SAN FRANCISCO — On Monday, the World Health Organization certified Paraguay as malaria free.
Paraguay, which has had no reported cases of indigenous malaria since 2012, is the first country in the Americas to be granted this status in 45 years. To be certified as malaria free, a country has to demonstrate at least three consecutive years without indigenous malaria transmission, as well as the capacity to prevent the return of malaria. WHO announced the news on the same day it released a status report on the E-2020, 21 countries WHO has determined have the potential to reach zero indigenous cases of malaria by 2020, of which Paraguay was the first to be certified malaria free.
“Receiving this certification is a recognition of more than five decades of hard work in Paraguay, both on the part of public sector workers, as well as the community itself, who have collaborated time and time again in order to achieve the elimination of malaria,” said Carlos Ignacio Morínigo, Paraguay’s minister of health, in a press release.
The growing number of examples of national malaria elimination are all part of the path to global eradication of the disease — each of the malaria-free certifications holds lessons for other countries working to get to zero malaria.
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“The countries within the Americas are generally better off than other regions, but Paraguay is one of the poorer countries in South America, so the fact that it was able to marshal its own resources and dedicate them to eliminating malaria and other vector borne diseases is very significant,” Kimberly Lindblade, team leader of the WHO Global Malaria Programme’s Elimination Unit, told Devex.
In 2011, Paraguay launched a five-year elimination plan, which focused on case management, community engagement, and education to promote self-monitoring and decision-making on malaria.
“The program adjusted its strategies to prioritize 100 percent case confirmation, reporting, and radical treatment, quality control of diagnostic laboratories, and the introduction of geographical information systems to improve surveillance,” reads a country briefing on Paraguay from Global Health Sciences at the University of California, San Francisco.
Paraguay was aiming for malaria-free certification by 2015, but faced some challenges. Those included deforestation and irresponsible irrigation methods, which left stagnant bodies of water that provided breeding grounds for mosquitos, and migration of poor and rural populations, who moved to work in industries such as farming, coal mining, and logging, making it difficult to test and treat.
“If you’re trying to eliminate, the health system has to be able to reach people who are coming from elsewhere, people who may not be documented, people who are coming back and forth informally,” Lindblade explained.
In 2016, with the support of the Global Fund to Fight AIDS, Tuberculosis and Malaria, the Ministry of Public Health and Social Welfare launched a three-year initiative to improve the skills of front line health workers in Paraguay in areas including disease prevention, identification of suspected cases, accurate diagnosis, and prompt response.
“It was critical at a point when Paraguay was having to transition from a vertical malaria elimination program to an integrated program within its health system,” Lindblade said. “It was essential in helping to train the health workers who are part of the regular health system to take on the functions of the vertical program that had been there in the past … Over the next few years, the country is probably just fine with the system they’ve had in place since 2016, but the problem will be in the future generations, when … you get a new group of medical professionals for whom malaria is an exotic disease — to keep them vigilant and trained and able to recognize malaria is where the real challenge comes in.”
After Paraguay handed in its request for malaria-free certification in 2016, WHO staff went on a precertification mission. This resulted in recommendations about what the country needed to do in order to prepare its national elimination report, which Paraguay submitted in early 2018.
Certification teams travel to countries to validate these reports, before passing on evaluation reports to WHO’s Malaria Elimination Certification Panel, which submits recommendations through WHO’s Malaria Policy Advisory Committee to Director-General Tedros Adhanom Ghebreyesus, who makes the ultimate call. In April, WHO established the Malaria Elimination Oversight Committee, which will work within countries to achieve malaria-free status — in part by identifying what might threaten elimination and then working with national malaria programs, WHO, or regional initiatives to help countries address those risks.
“More countries are pushing for elimination and certification,” Lindblade said. “This unit was created because WHO recognized the need for a standing committee to improve policies and make them more transparent to countries than they were before.”
Lindblade spoke with Devex from Costa Rica, which has had almost three years without indigenous cases. Paraguay was of course the key milestone in WHO’s brief on the E-2020 initiative, but another success for malaria elimination in the Americas is El Salvador. In 2017, El Salvador reported zero indigenous cases for the first time, adding to the momentum in Central America, which is moving quickly toward elimination. Paraguay will continue to report on its malaria-free status through the Pan American Health Organization, Lindblade said, explaining that this public health agency will play a critical role in malaria elimination in the region. One of the largest threats to countries like Paraguay is what happens in the rest of the Americas and in particular, bordering countries.
The WHO report on the 21 countries notes that eight of them reported increases in indigenous malaria cases in 2017 and outlines what factors are slowing their progress.
“At the midpoint to 2020, we seek not only to assess the progress made across the malaria- eliminating countries, but also to bring a level of urgency to address the elimination issues and bottlenecks identified in this report,” Pedro Alonso, director of WHO’s Global Malaria Programme, wrote in the E-2020 report released today. “Fortunately, the challenges countries are facing are not necessarily new, and we know they can be tackled with added resources, resolve, and political commitment.”
Morínigo, from Paraguay’s health ministry, added in a press release that: “Reaching this goal also implies that we must now face the challenge of maintaining it.”
To stay malaria free, Paraguay will need to keep surveillance systems up to date, including training community health workers on malaria, integrating malaria activities into health services, ensuring that the expertise and leadership of the national malaria elimination program remains in the national health system, and maintaining political commitment so that the country has the resources it needs to stay malaria free, WHO says.
With regard to the threat from countries in the region, “Venezuela is just putting the whole region backward in terms of targets,” said Leopoldo Villegas, an international health adviser and former adviser to the Venezuelan Ministry of Health, in an interview with Devex Sunday.
He talked about how “the worst malaria epidemic on the continent and the worst increase of malaria in the world” threatens regional progress against the disease, particularly as Venezuela exports cases to Colombia and Brazil.
“If Venezuela spreads malaria to Brazil, what happens to rest of countries? Brazil touches everybody,” he said.
Last year, Algeria started the certification process and is likely the next E-2020 country to be granted the malaria-free status — and after zero indigenous cases since 2011, Uzbekistan and Argentina have also requested WHO certification of elimination.