Worldwide, malaria is a major public health problem with 228 million new infections and 405,000 deaths annually . Afghanistan, a country in the WHO Eastern Mediterranean Region, has relatively low transmission of malaria . The Afghanistan National Malaria and Leishmania Control Program reported 174,893 malaria cases and zero deaths in 2019, the lowest number that has ever been reported for the country. The two main species of malaria in Afghanistan are Plasmodium vivax (PV, 98% of all cases) and Plasmodium falciparum (PF, 2%) .
In Afghanistan, malaria incidence rates vary by location. The variation results from differences in parasites, vectors, human population density, behaviors, ecological, high temperature, humidity and agriculture (rice cultivation), socio-economic conditions, and access to health services for detection and treatment of malaria. Nationally, 27% of the Afghan population lives in areas at high risk for malaria. Areas at high risk are defined as provinces and districts with annual parasite incidence (API) rate per 1000 persons at risk of 1 or above and test positivity rate (TPR) at 9% and above. Half (50%) of the population lives in areas at medium risk (API < 1, TPR < 9%), and the remaining 23% live in areas with low and very low risk of malaria transmission or its absence in malaria free areas . In 2019, more than 93% of total malaria cases were reported from six provinces that border with Pakistan (Nangarhar, Laghman, Kunar, Nooristan, Khost, and Paktika) and one district of Kabul. Nangarhar is one highest endemic province in the country and accounted for more than 45% of total malaria cases and 35% of total PF cases .
Malaria diagnosis either by microscopy or rapid diagnostic tests is recommended by WHO for all suspected malaria cases before starting the treatment. Early and accurate diagnosis is essential both for effective management of the disease, and for malaria surveillance and elimination strategies. In Afghanistan, the Community-Based Management of Malaria (CBMM) strategy was designed to progressively expand access to malaria diagnosis and effective antimalarial treatment at non-diagnostic health facilities and community including health posts . Malaria diagnosis using microscopy has been available in all hospitals and Comprehensive Health Centers (CHCs) of Afghanistan. Since 2013, the focus of the CBMM in Afghanistan has changed to specifically increase access to rapid diagnostic testing (RDT) and timely treatment at the community level in all malaria endemic and non-endemic areas of Afghanistan. The programme consists of two key modules; case management, vector control; CBMM was scaled up nationwide in 2016 with the support of the Global Fund. A main pillar of this revised strategy is introducing RDT in all health facilities, not only those providing diagnosis and treatment for malaria, and expanding screening of malaria to health posts to run community-based screening programs. In addition, the CBMM expanded the community-based malaria case management program using networks of community health workers (CHW) to reach all patients with suspected malaria at a level closer to the home. Since 2016, more than 30,000 CHWs were trained on malaria case management, RDT use and distribution of Long-lasting insecticidal net (LLIN) to community through mass campaign. Other malaria commodities, including medicines, were supplied to health posts and health facilities without laboratory services. As a result, in 2017 more than 90% of CHW reported screening and referral of newly identified cases of malaria, and more than 50% reported providing counselling, chloroquine treatment for PV, and artemisinin-based combination therapy for PF to suspected and confirmed malaria cases .
While the magnitude of the scale-up and shift in focus of the CBMM are encouraging, the effectiveness of the program in Afghanistan has not yet been evaluated. In this study, we assessed trends in annual malaria incidence and death rates during two time periods, four years before the expansion of CBMM (2012–2015), and four years after expansion the CBMM program (2016–2019). We also tracked additional indicators of program impact. The scope of our analysis included both national and subnational trends in Afghanistan.