Supporting countries to achieve their malaria elimination goals: the WHO E-2020 initiative.

BACKGROUND: Malaria causes more than 200 million cases of illness and 400,000 deaths each year across 90 countries. The World Health Organization (WHO) set a goal for 35 countries to eliminate malaria by 2030, with an intermediate milestone of 10 countries by 2020. In 2017, the WHO established the Elimination-2020 (E-2020) initiative to help countries achieve their malaria elimination goals and included 21 countries with the potential to eliminate malaria by 2020. METHODS: Across its three levels of activity (country, region and global), the WHO developed normative and implementation guidance on strategies and activities to eliminate malaria; provided technical support and subnational operational assistance; convened national malaria programme managers at three global meetings to share innovations and best practices; advised countries on strengthening their strategy to prevent re-establishment and preparing for WHO malaria certification; and contributed to maintaining momentum towards elimination through periodic evaluations, monitoring and oversight of progress in the E-2020 countries. Changes in the number of indigenous cases in E-2020 countries between 2016 and 2020 are reported, along with the number of countries that eliminated malaria and received WHO certification. RESULTS: The median number of indigenous cases in the E-2020 countries declined from 165.5 (interquartile range [IQR] 14.25-563.75) in 2016 to 78 (IQR 0-356) in 2020; 12 (57%) countries reported reductions in indigenous cases over that period, of which 7 (33%) interrupted malaria transmission and maintained a malaria-free status through 2020 and 4 (19%) were certified malaria-free by the WHO. Two countries experienced outbreaks of malaria in 2020 and 2021 attributed, in part, to the COVID-19 pandemic. CONCLUSIONS: Although the E-2020 countries contributed to the achievement of the 2020 global elimination milestone, the initiative highlights the difficulties countries face to interrupt malaria transmission, even when numbers of cases are very low. The 2025 global elimination milestone is now approaching, and the lessons learned, experience gained, and updated guidance developed during the E-2020 initiative will help serve the countries seeking to eliminate malaria by 2025.

Country-Owned, Country-Driven: Perspectives from the World Health Organization on Malaria Elimination.

Malaria has infected and killed humans since long before history began recording evidence of the parasite's pernicious influence. The extraordinary discoveries of the Plasmodium parasite by Charles Louis Alphonse Laveran in 1880, and the role of the Anopheles mosquito in transmission of the parasite to humans by Sir Ronald Ross in 1897, led to an understanding of the parasite life cycle and ultimately to the development of interventions that would interrupt disease transmission. Almost as soon as the insecticidal properties of dichlorodiphenyltrichloroethane (DDT) were discovered in 1939, the public health profession began battling to achieve a world free of malaria. That vision persists as the aim of all malariologists and, increasingly, the goal of all nations that remain endemic for malaria. This chapter recounts the history of malaria eradication and elimination efforts throughout the world and focuses on the current status of country-led and country-driven malaria elimination programs, along with the technical strategies recommended by the World Health Organization (WHO) for achievement of malaria elimination.

A Historical Review of WHO Certification of Malaria Elimination.

A malaria-free world remains the vision of the global community. Malaria elimination within the territory of a country is a pathway to achieving the ultimate goal of eradication. Certification of malaria elimination in a country is the official recognition of this important achievement. The concepts of eradication and elimination, and criteria for certification of malaria elimination, have guided national programs in their efforts to achieve and maintain elimination. They have evolved from the experiences and setbacks of the global eradication program, and on the contemporaneous understanding of the concepts of achieving and maintaining elimination. WHO's certification has been successful, with the majority of certified countries remaining malaria free, but to operationalize the criterion for preventing re-establishment of transmission remains challenging.

A comparison of the larvivorous habits of exotic Poecilia reticulata and native Aplocheilus parvus.

