Campaign against Malaria : challenges ahead for Lanka

by Amarasiri de Silva

Between 2020 and 2022, the World Health Organization (WHO) granted Malaria-free status to 12 countries, recognising their successful efforts in combating the disease. The nations awarded this prestigious certification include the United Arab Emirates, Morocco, Turkmenistan, Armenia, Argentina, Kyrgyzstan, Uzbekistan, Paraguay, Algeria, China, El Salvador, and Sri Lanka. The WHO officially acknowledges these countries as Malaria-free.

However, it is essential to note that the USA is not entirely Malaria-free, as isolated cases of home-grown Malaria continue to be reported. In south Asia, most countries, except Sri Lanka, are endemic to Malaria. India represents approximately 3% of the global malaria burden, signifying the significant impact of the disease in the country. In Pakistan, around 217 million people face a moderate risk of Malaria, while approximately 63 million are exposed to high risk. Malaria remains endemic in 13 out of 64 districts in Bangladesh, highlighting the ongoing challenges in combating the disease. Approximately 14 million people in Bangladesh are at risk of Malaria. The fight against Malaria remains an ongoing global challenge, with various countries grappling with its impact and implementing measures to control its spread and reduce its burden on communities.

This article focuses on Sri Lanka’s recent achievements in Malaria control, celebrating its success in eliminating Malaria. However, it also sheds light on the challenges ahead for Sri Lanka as it strives to maintain this Malaria-free status.

The southward shifting of kingdoms in Sri Lanka is believed to have been influenced by foreign invasions and epidemics such as Malaria and kidney disease. According to the ancient chronicle, Mahavamsa, which traces the history of Sri Lanka from the 3rd century B.C., the island faced numerous foreign invasions beginning in 300 A.D. These invasions resulted in extensive damage to irrigation systems, leading to disruptions in agriculture. Abandonment of irrigation tanks and cascades, which served as breeding grounds for malaria-carrying mosquitoes, contributed to a devastating “depopulating sickness,” causing significant population declines during that era.

During the Dutch occupation in the 17th century, the southern part of the country experienced another calamity known as the “fever pestilence.” This outbreak profoundly impacted the population, leading to a considerable decrease in numbers. Scholars have postulated that Malaria might have been the disease described in these ancient records, given its prevalence during historical times.

By the 1880s, the local population had given the disease a colloquial name – “Kelae Una,” meaning “forest fever.” This name reflects the understanding that Malaria was often associated with forested areas, which served as ideal habitats for mosquito vectors.

Overall, the historical records shed light on the significant influence of epidemics like Malaria on the shifting fortunes of kingdoms in Sri Lanka. These accounts underscore the critical role that infectious diseases have played in shaping the nation’s history and population dynamics throughout the ages.

The historical accounts offer a glimpse into the significance of Malaria in shaping the island’s history and underscore the importance of understanding the past to inform present-day efforts in malaria control and prevention.

Malaria, a persistent and deadly disease, has plagued humanity for centuries, causing immense suffering and claiming the lives of more than half a million people, annually. While significant progress has been made in the fight against Malaria, the world’s mortality rates for Malaria have remained relatively stagnant since 2015. However, amidst these challenges, a ray of hope emerges as the first-ever Malaria vaccine, RTS, S, begins to be rolled out to children in African countries (RTS, S/AS01 (RTS, S) is a vaccine that acts against Plasmodium falciparum, the deadliest Malaria parasite globally and the most prevalent in Africa. RTS, S is the first Malaria vaccine recommended for use to prevent Malaria in children in areas of moderate to high Malaria transmission). It’s important to explore the potential impact of new vaccines and innovative approaches to combat Malaria in Sri Lanka, considering the current Malaria landscape and the potential threats posed by climate change.

Malaria, once a significant public health concern in Sri Lanka, reached a pivotal turning point in 2012, when it was officially declared eliminated. Subsequently, in 2016, the World Health Organization (WHO) granted Sri Lanka the much-coveted certification, affirming the nation’s successful fight against the disease. This achievement culminated in meticulous planning, collaborative efforts, and dedicated expertise in Malaria control at both central and local levels.

