Comment
1038 www.thelancet.com Vol 388 September 10, 2016
Against the odds, Sri Lanka eliminates malaria
Sri Lanka’s achievement in eliminating malaria, certifi ed by WHO on Sept 5, 2016, is an inspiring public health success story.1 With its population of about 22 million,
this Indian Ocean island is the largest lower-middle-income country in the malaria-endemic tropics to achieve elimination.2,3 Income per person in Sri Lanka is
still below the level at which countries typically succeed in eliminating malaria.2 More than 80% of Sri Lanka’s
population live in rural areas, providing ideal ecosystems for Anopheles culicifacies, one of the main vectors for malaria in the region. And, remarkably, the groundwork for elimination was laid during a period of internal armed confl ict.4
The elimination of malaria brings to an end one of Sri Lanka’s most devastating health burdens. Of the country’s 25 districts, only six had low to no risk for malaria.4,5 Epidemics and endemic transmission
intensifi ed in the 19th and 20th centuries as plantation, irrigation, and agricultural projects— undertaken by the British colonial administration and
then by the independent government—opened up forested areas.5 Major epidemics occurred every few
years. The 1934–35 epidemic killed over 1·5% of the population.5
In 1945, Sri Lanka was a regional pioneer in introducing indoor residual spraying (IRS) with dichlorodiphenyltrichloroethane (DDT).4,5 The dramatic
results led to IRS being used across the country, and in 1958Sri Lanka joined WHO’s Global Malaria Eradication Programme. By 1963, there were just 17 cases of malaria reported in Sri Lanka, of which 11 were imported.5,6
Elimination seemed certain. But the subsequent scaling back of IRS led to the resurgence of malaria, with about 1·5 million cases in Sri Lanka during 1967–69.2–6 For the
next 30 years, Sri Lanka did its best to control malaria but with little success.
Then in the late 1980s technical leadership by Sri Lanka’s Anti-Malaria Campaign (AMC) Directorate led to the jettisoning of single vector-control methods, such as IRS, in favour of integrated vector management. This integrated approach relied on several carefully selected interventions, including vector control in major irrigation and agriculture projects, rigorous entomological surveillance leading to targeted spraying in high-risk areas, new classes of insecticides for IRS, insecticide-treated nets and larval control, and strengthened parasitological surveillance for active case detection combined with rapid response.5
Despite these eff orts, major epidemics occurred during the 1980s and 1990s. In the country’s 1986–87 epidemic there were more than 600 000 cases of malaria, while in 1999 the number of confi rmed cases ofmalaria was 264 549.4,5 Fortunately, mortality was limited by
wide access to quality treatment and because most infections were Plasmodium vivax malaria rather than
Published Online
September 5, 2016 http://dx.doi.org/10.1016/ S0140-6736(16)31572-0
8 New Zealand Ministry of Health. New Zealand Suicide Prevention Strategy 2006–2016. 2006. https://www.health.govt.nz/system/fi les/documents/ publications/suicide-prevention-strategy-2006–2016.pdf
(accessed July 30, 2016).
9 Cliff ord AC, Doran CM, Tsey K. A systematic review of suicide prevention interventions targeting indigenous peoples in Australia, United States, Canada and New Zealand. BMC Public Health 2014; 14: 201. 10 Wexler LM, Gone JP. Culturally responsive suicide prevention in
indigenous communities: unexamined assumptions and new possibilities. Am J Public Health 2012; 102: 800–06.
11 Chachamovich E, Kirmayer LJ, Haggarty JM, Cargo M, Mccormick R, Turecki G. Suicide among Inuit: results from a large, epidemiologically representative follow-back study in Nunavut. Can J Psychiatry 2015; 60: 268–75.
