Lessons from Sri Lanka on malaria elimination

Dr. Risintha Premaratne was watching the evening news when he learned the Sri Lankan Navy had rescued a group of Burmese asylum-seekers from a sinking ship headed for Indonesia and Australia. Acting quickly, he picked up the phone and started to make the calls needed to ensure that by the time these passengers reached Sri Lanka’s shores, staff from the Anti Malaria Campaign, which he directed, were at a nearby hospital to screen them for malaria.

Premaratne, who is the director of research at the Sri Lankan Ministry of Health and was the national coordinator for preparation for malaria-free certification, often references this story when he meets with representatives of other countries working toward the same goals. It shows how seriously his country treats the threat from the killer disease, he told Devex. By 2013, the year he made that phone call, Sri Lanka was down to zero cases of malaria, despite 25 years of civil war that coincided with its elimination effort.

So it was no wonder he wanted to act quickly to deal with any threat from a reintroduction of the disease. “Sri Lanka became a malaria-free country by eliminating the malaria parasites, not the vector,” Premaratne told Devex. “Increased travel to and from neighboring malarious countries resulting in cases of imported malaria, combined with the continued presence of malaria vector mosquitoes in formerly endemic areas in the country, make it both receptive and vulnerable for the reintroduction of malaria.”

After staying malaria-free for three consecutive years, the country was able to apply for World Health Organization certification of malaria elimination. Since Sri Lanka was declared malaria-free on Sept. 5, the country has now emerged as an example of what is needed to eliminate malaria and what are the opportunities and challenges of malaria-free status. It also shows the need for regional collaboration in order to achieve global malaria eradication.

“Eliminating malaria from a country is no easy feat and what Sri Lanka has accomplished deserves special praise,” said Ray Chambers, the United Nations secretary-general’s special envoy for health in Agenda 2030 and for malaria. “Against formidable odds — a high burden of malaria and decades of civil conflict — Sri Lanka is a testament to what can be achieved when there is unwavering commitment and collective resolve across sectors to defeat the disease.”

Getting to zero

This is not the first time Sri Lanka has had the opportunity to eliminate malaria. In 1963, the country was down to just 17 cases, but those never translated to full malaria elimination. In fact, Sri Lanka became the textbook case for resurgence of the disease.

“The main reason malaria came back was that complacency set in,” Premaratne told Devex, explaining that the country scaled back indoor residual spraying. “There was so much success that malaria became a forgotten disease.”

By 1999, the number of malaria cases in Sri Lanka had climbed to 269,549. The Sri Lankan government ramped up its efforts in surveillance, treatment, insecticide treated nets, and indoor residual spraying, with the launch of initiatives including the Roll Back Malaria Partnership. The Global Fund to Fight AIDS, Tuberculosis and Malaria provided advocacy, support, and funding as the country expand these interventions. But experts who spoke with Devex said Sri Lanka deserves credit for its own success.

“The key elements there have been true country ownership,” said Pedro Alonso, director of the WHO’s malaria program. “The country has really taken responsibility for the problem and driven the response. There was external assistance, and financial assistance, that really helped accelerate the process, but it was really led by the country.”

The day after the World Health Organization declared Sri Lanka malaria-free, Raj Ghosh, director of vaccine delivery at the India country office of the Bill & Melinda Gates Foundation, sent an email to the organization’s staff about this major public health accomplishment by their “small island neighbor land.”

India emerged from a monsoon season with record deaths from malaria and other mosquito-borne diseases, including dengue fever and chikungunya, to the news that Sri Lanka had been certified malaria-free.

“The principle strategy is simple and V.A.S.T.,” he wrote in the email, spelling out an acronym for what he saw as the keys to Sri Lanka’s success: vector control, access, surveillance and treatment.

Ghosh explained to Devex that when he first traveled to Sri Lanka 10 years ago, in his capacity as immunization director for South Asia for PATH and was impressed with what he calls the three D’s that Sri Lanka had in place: good data, leading to good decision-making, leading to good delivery.

Whereas in most countries one can draw a straight line between gross domestic product per capita and life expectancy, Sri Lanka is a positive outlier, due to its commitment to health and its strong health infrastructure, he said.

The country’s public health care system has led to exceptional health achievements not only when it comes to malaria but also when it comes to issues such as child and maternal mortality, which has been on a steep downward trajectory.

Now, when Ghosh looks at the way Sri Lanka won the war on malaria, Ghosh said he sees plenty lessons for India, which has committed to eliminating malaria by 2030, a target that Sri Lanka now depends on in part in order to keep its malaria-free status.

Following its success, the Sri Lankan government sent a letter to the Indian government, encouraging its neighbor to reduce its malaria burden so it does not export infections across borders.

“We’ll do whatever we can on our side if it helps to bring down the numbers because as long as India has high numbers it’s going to be a threat to all the countries around India,” Premaratne told Devex.

Last week, he presented at the Malaria Elimination Group meeting in Chennai, India, where representatives from malaria endemic countries in Asia and Africa took close notes about his experiences, while also acknowledging that some of the approaches that worked in Sri Lanka might not be as easily transferable.

