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Global Health Group, World Health Organization Launch Country Case Studies on Malaria Elimination

October 11, 2012 - 19:31 -- The Global Heal...

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.

Comments

Submitted by Anton Alexander on

It is depressing to read about re-introduction of malaria in places where there has been so much effort to be rid of the disease. Kligler, the architect of probably the first successful national malaria eradication campaign anywhere stressed the education of the general population about malaria was as important as the other eradication steps. Education of the Palestine population succeeded in the 1920s, '30s and '40s in inducing the people of the country to take an interest in health problems and to co-operate in measures for the prevention of disease. Kligler pointed out that it was possible to obtain the population’s active co-operation only after the population understood fully the significance and value of the work. The population would also then have appreciated the maintenance of anti-malarial-engineering work is at least as important as the original project.
If the powers that be understood this, believed in this, and implemented it, I wonder how often re-introduction of this disease would occur.

William Jobin's picture
Submitted by William Jobin on

Anton I know you admire and love the success story of malaria suppression in the Holy Land. But don't be depressed when you read about the difficulties of suppressing malaria in Sub-Saharan Africa (SSA). They are two different worlds, with different mosquito vectors, colder winters, and many other differences. Thus you will notice that all of the countries on the Mediterranean rim of Africa have successfully suppressed malaria: Morocco, Algeria, Tunisia, Libya, Egypt, Palestine, Israel, Lebanon and Syria. ......... Simple swamp drainage and planting of eucalyptus trees is a good start, as they found in the Holy Land. And it was obviously sufficient. It will also be a good start in SS Africa. but NOT sufficient.......... THE SECOND LAW FOR FIGHTING MALARIA IN SS AFRICA IS THE KITCHEN SINK LAW. You don't have to throw the Kitchen Sink at it, but if you want to suppress malaria in SS Africa you better throw everything else........Cheer up Anton, we just need to use our brains, all available methods in a rationalized strategy - and persist.

William Jobin Director of Blue Nile Associates

Submitted by Guest (not verified) on

Bill, thank you for your thoughts, and attempt to cheer me up. You are correct – (1) I do admire the success story of malaria suppression in Palestine, and (2) there are differences re malaria suppression between Israel/Palestine and Sub Saharan Africa (including scale of problem). And I am also grateful to you for providing me with your comment ‘simple swamp drainage and planting of eucalyptus trees is a good start, as they found in the Holy Land’, because a MalariaWorld reader once wrote to me that I made the eradication of malaria in Palestine appear so easy, “then why hadn’t malaria been eradicated in Africa”. And so I think the way or style in which I have attempted to draw the attention of the MalariaWorld readership to probably the first successful national malaria eradication campaign anywhere is at fault. That campaign commenced in 1922 and it took 45 years from its start to formal eradication - eradication of malaria in Palestine/Israel was not easy. I would urge you to read my blog earlier this month at http://www.malariaworld.org/blog/enthusiasm-alone-was-insufficient-defea... because ‘simple swamp drainage and planting of eucalyptus trees’ is precisely what the early Zionists did pre-1914 in Palestine before the arrival of Dr Kligler, the architect of the successful malaria eradication campaign. Before Kligler arrived in 1920, approximately 75,000 Zionists had tried to settle in Palestine, and by 1914, half that number had either died or left, unable to cope after attempts to control malaria by means of ‘simple’ swamp drainage and planting 400,000 eucalyptus trees – which just didn’t work. I think Kligler’s methods have wider application than just those countries around the African rim of the Mediterranean. The Malaria Commission of the League of Nations was intrigued by Kligler’s eradication methods and inspected them in Palestine in 1925. The Italian member of the commission offered congratulations on the success of the antimalarial campaign he had seen, and commented that in Italy they had been applying large drainage schemes, but without success. The Italian member suggested the ideal method of drainage was that which he had just seen in Palestine, and I think Italian eradication began to make significant progress after the Commission’s visit to Palestine. In 1930, Kligler wrote ‘If the work in Palestine differs from that which had been done previously in other parts of the world, the principal point of departure lies in the fact that investigation preceded action. ……. The exact direction [based on which methods of control to choose] could be determined only after a thorough as well as comprehensive study of the problem. ………. [Also] The educational aspect of the work was certainly as important, if not more so, as any other.’ I recognise the similarity of some of Kligler’s suggestions in some of your suggestions in your blogs, and it would seem Kligler’s principles are relevant everywhere. He always stressed that each outbreak of malaria was a local problem, to be treated accordingly. If I make this sound easy, or simple, then I must apologise. Eradication is very hard work and it may be necessary, as you wrote, to throw ‘ the kitchen sink’ at the problem but if so, remember to do it only as part of a rigorous organisation established beforehand. Kligler’s methods in Palestine and also general principles may be studied at www.kligler1930.com . He eradicated malaria without vaccines, without reliance on bednets. His methods worked and for this I admire the success story of malaria elimination in Palestine. Anton Alexander

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Submitted by William Jobin on