The journey toward Malaria elimination in Sri Lanka showcased some key epidemiological features. Notably, there has been a steady decline in the incidence of Malaria cases since 1999, marking a crucial milestone in the path to eradication. Additionally, Sri Lanka witnessed the simultaneous elimination of two primary Malaria-causing parasites, Plasmodium falciparum and Plasmodium vivax, a feat that underscored the effectiveness of the country’s elimination strategies.

The success in eliminating Malaria was rooted in a well-coordinated approach. Central authorities collaborated with dedicated personnel at all levels at the national centre and on the ground in all districts for several years. This synergy of efforts formed the firm foundation upon which Sri Lanka’s elimination endeavours were built.

The historical backdrop of Malaria in Sri Lanka was riddled with a tragic chapter in the form of a massive epidemic in 1934/35. Over 1.5 million Malaria cases were reported during that devastating outbreak, leading to a staggering death toll of 80,000. However, the country’s health authorities demonstrated resilience and commitment to combat the disease in the following decades.

The significant milestone in the battle against Malaria was reporting the last indigenous case of the disease in October 2012. Remarkably, this milestone was achieved ahead of the established targets, underscoring the effectiveness of Sri Lanka’s elimination efforts. After this achievement, Sri Lanka has maintained an admirable record of zero cases of indigenous Malaria.

Despite eliminating indigenous Malaria, Sri Lanka faced new challenges in the form of imported cases. In 2018, the country reported its first case of Malaria, originating from an external source, six years after achieving elimination status. The rise in imported cases can be attributed to increased foreign labour migration from countries like India and China and an influx of tourists from various parts of the world.

This surge in external mobility introduced a setback to the elimination efforts, creating a higher vulnerability to potential malaria resurgence. Coupled with the prevailing receptivity within the country, the risk of Malaria resurgence escalated, necessitating continued vigilance and proactive measures.

Sri Lanka’s journey toward Malaria elimination is a testament to the power of strategic planning, effective implementation, and tireless dedication. While the country successfully achieved Malaria elimination in 2012 and has sustained a Malaria-free status to date, the rise in imported cases serves as a reminder that ongoing surveillance and preparedness are imperative to safeguard against potential resurgences. By upholding its commitment to Malaria control and continued vigilance, Sri Lanka remains an inspiring model for other nations seeking to combat and eradicate this tenacious disease.

The emergence of new drug-resistant strains and the potential spread of Malaria to new regions due to climate change pose fresh challenges that warrant continued vigilance.

The introduction of RTS, S, the first Malaria vaccine, brings renewed hope to the fight against this relentless disease. Developed by GlaxoSmithKline (GSK) in partnership with PATH Malaria Vaccine Initiative, the vaccine targets the Plasmodium falciparum parasite, responsible for most Malaria-related deaths. As the vaccine is rolled out to children in Africa, its efficacy and impact will be closely monitored. Should RTS, S successfully reduce Malaria cases, it could serve as a beacon of hope for countries like Sri Lanka, which have already made significant strides but remain vulnerable to resurgence. By learning from the experiences of African countries and building on their successes, Sri Lanka could potentially integrate RTS, S into its existing Malaria control programmes to further bolster protection against the disease.

Artemisinin-based combination therapies (ACTs) have long been regarded as the most effective treatment for Malaria. However, recent reports of artemisinin resistance in certain regions cause concern. The spread of resistance compromises the effectiveness of these life-saving drugs, potentially leading to increased Malaria-related fatalities. In light of this threat, researchers are working tirelessly to find alternative treatments and preventive measures. Developing new vaccines targeting the Malaria parasite at various stages of its life cycle offers a promising approach. By attacking the parasite from multiple angles, these vaccines could potentially thwart the development of resistance and ensure sustained protection against Malaria.

