Shrinking the Malaria Map

UCSF Global Health Group’s Malaria Elimination Initiative (MEI)

Eastern Mediterranean and Europe

Goal

To sustain zero local transmission in Europe, and eliminate malaria from the Arabian Peninsula by 2017. 

Overview

Malaria-eliminating countries in the WHO Eastern Mediterranean (EMRO) and WHO European (EURO) regions have collectively achieved a staggering 99% reduction in malaria cases between 2000 and 2014. As of 2015, the EURO region is completely malaria free.

According to the 2015 World Malaria Report, five countries (Iran, Iraq, Morocco, Saudi Arabia, and Syria) in the WHO EMRO region achieved at least a 75% decrease in malaria incidence between 2000 and 2014. Iraq, Egypt, Oman, and Syria have achieved elimination and are in the prevention of reintroduction phase. United Arab Emirates was certified malaria-free in 2007, and Morocco was certified malaria-free in 2010. Today, there is focal transmission in Iran and Saudi Arabia, with only 376 and 51 locally acquired cases, respectively.

The WHO EURO region has attained their malaria elimination goal, as outlined in the 2005 Tashkent Declaration. Turkmenistan and Armenia have been certified as malaria-free. Four countries (Azerbaijan, Georgia, Kyrgyzstan, and Uzbekistan) have sustained zero local transmission for the past three years or more and are in the prevention of reintroduction phase. Greece, although malaria-free since 1974, experienced an outbreak in 2010, peaking at 40 local cases in 2011. Through intensive efforts, Greece reported zero cases in 2013 and 2014. Turkey and Tajikistan are in the elimination phase and reported zero indigenous cases in 2015.  

[green]
Malaria-free >3 years
[blue]
Malaria-free < 3 years
[magenta]
Eliminating malaria
[pink]
Controlling malaria
4
Eliminating countries in this region
Reported malaria cases in 5 malaria-eliminating countries in Eastern Mediterranean and Europe
Reported malaria cases in 5 malaria-eliminating countries in Eastern Mediterranean and Europe
P falciparum transmission limit (2010) for WHO EMRO region
P falciparum transmission limit (2010) for WHO EMRO region
P vivax transmission limit (2010) for WHO EURO region
P vivax transmission limit (2010) for WHO EURO region

Regional collaborations

Gulf Cooperation Council

Established in 1981, the Gulf Cooperation Council (GCC) is a political and economic alliance among the governments of six Middle Eastern countries. GCC is an excellent example of malaria-free countries (Bahrain, Kuwait, Qatar, and United Arab Emirates) showing their commitment to regional elimination. GCC Malaria Fund and Malaria-Free Arabian Peninsula Initiative provide financial and technical assistance to Oman, Saudi Arabia, and non-GCC neighbor Yemen. GCC works in conjunction with the WHO EMRO office, as well as with Yemen’s National Malaria Control Program, to control malaria at the Saudi–­Yemen border and prevent reestablishment of transmission in malaria-free countries in the region.

Challenges to elimination

Political instability

Political instability, particularly in the Middle East, presents a serious challenge to global malaria elimination. For example, malaria control in Afghanistan from the 1950s to 1979 was implemented through a vertical government program, but little of that original program remained functional during and after the Soviet invasion and civil war in the 1980s. Political upheaval and civil conflict lead to increased population movement, insecurity and inaccessibility; emigration of health staff; and declines in basic health service delivery. Furthermore, mobile populations and refugees are hard to track, which limits the reach and effectiveness of malaria prevention and treatment measures. As a result, epidemics become frequent and disease burden increases. A coordinated effort between public and non-governmental organizations is essential in rebuilding general health systems and malaria control programs post-conflict.

Importation from malaria-endemic neighbors

The greatest threat to the commendable progress made in the WHO EMRO and WHO EURO regions is the importation of malaria cases from endemic neighbors. Imported cases are attributable to porous borders and trade routes such as the trans-Saharan highway that cuts across malarious and non-malarious regions. Unregulated population movement at the Iran–Pakistan, Saudi–Yemen, and Tajikistan–Afghanistan borders increases the risk of importation. Countries in this region must strengthen cross-border collaboration and maintain robust surveillance, case detection, and outbreak response in order to achieve elimination and prevent reintroduction.