Shrinking the Malaria Map

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

Sri Lanka celebrates malaria-free certification after long history of malaria control

06 September 2016
By Anne Bulchis and Erika Larson

On September 6th, Sri Lanka made history as one of the first South Asian countries to receive the WHO’s malaria-free certification. The WHO’s Director General, Margaret Chan, presented the certificate during the South and East Asia region’s health ministers’ meeting in Colombo. The certification marks Sri Lanka’s success in sustaining zero local malaria cases for three consecutive years.

A history of progress, deadly setbacks, and successful elimination

Sri Lanka’s malaria program began in 1911. Two decades later, Sri Lanka recorded a massive malaria epidemic in 1934-1935 that caused between 1.5-5.5 million cases and 80,000 deaths in a span of nine months. Due to an aggressive malaria control program during WHO's Global Malaria Eradication Program, Sri Lanka drove down malaria to fewer than 20 cases per year in the early 1960s. Prematurely assuming the job was done, the government scaled back malaria interventions. As a result, the country was battling a devastating resurgence of more than half a million malaria cases by 1969.

With support from its partners, the Sri Lanka’s Anti-Malaria Campaign (AMC) once again set its sights on malaria elimination. The country decreased local malaria cases from more than 210,000 in 2000 to zero by the end of 2012. Sri Lanka has not had a single death from malaria since 2007 and has sustained zero local malaria cases since November 2012. Today, all of the country’s malaria cases are imported, mostly by travelers coming or returning from India, Pakistan, and Africa. In 2015 there were 36 imported cases—down from 49 imported cases in 2014.

Success against all odds

Sri Lanka’s malaria elimination success is an unlikely story. Nearly 30 years of civil war between the Liberation Tigers of the Tamil Eelam and the government of Sri Lanka made many areas, especially in the north and eastern regions, inaccessible. Effective malaria interventions were hampered by crumbling health infrastructure. However, two years after launching of the pre-elimination program in 2009, Sri Lanka’s Ministry of Health received a grant of USD $15.5 million from The Global Fund to Fight AIDS, Tuberculosis, and Malaria to improve public health infrastructure in these post-conflict areas. As a result, Sri Lanka was able to scale up vector control measures, such as indoor residual spraying (IRS,) and deploy mobile clinics to improve surveillance, prevention, and treatment of malaria in high-risk populations, including mobile military personnel.

Future vigilance is required

While Sri Lanka has sustained zero local malaria cases since November 2012, the country will need to maintain efforts to prevent reintroduction of the disease. Given that imported cases could spark a resurgence in malaria, maintaining investments in strong surveillance, tracking, and treating of imported cases is critical. After all, Sri Lanka's malaria cases from 1999-2012 mimic the trend observed from 1949-1962. Continued investment in Sri Lanka's anti-malaria efforts is also a "best buy," generating an estimated 13:1 return on investment. A recent report by the MEI estimates that the first year of a six-year malaria resurgence in Sri Lanka today could cost USD $169 million, whereas preventing that resurgence would require a relatively minimal level of financing. But the necessary political and financial commitments to sustain Sri Lanka's elimination efforts are in danger. Like in many elimination settings, malaria has become a forgotten disease among the nation's political leaders, doctors, and communities. While Sri Lanka's success should be celebrated, maintaining that success requires investment in surveillance and timely diagnosis and treatment, thereby preventing future cases.

Sri Lanka emerges as a leader in the region

Sri Lanka is a shining example of malaria elimination in the Asia Pacific. It is the first country to successfully receive the WHO certification after 18 regional leaders endorsed a commitment and a roadmap to achieve a malaria-free Asia Pacific by 2030. As countries in Asia Pacific cross the finish line, the threat of cross-border malaria is a reminder that elimination will require a collaborative regional approach. Sri Lanka’s success should spur action in neighboring countries. As the region rallies behind the 2030 goal, we celebrate Sri Lanka’s role in leading the charge.