Many countries are nearing — or have already achieved — malaria elimination, as documented by a new series of case studies by The Global Health Group at the University of California, San Francisco and the World Health Organization (WHO) Global Malaria Programme. Having worked in collaboration with ministries of health in affected countries, the two organizations highlight new evidence about what works — and what does not — for reaching and sustaining zero malaria transmission.
The first four case studies of this series — Turkmenistan, Cape Verde, Sri Lanka and Mauritius — chronicle their malaria histories, program successes, challenges and future outlooks. The Mauritius and Turkmenistan case studies present lessons from successful elimination efforts and the Cape Verde and Sri Lanka case studies present lessons from countries that are making remarkable progress towards malaria freedom. This documentation provides insight and evidence that other countries can use for their own malaria programs.
"As we continue to shrink the global malaria map, and as more countries successfully eliminate malaria, a wealth of previously un-tapped knowledge about elimination has been generated," said Sir Richard Feachem, Director of The Global Health Group, part of UCSF Global Health Sciences. "To reach zero malaria transmission, countries need to understand what strategies work, where and under which conditions they work best, and how and when should they be implemented. The UCSF Global Health Group partnered with the WHO to answer these critical questions and provide evidence to other countries."
One resounding lesson from the case studies was reinforced by all countries, whether they are currently malaria-free or working toward elimination: whenever funding for malaria was cut or program capacity decreased, even if elimination was within reach, malaria cases rebounded within a few years.
"With the launch of these case studies, the world is presented with further evidence that there is no room for complacency," said Feachem. "The histories and experiences of these four countries echo the need to maintain a long-term commitment and focus on achieving — and maintaining — zero malaria."
The path to zero malaria is achievable, yet is not simple, as exemplified by the Mauritius and Turkmenistan case studies. Mauritius ended local transmission in 1969; however, natural disasters and migration spurred malaria outbreaks between 1975 and 1981 and malaria was reintroduced. Mauritius subsequently executed a second elimination campaign in which mass drug administration and active case detection, in combination with other interventions, drove local malaria cases to zero again by 1998. They have been malaria-free since.
Turkmenistan similarly followed a circuitous road to elimination. The country successfully interrupted transmission in 1960, only to experience a resurgence thirty years later, at the same time as a war with Afghanistan, the collapse of the Soviet Union and a construction boom. With renewed political commitment to malaria elimination and technical support from the WHO, Turkmenistan was officially certified malaria-free in 2010.
"The experiences documented in these case studies highlight the need to maintain constant vigilance and strong national malaria control programs as countries enter into the pre-elimination and elimination stage, and even after countries achieve zero cases," said Robert Newman, Director of the WHO Global Malaria Programme in Geneva. "It is critical that countries maintain both political and financial commitment, and continue working closely with WHO and key partners to sustain and advance these impressive gains."
The island nations of Sri Lanka and Cape Verde are working to eliminate malaria by 2014 and 2020, respectively. Similar to the other countries in the case study series, Sri Lanka nearly eliminated malaria during the Global Malaria Eradication Program in the 1950s and 1960s, reporting just 17 cases in 1963. However, malaria program activities were then consolidated and scaled down, which contributed to a resurgence of 1.5 million cases a few years later. As highlighted by a recent publication in PLOS ONE, Sri Lanka is again on the brink of eliminating malaria, reducing cases by 99.9% since 1999.
Cape Verde, an African archipelago, historically faced a serious burden of malaria but ended local malaria transmission in 1968. Following this success, malaria program operations were reduced, leaving Cape Verde vulnerable to a malaria outbreak that struck the island from 1977 to 1979 (see graph below). With improved surveillance, as well as diagnosis and treatment of cases, Cape Verde has steadily reduced its burden and today is working to eliminate the final cases of malaria by 2020.
The Global Health Group and the WHO Global Malaria Programme are currently finalizing case studies for Bhutan, Malaysia, the Philippines, Réunion, Tunisia and Turkey, which will be released over the next eight months. All case studies in the series are being conducted jointly with Ministries of Health and other partners, and with funding from the Bill & Melinda Gates Foundation.
The Global Health Group at UCSF Global Health Sciences is dedicated to translating new approaches in global health into large-scale action to improve the lives of millions of people. The Group's Malaria Elimination Initiative provides research and support to the 34 countries that are pursuing an evidence-based path to malaria elimination. The Global Health Group received funding from the Bill & Melinda Gates Foundation for this research. Visit www.globalhealthsciences.ucsf.edu/global-health-group.
The WHO Global Malaria Programme sets evidence-based norms, standards, policies and guidelines to support 99 malaria-affected countries as they scale up their prevention and control efforts. The Programme also keeps independent score of global progress in the fight against malaria. Its flagship annual publication, the World Malaria Report, contains the latest available data on the impact of malaria interventions around the world. Visit www.who.int/malaria.