12 Kirmayer LJ, Brass G. Addressing global health disparities among Indigenous peoples. Lancet 2016; 388: 105–06.
Ministry
of Health, Nutrition and Indigenous Medicine ,
Government
Comment
www.thelancet.com Vol 388 September 10, 2016 1039
P falciparum, with a peak of 115 malaria-related deaths recorded in Sri Lanka in 1998.4,5
A turnaround began in 1999–2000.4–7 The Sri Lankan
Government’s commitment to tackling malaria was renewed by the advocacy and technical support of the Roll Back Malaria Partnership.5 Across the country,
malaria vector control, surveillance, and treatment interventions were ratcheted up. In subsequent years malaria incidence fell substantially in Sri Lanka— there was a 68% reduction in 2000–01 alone.5 By
2007, with further expansion of these interventions made possible by grants from the Global Fund to Fight AIDS, Tuberculosis and Malaria, there were just 198 indigenous and imported malaria cases in the country, representing a 99% reduction in incidence from the 1999 level.5 In 2008, for the fi rst time,
there were no indigenous malaria-related deaths in Sri Lanka.4–7
Strikingly, these achievements were made despite the challenges posed by the protracted armed confl ict between the government and the Liberation Tigers of Tamil Eelam (LTTE), which began in the early 1980s.4,6,7
By 2000, Sri Lanka’s eight confl ict-aff ected districts accounted for most malaria infections, after a surge in annual parasite incidence as anti-malaria eff orts and primary health services buckled from decades of confl ict in these districts.4,5,7 Integrated vector control
and treatment interventions were scaled up in the confl ict-aff ected districts by the AMC Directorate and the regional malaria teams, often in partnership with non-governmental organisations and the military.4,5
With their ranks aff ected by malaria, the LTTE assured the AMC Directorate that they would support malaria control measures.4
The at-risk population protected by IRS in confl ict districts increased from 23·5% in 1995 to 52·2% in 2000, higher than the corresponding coverage of 43·7% in non-confl ict districts.4,7 The introduction
of insecticide-treated nets, and then long-lasting insecticidal nets, also reduced transmission.4 By 2005,
long-lasting insecticidal nets were used by 38·1% of the at-risk population in districts aff ected by confl ict, distributed by the AMC, Sarvodaya (a Sri Lankan
non-governmental organisation), UNICEF, and WHO.4
Access to diagnosis and treatment services, often provided by mobile malaria clinics, was stepped up
through the combined eff orts of health staff , the Sri Lanka Red Cross, the International Committee of the Red Cross, and Médecins Sans Frontières.4,5 By 2005
annual parasite incidence rates in both the confl ict and non-confl ict districts had equalised to a fraction of earlier levels.4,7And in October, 2012—just a few years
after the armed confl ict had ended in May, 2009— Sri Lanka had recorded its last case of indigenous malaria.4–7
Inevitably, diffi cult challenges still remain. These range from preventing the reintroduction of malaria from imported cases to the pressing need to tackle the threats posed by Aedes and Culex mosquitoes, including the burden of dengue, chikungunya, and Japanese encephalitis, and the potential threat of Zika virus disease and even yellow fever.5–8 These challenges
will be resolutely addressed because Sri Lanka is committed to combating and eliminating mosquito-borne and other infectious diseases as a key part of the country’s pledge to achieving the Sustainable Development Goals for 2030. The elimination of malaria is a fi rst milestone in reaching the SDG health goals in Sri Lanka.
Rajitha Senaratne, *Poonam Khetrapal Singh Ministry of Health, Nutrition and Indigenous Medicine, Government of Sri Lanka, Colombo , Sri Lanka (RS); and WHO Regional Offi ce for South-East Asia, New Delhi 110002, India (PKS) [email protected]
RS is the Minister of Health, Nutrition and Indigenous Medicine, Government of Sri Lanka; PKS is Regional Director of WHO Regional Offi ce for South-East Asia. We declare no competing interests.
© 2016. World Health Organization. Published by Elsevier Ltd/Inc/BV. All rights reserved.
1 WHO Regional Offi ce for South-East Asia. WHO certifi es Sri Lanka malaria-free. Sept 5, 2016. http://www.searo.who.int/en/ (accessed Sept 5, 2016). 2 Feachem RGA, Phillips A, Hwang J, et al. Shrinking the malaria map:
progress and prospects. Lancet 2010; 367: 1566–78.
3 WHO. World malaria report 2015. Geneva: World Health Organization, 2015. 4 Abeyasinghe RR, Galappaththy GN, Smith Gueye C, Kahn JG, Feachem RG.
Malaria control and elimination in Sri Lanka: documenting progress and success factors in a confl ict setting. PLoS One 2012; 7: e43162. 5 Ministry of Health, Nutrition and Indigenous Medicine, Government of
Sri Lanka. Malaria elimination in Sri Lanka: national report for WHO certifi cation. Colombo: Government of Sri Lanka, 2016. 6 Premaratne R, Ortega L, Navaratnasingham J, Mendis KN. Malaria
elimination from Sri Lanka: what it would take to reach the goal. WHO South East Asia J Public Health 2014; 3: 85–89.
7 Ministry of Health Sri Lanka, WHO, Global Health Group of University of California, San Francisco. Eliminating malaria: case-study 3 progress towards elimination in Sri Lanka. Geneva: World Health Organization, 2012. 8 Dissanayake C. Maintaining momentum in Sri Lanka to ensure that malaria