BACKGROUND: The exotic fish Poecilia reticulata is promoted in the tropics as a biological control agent for aquatic pathogenic carriers, such as mosquitoes. Such control measures are often adopted blindly, ignoring the potential of native species and the adverse effects of introduced species. The present study was conducted to assess the diet composition of two species of fish, the native Aplocheilus parvus and exotic P. reticulata, and to assess the availability of food items in their natural environment in four types of aquatic systems. Diet composition was estimated using 24 h gut contents analysis, in a clay quarry pit and a perennial reservoir for A. parvus, and in a man-made canal and a second-order natural stream for P. reticulata. Food items in these environments were quantified by analyzing water samples collected every 2 h. RESULTS: The diet of A. parvus in the clay quarry pit and reservoir consisted of adult or larval stages of Insecta, Maxillopoda and Malacostraca. In both habitats, A. parvus selectively fed on insect parts and insect larvae. The diet of P. reticulata consisted of filamentous algae, diatoms and detritus. The diet of A. parvus showed active selection of insectivore food items against their low availability. In contrast, the diet of P. reticulata showed consumption of food items in accordance with their availability in the environment. The highest mean number of food items in the gut for A. parvus was recorded around mid-day in the clay quarry pit, but no peak feeding time was identified in the perennial reservoir. For P. reticulata, peak feeding was recorded around mid-day in both the habitats. CONCLUSION: Irrespective of the type of environment and rate of occurrence, A. parvus preferred insect and insect larvae, whereas P. reticulata consumed the most readily available food items. The active selection of insects by A. parvus suggests they may have value as a biological control agent.

Use of a public-private partnership in malaria elimination efforts in Sri Lanka; a case study.

BACKGROUND: In special circumstances, establishing public private partnerships for malaria elimination may achieve targets faster than the state sector acting by itself. Following the end of the separatist war in Sri Lanka in 2009, the Anti Malaria Campaign (AMC) of Sri Lanka intensified malaria surveillance jointly with a private sector partner, Tropical and Environmental Diseases and Health Associates Private Limited (TEDHA) with a view to achieving malaria elimination targets by 2014. METHODS: This is a case study on how public private partnerships can be effectively utilized to achieve malaria elimination goals. TEDHA established 50 Malaria Diagnostic Laboratories and 17 entomology surveillance sentinel sites in consultation with the AMC in areas difficult to access by government officials (five districts in two provinces affected by war). RESULTS: TEDHA screened 994,448 individuals for malaria, of which 243,867 were screened at mobile malaria clinics as compared to 1,102,054 screened by the AMC. Nine malaria positives were diagnosed by TEDHA, while the AMC diagnosed 103 malaria cases in the same districts in parallel. Over 13,000 entomological activity days were completed. Relevant information was shared with AMC and the data recorded in the health information system. CONCLUSIONS: A successful public-private partnership model for malaria elimination was initiated at a time when the health system was in disarray in war ravaged areas of Sri Lanka. This ensured a high annual blood examination rate and screening of vulnerable people in receptive areas. These were important for certification of malaria-free status which Sri Lanka eventually received in 2016.

Treatment Failure of Dihydroartemisinin/Piperaquine for Plasmodium falciparum Malaria, Vietnam.

We conducted a study in Binh Phuoc, Vietnam, in 2015 on the therapeutic efficacy of dihydroartemisinin/piperaquine for Plasmodium falciparum malaria. A high number of treatment failures (14/40) was found, and piperaquine resistance in Vietnam was confirmed. A change in the malaria treatment policy for Vietnam is in process.

Species composition and population dynamics of malaria vectors in three previously ignored aquatic systems in Sri Lanka.

