achieve zero indigenous malaria case, although we had almost eliminated falciparum malaria, but vivax was the one which we were dealing. So we set our next target for 2023. But also with COVID now in 2020, we had a little resurgence of malaria. So we have few, about 40 or 50 cases, malaria cases also detected in the first year of COVID. And now we have reset our target for 2025 for malaria certification.  

And the main issue that we are facing the challenges in the last mile is that malaria is still getting introduced because we have long border with India where the malaria is endemic in those areas where they're still taking the control measures. So whenever there is an increase there, we are worried that they will be in introduction in the border areas. The borders are very, very porous in our situation.  And the other thing is that though our populations are very, very aware about malaria transmission, how it is transmitted, but because in the last few years, almost 10 years now, we are dealing with very few cases of malaria. So because of that our populations are becoming very complacent. And also the service providers, the health workers are also getting very less cases of malaria now. So they are also losing their skills to do the microscopy, and relying too much on the rapid diagnostic tests. And so these are some of the few challenges that we have to deal with when the diseases go into elimination.  

And the other most important thing is that when we reach this stage, I think for the finances and policymakers here it is very difficult to convince them that we are still dealing with malaria. So it gets deprioritized. They say, oh, there are no malaria cases now and people are not dying so why are we trying to mobilize more funds for malaria, but the message is that when malaria is eliminated or any disease gets eliminated, to prevent reintroduction of those diseases in the country, we have to really strengthen our surveillance system, and case surveillance has to also improve. We need better tools, more sensitive tools to deal with asymptomatic cases that may still be carrying the vivax parasites, the people who are coming may be asymptomatic.

So these are some of the challenges we face and Bhutan is at the verge of graduating from low income country to middle low middle income country by 2023. So then we have a huge challenge now as we have donor funds that are supporting us now. 

Dr Stephanie Williams  08:40

That was a fascinating overview of the malaria control program and the different stages that you have been through. And I think that that point about the consequences of success have control, the costs per case, when you only have a handful of cases get higher, and that there is a payment, there's a cost to sustaining control, that as you say, it's hard to convince for more resources, when the disease trajectory looks so positive, but there has been expensive to get there and will cost money to sustain.  Can I just ask a follow up question, because you use gave a great overview of the population, individual, clinician and tools challenges in the last mile. How have your public health strategies had to change in terms of your surveillance approaches or your data management? Or how you find cases for example, how are you changing what you do to find the fewer cases?

Dr Karma Lhazeen  10: 00

What we have done is that now not to miss any cases, we have a weekly fever surveillance system in the country. So whenever there is a huge number ... every fever case, gets a malaria test done. And so we have this surveillance system put in place quite some time back when we got around mid-2000s, 2005-07. Around that time, what we did was that we put in that surveillance. So whenever there is any increase in fever cases in the community, we, especially in the southern districts, every case gets a malaria test done. And in the non-malarious area, we are creating awareness that if you have gone to a malaria endemic place and come back, we assess the travel history, and also do a test to exclude malaria. And in all the foreign workers that are coming into the country, we have a screening system in the point of entry, we have a good disease screening system. So Malaria is one of them. And for the government system, it's quite overwhelming to have hundreds of people coming in for tests and it may reprioritize cases that need treatment in the hospital. So we have allowed private diagnostic centres to come up in these southern border areas where they can do the malaria screening. So we have that system in place for surveillance. And also, for Bhutan, we are tying up with climate and global warming. So we have, right from the mountainous northern area to the southern border, the surveillance for climate sensitive diseases, and we have put in place to monitor climate sensitive diseases like pneumonia, diarrhea diseases and vector borne diseases. So these are in place. And now we anticipate that in future most of the cases need better tools. So we are also trying to see how we can develop better tools get better tools for diagnosis of malaria and maybe molecular techniques that might be needed to be used to see whether they are indigenous or whether they are introduced cases. So these are some of the activities that we have put in place.

Dr Stephanie Williams  12:50

And in addition to your national responsibilities, Dr Lhazeen, you're also Chair of the Asia Pacific Leaders Malaria Alliance Vivax Working Group, can you tell us a bit about how this group supports the region?