Beyond vaccines, researchers are exploring other innovative avenues to combat Malaria. Monoclonal antibodies, which have successfully treated various diseases, are being studied as a potential tool to prevent and treat Malaria infections. These antibodies could provide temporary immunity and act as a complement to existing preventive measures. Moreover, the concept of gene drive technology is being explored as a means to suppress or replace mosquito populations. By modifying mosquito genes to reduce their ability to transmit Malaria, this approach could offer a sustainable and environmentally friendly method of vector control. However, it is essential to consider the ethical and ecological implications of implementing gene drive technology.

The battle against Malaria has been long and challenging, but recent advancements in vaccines and innovative approaches offer hope for a brighter future. As RTS, S begins to be distributed in African countries, its potential benefits may extend to regions like Sri Lanka. By adopting an integrated approach that includes new vaccines, alternative treatments, and cutting-edge innovations, Sri Lanka can strengthen its defenses against Malaria. Nevertheless, it is vital to remain vigilant and adaptive in the face of evolving challenges to ensure that progress in the fight against Malaria remains steadfast. Together, with global cooperation and sustained commitment, we can envision a world where Malaria no longer threatens human life.

In order to achieve successful Malaria elimination in Sri Lanka, the Malaria elimination programme must take into account the intricate interplay of social and cultural factors that influence the disease. Understanding and addressing these factors are crucial for effective control measures. One of the key aspects that demand attention is people’s behaviours and practices related to Malaria prevention. Local communities’ knowledge, attitudes, and beliefs regarding Malaria transmission and prevention play a significant role in the success of control efforts. Conducting awareness campaigns and educational programmes tailored to the specific needs of different communities can foster positive behavioural changes, such as using preventive measures and seeking timely treatment.

Furthermore, attention to sleeping patterns is imperative in Malaria control. The Anopheles mosquito, responsible for transmitting Malaria, is predominantly active during the nighttime. Therefore, promoting the use of insecticide-treated bed nets and ensuring their widespread distribution can serve as a potent intervention. The exemplary case of the Kataragama-Buttala area in the 1990s, led by Professor Kamini Mendis, stands as a powerful testament to the success of bed net implementation in curbing Malaria transmission rates. This particular initiative highlighted the remarkable effectiveness of such interventions in combatting the spread of the disease.

Additionally, the Malaria elimination programme should engage with local communities to identify and address any unique challenges they may face in adopting preventive measures. Factors such as housing conditions, access to healthcare, and economic constraints can impact the feasibility of implementing control strategies. Tailoring interventions to suit the specific social and economic contexts of different regions can enhance the programme’s effectiveness and sustainability.

In conclusion, achieving Malaria elimination in Sri Lanka requires a comprehensive approach that takes into account the social and cultural dynamics of the disease. By understanding and addressing people’s behaviours, promoting preventive practices, and implementing successful interventions, like bed nets, the country can make significant strides towards its goal of a Malaria-free future.

In the event of a resurgence of Malaria, whether we should implement the RTS, S vaccine requires careful contemplation. In 2021, the World Health Organization (WHO) recommended the broader use of the RTS, S vaccine in the fight against Malaria. Subsequently, the Gavi Board approved funding to facilitate the roll-out of the Malaria vaccine in sub-Saharan Africa. This groundbreaking development marks the first-ever recommendation and support for a Malaria vaccine and represents a remarkable achievement as the world’s first vaccine targeting a parasite.

As discussed in the WHO document on Malaria free Sri Lanka, the new challenge lies in enhancing our astuteness, adaptability, and ability to strategize on the go. We must proactively identify and address potential threats from frequent travel. Our goal is to prevent the re-emergence of Malaria while remaining prepared for any unforeseen circumstances. Being proactive and forward-thinking is essential. Who can predict that amidst the lush greenery of an endemic area near human settlements, the Anopheles mosquito may lurk, waiting for an opportunity? All may seem peaceful, but this tranquility can be disrupted when an unsuspecting febrile traveller returns from overseas, relying on only mere paracetamol to combat their illness.