While other countries can learn from Sri Lanka, the suite of malaria interventions that will work for each country have to be tailored to their specific contexts, said Ashley Birkett, director of PATH’s Malaria Vaccine Initiative, who was in attendance for the presentation. He noting how, as an island nation, Sri Lanka has a unique ability to monitor its borders, and how the expensive and labor intensive method of indoor residual spraying is not a realistic solution for India.

“There is no question we can eliminate malaria today from many parts of the world using the tools we have,” he told Devex. “But very few people believe we can eliminate malaria from all countries with the tools we have.”

Malaria-free, for now

When Bill and Melinda Gates called for the global eradication of malaria in 2007, they caused some controversy. Just talking about controlling the disease, they argued, suggests it is acceptable for some people to have malaria, when in fact no one should be at risk from it.

“Up until 2007, the E word [eradication] could not be used in polite company,” said Sir Richard Feachem, director of the Global Health Group at the University of California, San Francisco, who worked in close partnership with officials in Sri Lanka on their malaria elimination efforts.

But as a growing number of countries have a shrinking number of cases, international consensus is emerging in favor of regional elimination leading to global eradication, he said.

“Elimination is possible in the long term for all countries and in the short term for a subset of them,” Feachem said. “Sri Lanka was one. China is another. Swaziland is another. This is a list of countries that will eliminate malaria by 2020 if they keep on track.”

Seven countries in the last five years have been certified by the WHO as malaria-free, with Kyrgyzstan serving as the most recent example when it was certified last month.

When a country is designated as malaria-free by the WHO, they have reached a stage of elimination, versus eradication, meaning they will need to keep their anti malaria public health programs running.

“This stage is all about vigilance in Sri Lanka,” said Roly Gosling at the University of San Francisco. “The biggest risk is that reintroduced parasites catch hold and malaria transmission starts up again.”

This vigilance is all the more critical, and difficult to maintain, in the face of political instability, massive population size, and emerging global health threats, such as the recent Ebola and Zika epidemics.

Medical practitioners must remain alert for malaria cases and make sure that receptive areas are monitored for any increase in potentially high-risk people migrating there, Gosling added.

“We didn’t want a repeat of history to happen,” Premaratne said. “And during the prevention of reintroduction phase we will continue to work with this same kind of scrutiny.”

This phase, which prioritizes surveillance to detect all cases of imported malaria and rapid response to cases as they arise, will continue as long as malaria parasites are prevalent in neighboring countries, he said.

The E word

WHO’s Global Malaria Eradication Program, which spanned from 1955 to 1969, also offers lessons for more recent efforts to end this disease. But in this case the reason is because of failure versus success. That past campaign failed due to its rigid approach, the emergence of drug and insecticide resistance, and the withdrawal of funding assistance.

“Historically, eradication efforts have been positioned as eradication campaigns, so it’s very top down, and almost invariably uses some kind of single tool to get the job done,” said Bruno Moonen, deputy director for malaria at the Gates Foundation. “When we talk about malaria eradication, we are not talking about the next vertical, top down, centrally managed effort. We see this as a country-driven and regionally coordinated effort.”

Donors tend to walk away when elimination is reached, and the World Malaria Report released earlier this week shows cause for concern for malaria funding. When the money leaves, the malaria returns, and as the parasite adapts, so too do the strategies.

“Short of the ability for the world to completely eradicate the disease, which unfortunately evolution has proven to continue beating us on, you need to make sure countries understand that when they reach elimination they can’t let their surveillance guard down,” said Maurizio Vecchione of Global Good, a Seattle-based innovation lab funded by Gates that is working on a range of tools to tackle malaria. “Sometimes when countries hit that magic threshold of incidence they lose funding for their malaria programs. But the disease can return if you let your guard down.”

When it comes to malaria, while the world is getting smarter, the fight will only get harder. It is a globally complex field of endeavor, from tackling the drug resistant malaria emerging from the Greater Mekong subregion to ending the disease in poor countries that lack health infrastructure or have been hit by conflict. But Sri Lanka stands as an example of how that can work.

“As we talk about ending this disease globally, we’re going to have to solve it in really difficult settings, including settings disrupted by strife,” Martin Edlund, CEO of Malaria No More, told Devex. “Here’s a country that in many ways was a poster child of disruptions. The fact that they succeeded despite those challenges is significant and confidence inspiring.”

At the same time, as Moonen explained, malaria is a disease of the rural poor, so global development efforts and malaria eradication efforts go hand in hand, with less rural people and less poor people meaning less malaria, he said.

A decade from now, in Sri Lanka as well as other countries that will have eliminated malaria, more and more people who have never seen a case of malaria and will think less and less about it, said Larry Slutsker, director of malaria and neglected tropical diseases at PATH. He emphasized how crucial it is for Sri Lanka, Kyrgyzstan, and countries that will soon receive malaria-free status to maintain robust systems in order to provide a safety net, as was required with smallpox, and as is needed with polio.

Still, the message from Premaratne in his presentations around the world is an uplifting one.

“Marching toward elimination is very much within the reach of all of us,” he said.

EDITOR’S NOTE: The reporter traveled to Seattle on the Innovating to End Malaria fellowship funded by Malaria No More. Devex retains full editorial independence and responsibility for this content.

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