We should all be grateful to Richard Feachem, the Gates Foundation and Rob Newman for producing the first four case studies on suppression of malaria. The four reports on Mauritius, Sri Lanka, Turkmenistan and Cape Verde start to give us some realistic perspective on the way to fight malaria. The case studies document a finding of Snowden in his book on malaria in Italy, namely that everything available has to be used. This is the Second Law for Fighting Malaria in Africa - "You don't have to throw the kitchen sink at malaria, but you better use everything else." Note that in one of the most successful cases - Turkmenistan - larval control and environmental management were important components in the fight since the beginning. But it is also important that we see how long the fight will be, even in the relatively easy situations of small islands and areas on the cool fringe like Turkemenistan. Cape Verde has taken 57 years to get stable suppression of malaria, and Sri Lanka has taken 66 years. In the slightly more successful situations of Mauritius it took 47 years to get to zero, and for Turkmenistan it took 80 years. I call this the First Law for Africa - "Fighting malaria in Africa is like building a beautiful mosque or a grand cathedral, it will take generations." Thus we see that ephemeral methods such as bednets which last for about 3 years, have no place in a grand strategy - permanent housing improvements and screens are more economical. A caveat needs to be raised in analyzing the four case studies however. None of them are on the continent of Africa. Cape Verde is close, but it is a tiny island. The challenge for malaria suppression is for the continent of Africa where the real problem is. So we are talking about 50-100 years for stable suppression of malaria in Africa. Thus we need to think of the long term, not of quick success. Finally the case studies indicate more success than the authors indicate. For legitimate public health objectives, there is no need to go to zero. Suppressing malaria to a few cases per year, as in Sri Lanka and Cape Verde - is success! Zero is an unrealistic and unnecessarily expensive goal, especially on the continent of Africa where re-introduction will always be occurring. Instead of trying to develop strategies to go to Zero, we need to organize the public health system to minimize re-introduction of malaria, while quickly treating infected people.

William Jobin Director of Blue Nile Associates

William Jobin's picture
Submitted by William Jobin on

Again I commend Richard Feachem and Rob Newman for the 4 case studies on malaria suppression, which will eventually develop into 10 case studies. There are two aspects of these case studies which make them invaluable. One is that they give the complete history for the country, recognizing that malaria suppresssion efforts began at least a century ago. Thus we need to build on the history. The second beautiful feature of these 4 case studies is that they recount the cost of malaria suppression operations, something scientists often overlook. I attribute this concern for costs to the impact of engineers who helped start all of these efforts. Look at the beautiful records for Mauritius where it is clear that engineers and their highly skilled draftsmen developed graphic data records in the pre-computer age. There are TWO CRITICAL ISSUES which these case studies help us with. .......FIRST CRITICAL ISSUE......When does it become more cost-effective to simply declare VICTORY at a low prevalence of malaria, and then concentrate on repelling reinvasions of the parasite, instead of trying to drive it to ZERO. ZERO is an expensive goal, as these case studies show. .....SECOND CRITICAL ISSUE........HOW LONG MUST THIS GO ON?...In countries which are progressing economically - like Mauritius and Turkmenistan - at what level of per capita income did malaria suppression solidify into malaria elimination? Obviously in Turkmenistan, the introduction of air-conditioning (and electricity for electric fans) marked a turning point in the fight against mosquitoes and thus malaria transmission. Also in Mauritius the last malaria death was recorded about 1951, the same year that the Central Electricity Board was established to coordinate the growing generation of electrical power. So one key factor is the widespread availability of electricity in malarious zones. Undoubtedly this is why malaria is no longer an issue in Italy or the other European countries where it simply faded away as people bought electric fans, screened their houses, and even added air conditioning. What could the poor anophelines do? In Turkmenistan there was a happy coincidence of hydropower and water, since most of the population lives along the rivers in this largely desert country. This probably also explains the quick success in the Tennessee Valley of the USA where malaria control and screening of houses was linked to the 17 hydroelectric reservoirs being constructed on the Tennessee River. Once those rural residents of the Tennessee Valley had screens and fans, they could keep their houses closed up tightly at night against the frustrated anophelines. The hydropower dams were finished about 1950. Malaria disappeared within 5 years, before the generalized use of DDT and chloroquine. Thus in African countries where large hydro projects are supplying electricity, we can expect to see progress in screened houses with electric fans and lights. This would be in Egypt around Aswan Dam, in Sudan around Merowe, Sennar and Roseires Dams, in Uganda around Bujagali Dam, in Ethiopia around several small dams including the huge new Millenium Renaissance Dam, in Zambia and Zimbabwe around Kariba Dam, in Senegal, Mali and Mauritania around Manantali Dam, etc..........
A second important factor is the quality of housing which includes metallic screens and closing of eaves to mosquito penetration. In 1951 houses in Mauritius were solid masonry with good window and door jambs, but with thatched roofs, favoring mosquito entry. According to the Case Study however, after 1960 the majority of houses were concrete with flat concrete roofs. And during the big Sugar Boom in 1974 huge numbers of houses were built of concrete with flat roofs.......So once again thank you Richard and Rob for the data to make these evaluations. We are learning.

William Jobin Director of Blue Nile Associates