Sri Lanka received WHO malaria-free certification on September 6, 2016, after sustaining zero cases of local malaria transmission for over three years.
Sri Lanka’s successful elimination of malaria is a remarkable public health achievement, particularly given the country’s long history of malaria control, the country’s natural receptivity to malaria transmission, and the context of a 30 year civil conflict. In 2000, more than 210,000 local cases were reported, and the last local case of malaria occurred in October 2012. The country has had no deaths from malaria since 2007, a marked decrease from 1998, when 115 malaria-related deaths were reported. Sri Lanka became the second country in the WHO South-East Asia Region, after the Maldives, to receive malaria-free certification in September 2016 – a historic milestone after nearly eliminating the disease in the 1960s only to suffer a devastating resurgence of the disease over the subsequent decades.
Today, importation is the only source of malaria in the country. According to the Anti-Malaria Campaign (AMC), nearly 40% of imported malaria cases are imported by travelers coming or returning from India. Other source countries include Pakistan and Sierra Leone. Because imported malaria could reintroduce malaria transmission, Sri Lanka has worked to reduce imported cases. In 2015, Sri Lanka experienced 36 imported cases, down from 49 imported cases in 2014 and 95 imported cases in 2013 (62% decrease in two years). As with the much of the Asia Pacific region, Plasmodium vivax has historically been the dominant malaria parasite in Sri Lanka. However, increasing numbers of imported cases in recent years have been P. falciparum infections. Anopheles culicifacies is the primary vector.
Sri Lanka’s tumultuous history with malaria elimination is often cited as an example of resurgence. The most notable epidemic was in the mid-1960s, when local malaria cases were reduced to only 17 due to the efforts of the global eradication program of the 1960s. However, given the success in driving down cases, the Sri Lankan government prematurely thought the job was done, withdrew resources, and curtailed indoor residual spraying (IRS) operations. As a result, malaria cases rapidly increased to 400,000 per year. It took Sri Lanka more than 50 years to return to elimination levels. With sustained political commitment and substantial financial support from Global Fund grants, Sri Lanka was able to scale up vector control, surveillance, prevention, and treatment, ultimately reducing local transmission to zero in 2012.
Given the threat posed by importation, and the country’s high receptivity to malaria in previously endemic areas, Sri Lanka’s AMC and international partners are committed to maintaining elimination and preventing reintroduction through sustained vigilance and increased investment in case detection and rapid response. The AMC’s National Malaria Strategic Plan 2014-2018 emphasizes rigorous surveillance activities, maintenance of diagnostic facilities, and strengthened outbreak preparedness as key measures to maintain elimination and prevent the resurgence of malaria. Sri Lanka has also spearheaded efforts to work more closely with India to share intelligence on malaria case data.
As a country partner in the Asia Pacific Malaria Elimination Network (APMEN), Sri Lanka’s success story serves as a model for its neighbors and the Asia Pacific region as countries work towards a malaria-free Asia Pacific by 2030.
Country briefing
Challenges to elimination
Imported cases
Much of Sri Lanka remains both receptive and vulnerable to malaria transmission, and the number of imported malaria cases has increased in recent years, which highlights the potential impact of importation on the risk of reintroducing the disease. The majority of imported cases originate in India, but recent clusters of imported infections have been detected among Pakistani asylum-seekers and Sri Lankan fishermen returning from Sierra Leone. Robust surveillance, border screening, prompt diagnosis and treatment, and thorough case investigation and follow-up are essential activities in the AMC’s current plan to prevent reintroduction of malaria.
Sustaining political and financial investment
In order to maintain elimination, Sri Lanka must sustain adequate levels of resources and attention for malaria surveillance and response. As the country nears its fourth year of zero local cases and celebrates its recent WHO malaria-free certification, political pressure to reallocate resources to competing public health threats, such as dengue fever, puts malaria prevention efforts at risk. The MEI’s recent collaborations with the AMC on an investment case for malaria revealed a 13:1 return on investment, underscoring the great value for resources dedicated to the prevention of reintroduction of malaria. As Sri Lanka’s history demonstrates, the risk of malaria’s resurgence is real if political and financial support decreases. Increasing domestic financing for malaria, particularly as the country anticipates future transition from external donor funding, will be critical to sustain elimination in Sri Lanka. To this end, the MEI is supporting the AMC to carry out strategic, targeted advocacy to ensure that malaria financing is adequately met and sustained at sub-national and national levels.