BACKGROUND: In 2015 alone there were an estimated 214 million new cases of malaria across the globe and 438,000 deaths were reported. Although indigenous malaria has not been reported in Sri Lanka since 2012, to date 247 imported cases of malaria have been identified. Knowledge of the locations, behaviour and vectorial capacity of potential malarial vectors is therefore needed to prevent future outbreaks. Attention is now being focused on some previously ignored habitats. METHODS: Active and abandoned granite and clay quarry pits, located in wet and intermediate zones, and agro wells located in the dry zone of Sri Lanka were mapped and sampled for 1 year, as potential mosquito breeding sites. Species composition and spatio-temporal variation in both malarial and other mosquito larvae were recorded. RESULTS: A total of 18 species of mosquito larvae were identified. Other than Anopheles culicifacies, the primary malaria vector, five species of potential malaria vectors (Anopheles vagus, Anopheles varuna, Anopheles nigerrimus, Anopheles peditaeniatus and Anopheles barbirostris) were found in all three aquatic systems. Additionally, Anopheles annularis was found in granite quarries and Anopheles subpictus and Anopheles pallidus in both types of quarry, but only during the initial sampling. Apart from potential malaria vectors, mosquito larvae such as Anopheles jamesii, Culex tritaeniorhynchus, Culex infula and Culex malayi were found in all three habitats at least once during the sampling period. Apart from potential malaria vectors and other mosquito larvae common to all three aquatic systems, Culex gelidus, Culex mimulus and Culex pseudo vishnui were detected in agro wells. Culex gelidus was also detected in granite quarry pits. Culex mimulus, Culex lutzia and Culex fuscocephala were detected in clay quarry pits. Accordingly, a total of 14, 13 and 15 mosquito species were identified in agro wells, granite and clay quarry pits, respectively. CONCLUSIONS: Although zero occurrence of indigenous malaria has been achieved in Sri Lanka, the current study emphasizes the potential for future epidemics. The presence of native flora and fauna in abandoned granite and clay quarry pits and the need to extract drinking water from agro wells demand bio-sensitive control methods in these three aquatic systems.

Mobility dynamics of migrant workers and their socio-behavioral parameters related to malaria in Tier II, Artemisinin Resistance Containment Zone, Myanmar.

BACKGROUND: Areas with dynamic population movements are likely to be associated with higher levels of drug-resistant malaria. Myanmar Artemisinin Resistance Containment (MARC) Project has been launching since 2012. One of its components includes enhancing strategic approaches for mobile/migrant populations. We aimed to ascertain the estimated population of mobile migrant workers and their families in terms of stability in work setting in townships classified as tier II (areas with significant inflows of people from areas with credible evidence of artemisinin resistance) for Artemisinin resistance; to identify knowledge, attitudes and practices related to prevention and control of malaria and to recommend cost-effective strategies in planning for prevention and control of malaria. METHODS: A prospective cross-sectional study conducted between June to December 2013 that covered 1,899 migrant groups from 16 tier II townships of Bago Region, and Kayin and Kayah States. Trained data collectors used a pre-tested and subsequently modified questionnaire and interviewed 2,381 respondents. Data of migrant groups were analyzed and compared by category depending upon the stability of their work setting. RESULTS: The estimated population of the 1,899 migrant groups categorized into three on the nature of their work setting was 56,030. Bago region was the commonest reported source of origin of migrant groups as well as their transit. Malaria volunteers were mostly within the reach of category 1 migrant groups (43/66, 65.2 %). Less stable migrant groups in category 3 had limited access to malaria information (14.7 %) and malaria care providers (22.1 %), low level of awareness and use of long-lasting insecticide-treated nets (46.6 and 38.8 %). Also, they had poor knowledge on malaria prevention on confirming suspected malaria and on using artemisinin combined therapy (ACT). Within two weeks prior to the survey, only 16.5 % of respondents in all categories combined reported acute undifferentiated fever. DISCUSSION AND CONCLUSIONS: Mobility dynamics of migrant groups was complex and increased their vulnerability to malaria. This phenomenon was accentuated in less stable areas. Even though migrant workers were familiar with rapid diagnostic tests for malaria, ACT still needed wide recognition to improve practices supportive of MARC including the use of appropriate personal protection. High mobility calls for re-designation of tier II townships to optimize ACT resistance containment.