Dr Karma Lhazeen  13:00

In our Asia Pacific APMEN [Asia-Pacific Malaria Elimination Network], we have about 21 countries in the network now, and we have about 50 partner institutions working to eliminate malaria and our target is that by 2030, we want to achieve that elimination target.

So, what we are doing is that in the APMEN we have three working groups. The Vivax working group is one of them, then we have a group that is looking at surveillance and then one for Vector control. So, for our group, from 2020 to 2021, we have been working in the Vivax working group. 

Now, this group has a huge responsibility of collecting all the evidence that have been collected by the previous Vivax Working Group chairman and his team. So, what we have identified is the overall goal of the Vivax malaria group is to contribute towards accelerating the uptake and implementation of the optimal radical cure for vivax malaria. So, we are focusing on that and helping countries in the network to improve/increase implementation of vivax radical cure into ongoing activities by developing technical outputs such as vivax radical cure roadmap, options assessment toolkit, and evidence briefs. We are working with regions like EMRO, Western Pacific region of WHO, South East Asia Region of WHO, Research Institutes and Experts by engaging the regional advisors and experts to support us in guiding us strategically. We are guided strategically by people who are really in their positions to get information, evidence, share that good technical know-how.

And we work with the program managers of the country's national program managers and we identify the gaps. We identify the implementation operational gaps, and then we try to show them how to prioritize the gaps which makes prioritization easy for the countries.

And we also facilitate the cross-regional learning. The other thing is that we bring them together in workshops and then we share our experiences. And in that way, the countries are able to share the best practices and the issues and challenges. 

Dr Stephanie Williams  17:00

That's fascinating. Can I bring you back to Bhutan, and ask you for your reflections on the success of the COVID-19 vaccine rollout. I've heard it presented a number of times but you achieved high coverage very early. I'm interested in your reflections on what worked in Bhutan.

Dr Karma Lhazeen  17:15

For Bhutan, the COVID vaccination program, Bhutan is a small country with very small population. And we were... as we were dealing with COVID whole of last year, we realized that whatever we do, whatever and however strict protocol we may follow, COVID is going to be there for quite some time unless vaccination/ immunization comes in. So we were waiting from the very beginning knowing that primary prevention would be the best option against COVID-19. So as soon as the vaccines started coming up, and there was announcement that these vaccines are being approved for use. Then we all started planning for it right from July last year. We started planning for the introduction of the vaccine. If the vaccine comes, we would need to meet the ultra cold chain requirement. And we were dealing with just two to eight degrees Celsius storage capacities in the country before that. 

So we started planning right from June-July last year for the introduction of this vaccination. So, we were assessing our capacity to do deal with these new vaccines that require different levels of cold chain management. So all this groundwork, we started at the program level to see how we can cope with all these things. So, also started identifying populations in the district and listing them as  we knew that once the vaccine is there in the market ,  will have to access it. So, we were guided by the wisdom from His Majesty himself. He said that if the vaccine comes that we have to make arrangements to get it for all populations. So it got all of us working, the government, the Prime Minister, the Finance Minister, Foreign Minister, the Health Minister, all of them were engaged in preparing  for our vaccines  access and delivery in the country. 

So we also got the opportunity to apply for COVAX facility and a lot of engaging meetings and all happened with COVAX facility.  Luckily for Bhutan, because of our very good relationship with India, our closest neighbor the first dose vaccines almost half a million doses from our good neighbor India. The rollout plans was to vaccinate within a week. So we started with development of vaccine delivery strategy. Micro plans were developed with engagement of each districts so that as soon as the vaccine comes how we are going to distribute to the high-risk areas and other parts of the country were planned. 

And then we were thinking and planning how to reach vaccines over the mountains in areas that are unreached by motorable roads. So we planned that to the unreached areas the vaccines would be sent by chopper services. As soon as we got the vaccines here, our drug regulatory Authority immediately started working on it for the approval to use it in the country which took almost one or two days only. 

And then as the vaccines came since our distribution plan was all ready, so overnight our people sat there and started packing and sending out to the districts. We have just three vaccine vans in the country for the 20 districts. So we had planned how all these vans will move from one place to the other by road, and to unreached places we were reaching them through the chopper services. That is how the vaccine were delivered. 

because we have to conduct a vaccination program in a short while, we have very little human resource there. So we also engaged and trained about 6000-7000 people, including medical workers. We had about 4-5000 vaccinators and most of them were health workers but we also inducted the final year students who are in the nursing schools and medical colleges. We trained them before the vaccine arrived and  engaged them for the vaccination program .We engaged volunteers to support the health team in the vaccination posts. So we had almost about 4000 workers and about 2000 volunteers. And we also had planned around 1200 vaccination posts across the country to do the vaccination. 

