Malaria Elimination and Eradication

Abstract

The world has made tremendous progress in the fight against malaria in the past 15 years. According to the World Malaria Report, malaria case incidence was reduced by 41 percent and malaria mortality rates were reduced by 62 percent between 2000 and 2015 (WHO 2016c). At the beginning of 2016, malaria was considered to be endemic in 91 countries and territories, down from 108 in 2000.Despite this progress, malaria continues to place a heavy toll on the world. In 2015, 212 million cases occurred globally, leading to 429,000 deaths, most of which occurred in children under age five years in Africa. These estimates are likely to be conservative, as adult deaths from malaria might well be underestimated in Africa and India (Adjuik and others 2006; Bawah and Binka 2007; Dhingra and others 2010; Gupta and Chowdhury 2014).More than 100 countries have eliminated malaria in the past century. Of the 106 countries with ongoing transmission in 2000, 57 reduced malaria incidence more than 75 percent by 2015, in line with the World Health Assembly target for 2015 of reducing the malaria burden by 75 percent. An additional 18 countries reduced incidence by more than 50 percent (WHO 2015e), also achieving target 6C of the Millennium Development Goals, which called for halting and beginning to reverse the global incidence of malaria by 2015.An increasing number of countries are moving toward the elimination of malaria. Since 2000, 12 countries have eliminated malaria; 4 were certified as malaria free by the World Health Organization (WHO) between 2007 and 2013 (Armenia, Morocco, Turkmenistan, and the United Arab Emirates); an additional 8 moved into the WHO’s prevention-of-reintroduction phase after sustaining at least three years of zero local malaria transmission (Argentina, the Arab Republic of Egypt, Iraq, Georgia, the Kyrgyz Republic, Oman, the Syrian Arab Republic, and Uzbekistan); and 5 interrupted local transmission (Azerbaijan, Costa Rica, Paraguay, Sri Lanka, and Turkey). The WHO European Region reported zero indigenous cases for the first time in 2015, in line with the goal of the Tashkent Declaration to eliminate malaria from the region by 2015.According to the WHO (2016a), an additional 21 countries are in a position to achieve at least one year of zero indigenous cases of malaria by 2020. These dramatic declines can be attributed to the scale-up of effective malaria control tools and technologies coupled with renewed political leadership and financial commitment.Bolstered by these successes, most national malaria programs now consider elimination to be an attainable goal, and the idea of eradication is once again on the global health agenda. Many countries have developed national elimination goals, and regional networks have been formed to facilitate collaboration (Newby and others 2016). Leaders from the Asia Pacific Leaders Malaria Alliance and the African Leaders Malaria Alliance endorsed regional goals for malaria elimination by 2030 in November 2014 and January 2015, respectively, galvanizing support for elimination and eradication (APLMA 2015; United Nations 2015).In this context, two new global malaria policy and advocacy documents supporting elimination and eradication were released in 2015: the Roll Back Malaria (RBM) Partnership’s Action and Investment to Defeat Malaria 2016–2030 and the WHO’s Global Technical Strategy for Malaria 2016–2030. The Global Technical Strategy (GTS), which the WHO ratified in May 2015, calls for at least another 40 percent reduction in malaria-related mortality and morbidity between 2015 and 2020. Other goals and targets are illustrated in table 12.1. A third document, launched in September 2015, From Aspiration to Action: What Will It Take to End Malaria?, outlines the resources and strategies needed for global eradication by 2040, calling by 2020 commit to eradication in the next five years (Gates and Chambers 2015).Despite these advances, malaria elimination and eradication face significant technical, operational, and financial challenges. About 3.2 billion people remain at risk of malaria; in 2015 alone, there were an estimated 214 million new cases of malaria and more than 400,000 malaria-related deaths. Global progress in malaria control and elimination is marked by vast disparities between and within countries, with vulnerable groups that have poor access to health services continuing to be marginalized. The Sub-Saharan Africa region shoulders the heaviest burden, with two countries—the Democratic Republic of Congo and Nigeria—accounting for more than 35 percent of global malaria deaths. In these areas, malaria control programs aim to maximize the reduction of malaria cases and deaths; elimination will likely require more potent tools and stronger health systems.A few countries that have successfully reduced malaria transmission are struggling to maintain their gains. An increased number of cases has recently been reported from a number of countries, including Cambodia, Djibouti, Madagascar, Uganda, and Republica Bolivariana de Venezuela (WHO 2015e). Furthermore, as the global malaria burden declines, emerging biological threats have the potential to critically weaken malaria responses in several parts of the world. In 2014, 60 countries reported resistance of mosquitoes to at least one insecticide used in vector control strategies; resistance of parasites to artemisinin, the cornerstone of malaria chemotherapy, has been detected in five countries in the Greater Mekong subregion, posing a serious threat to global health security.This chapter summarizes the literature on malaria elimination; describes the progress made; and discusses malaria epidemiology, interventions, and challenges. In addition, it presents empirical information on financing and economics, including cost information from various settings. It concludes with a discussion of the economic basis for eradication and recommendations for research.