Comparison of microscopy, nested-PCR, and Real-Time-PCR assays using high-throughput screening of pooled samples for diagnosis of malaria in asymptomatic carriers from areas of endemicity in Myanmar.

Asymptomatic infection is an important obstacle for controlling disease in countries where malaria is endemic. Because asymptomatic carriers do not seek treatment for their infections, they can have high levels of gametocytes and constitute a reservoir available for new infection. We employed a sample pooling/PCR-based molecular detection strategy for screening malaria infection in residents from areas of Myanmar where malaria is endemic. Blood samples (n = 1,552) were collected from residents in three areas of malaria endemicity (Kayin State, Bago, and Tanintharyi regions) of Myanmar. Two nested PCR and real-time PCR assays showed that asymptomatic infection was detected in about 1.0% to 9.4% of residents from the surveyed areas. The sensitivities of the two nested PCR and real-time PCR techniques were higher than that of microscopy examination (sensitivity, 100% versus 26.4%; kappa values, 0.2 to 0.5). Among the three regions, parasite-positive samples were highly detected in subjects from the Bago and Tanintharyi regions. Active surveillance of residents from regions of intense malaria transmission would reduce the risk of morbidity and mitigate transmission to the population in these areas of endemicity. Our data demonstrate that PCR-based molecular techniques are more efficient than microscopy for nationwide surveillance of malaria in countries where malaria is endemic.

On the road to eliminate malaria in Sri Lanka: lessons from history, challenges, gaps in knowledge and research needs.

Malaria is one of the most important tropical diseases that has caused devastation throughout the history of mankind. Malaria eradication programmes in the past have had many positive effects but failed to wipe out malaria from most tropical countries, including Sri Lanka. Encouraged by the impressive levels of reduction in malaria case numbers during the past decade, Sri Lanka has launched a programme to eliminate malaria by year 2014. This article reviews the historical milestones associated with the malaria eradication programme that failed subsequently and the events that led to the launch of the ongoing malaria elimination plans at national-level and its strategies that are operational across the entire country. The existing gaps in knowledge are also discussed together with the priority areas for research to fill in these gaps that are posing as challenges to the envisaged goal of wiping out malaria from this island nation.

Containing artemisinin resistance of Plasmodium falciparum in Myanmar: achievements, challenges and the way forward.

Artemisinin resistance is a major threat to global malaria control and elimination efforts. Myanmar detected the first indication of the resistance in 2009 in the eastern part of the country, bordering Thailand. Since 2010, WHO has played a vital role in ensuring that a comprehensive programme on the containment of the resistance is in place. This paper documents achievement made in terms of output, outcomes and early impact on malaria from July 2011 to December 2013. It also identifies enabling factors to success and, most importantly, challenges awaiting the national programme and its partners.

Active case detection for malaria elimination: a survey among Asia Pacific countries.