And we were extremely worried about the new vaccine being introduced and we were hearing so many things about the side effects AEFI [adverse event following immunisation] and all. We also had a national immunization technical advisory group that was formulated. And we since we have 20 districts in the country, we divided the districts into three regions and at regional level we had regional  immunization technical advisory groups identified to oversight and oversee the AEFIs and all that is being reported and to advise the teams at community level. So we had those things put up in place. And the AEFI also because we were worried after every person was vaccinated, we had a protocol developed, keep them 30 minutes at the vaccination post to observe for AEFI. So luckily, we don't have too many AEFIs reported. And at each vaccination post, we deployed 46 cluster doctors, so each deployed doctors to manage at the site. So in 1,100 vaccination posts we had only 46 doctors. Each doctor was looking at few clusters, a cluster of centers and going from one vaccination post to the other. So even in the most remote part, even if we had about 20 or 30 people to be vaccinated one chopper with health worker and a doctor were sent there to drop and pick them. We did not have any deaths due to COVID and we did not want to have a casualty due to vaccination. So that was why these were the precautions and planning that we made for ensuring that the vaccine was safely delivered to each individual.

Dr Stephanie Williams  25:25

I think we should call this episode three vaccine vans and some helicopters. I'm interested how you set about to do this in one week. What was the time it took to reach your target coverage in Bhutan?

Dr Karma Lhazeen  25:30

During the first dose vaccination we reached about 63% total population & eligible population above 18 reached was about 94%. But we did our second round of vaccination, second dose vaccination was around the end of July, and we did in about 5 days as planned. So as of September 2021, first dose coverage of total population is 80%, and about the second dose vaccination coverage is 68% of the total population. We also came to understand that now it is approved for the 12 to 17 children so we have started the vaccination of the 12 to 17 children as well. And children's vaccination is still ongoing.

Dr Stephanie Williams  26:50

So that ... It's worth reflecting that when you and colleagues were tasked with making the plan and getting ready, it was June 2020, six months before WHO issued their first emergency use authorization for, I think, the AstraZeneca vaccine. You've described a level of preparation that sounds so important to achieve your delivery within the days that you did it. I do want to ask so many more questions about vaccines. But I also want to ask you, as a final question, really, is with everything that you have on your plate? How do you personally keep motivated and healthy as the demands on all health leaders continue to rise as the pandemic continues?

Dr Karma Lhazeen  27:40

In fact, for Bhutan, we were very fortunate that we had His Majesty as the guiding force behind the COVID response, as well as the vaccination drive. If we are not shown the vision, and we would still be waiting for things to come as it gets approved. So that drive has come through the vision of His Majesty who is always there for us. He has been visiting every nook and corner of the country during the COVID pandemic , going there following all the COVID protocols as we are doing going to the high risk areas. After the visit coming and staying in the quarantined facilities like we do. There's no difference between our VIPs and the common people, the same protocol is being followed. 

We had planned strategy for the elderly patients so they were getting special attention and focus from His Majesty. The disabled people, people who are not able to reach the health centers for vaccination, we were providing them home-based vaccination. We were going door to door vaccinating the people who could not come to the health centre. So that is how everybody working in the field, everybody was really kept motivated. Even the people who are not doing anything, were at least motivated and abiding by the COVID protocols and tried to support in the best way possible. So we thought a lot of good things emerged from the disaster, everybody wanted to contribute. And at the end, the volunteers were recognized the health ministry was also recognized for all the hard work and stressful work that the Ministry of Health did during COVID pandemic. 

Dr Stephanie Williams  30:05

Thank you, Dr Lhazeen, for your insights on the unique experience of leading a COVID-19 vaccine rollout for a mountainous nation of less than 800,000 people.

You have been listening to Dr Karma Lhazeen, Director of the Department of Medical Services at the Ministry of Health in the Kingdom of Bhutan.

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