BACKGROUND: Moving from malaria control to elimination requires national malaria control programmes to implement strategies to detect both symptomatic and asymptomatic cases in the community. In order to do this, malaria elimination programmes follow up malaria cases reported by health facilities to carry out case investigations that will determine the origin of the infection, whether it has been imported or is due to local malaria transmission. If necessary, the malaria programme will also carry out active surveillance to find additional malaria cases in the locality to prevent further transmission. To understand current practices and share information on malaria elimination strategies, a survey specifically addressing country policies on case investigation and reactive case detection was carried out among fourteen countries of the Asia Pacific Malaria Elimination Network (APMEN). METHODS: A questionnaire was distributed to the malaria control programme managers amongst 14 countries in the Asia Pacific who have national or sub-national malaria elimination goals. RESULTS: Results indicate that there are a wide variety of case investigation and active case detection activities employed by the 13 countries that responded to the survey. All respondents report conducting case investigation as part of surveillance activities. More than half of these countries conduct investigations for each case. Over half aim to accomplish the investigation within one to two days of a case report. Programmes collect a broad array of demographic data during investigation procedures and definitions for imported cases are varied across respondents. Some countries report intra-national (from a different province or district) importation while others report only international importation (from a different country). Reactive case detection in respondent countries is defined as screening households within a pre-determined radius in order to identify other locally acquired infections, whether symptomatic or asymptomatic. Respondents report that reactive case detection can be triggered in different ways, in some cases with only a single case report and in others if a defined threshold of multiple cases occurs. The spatial range of screening conducted varies from a certain number of households to an entire administrative unit (e g, village). Some countries target symptomatic people whereas others target all people in order to detect asymptomatic infections. The majority of respondent programmes collect a range of information from those screened for malaria, similar to the range of information collected during case investigation. CONCLUSION: Case investigation and reactive case detection are implemented in the malaria elimination programmes in the Asia Pacific, however practices vary widely from country to country. There is little evidence available to support countries in deciding which methods to maintain, change or adopt for improved effectiveness and efficiency. The development and use of common evaluation metrics for these activities will allow malaria programmes to assess performance and results of resource-intensive surveillance measures and may benefit other countries that are considering implementing these activities.

Primaquine for preventing relapse in people with Plasmodium vivax malaria treated with chloroquine.

BACKGROUND: Plasmodium vivax infections are an important contributor to the malaria burden worldwide. The World Health Organization recommends a 14-day course of primaquine (0.25 mg/kg/day, giving an adult dose of 15 mg/day) to eradicate the liver stage of the parasite and prevent relapse of the disease. Many people find a 14-day primaquine regimen difficult to complete, and there is a potential risk of haemolytic anaemia in people with glucose-6-phosphate-dehydrogenase enzyme (G6PD) deficiency. This review evaluates primaquine in P. vivax, particularly alternatives to the standard 14-day course. OBJECTIVES: To compare alternative primaquine regimens to the recommended 14-day regimen for preventing relapses (radical cure) in people with P. vivax malaria treated for blood stage infection with chloroquine. We also summarize trials comparing primaquine to no primaquine that led to the recommendation for the 14-day regimen. SEARCH METHODS: We searched the Cochrane Infectious Diseases Group's Specialized Register, CENTRAL (The Cochrane Library), MEDLINE, EMBASE and LILACS up to 8 October 2013. We checked conference proceedings, trial registries and reference lists and contacted researchers and pharmaceutical companies for eligible studies. SELECTION CRITERIA: Randomized controlled trials (RCTs) and quasi-RCTs comparing various primaquine dosing regimens with the standard primaquine regimen (15 mg/day for 14 days), or with no primaquine, in people with vivax malaria treated for blood stage infection with chloroquine. DATA COLLECTION AND ANALYSIS: We independently assessed trial eligibility, trial quality, and extracted data. We calculated risk ratios (RR) with 95% confidence intervals (CI) for dichotomous data, and used the random-effects model in meta-analyses if there was significant heterogeneity. We assessed the overall quality of the evidence using the GRADE approach. MAIN RESULTS: We included 15 trials (two cluster-RCTs) of 4377 adult and child participants. Most trials excluded people with G6PD deficiency. Trials compared various regimens of primaquine with the standard primaquine regimen, or with placebo or no treatment. All trials treated blood stage infection with chloroquine. Alternative primaquine regimens compared to 14-day primaquineRelapse rates were higher over six months with the five-day primaquine regimen than the standard 14-day regimen (RR 10.05, 95% CI 2.82 to 35.86; two trials, 186 participants, moderate quality evidence). Similarly, relapse over six months was higher with three days of primaquine than the standard 14-day regimen (RR 3.18, 95% CI 2.1 to 4.81; two trials, 262 participants, moderate quality evidence; six months follow-up); and with primaquine for seven days followed up over two months, compared to 14-day primaquine (RR 2.24, 95% CI 1.24 to 4.03; one trial, 126 participants, low quality evidence).Relapse with once-weekly supervised primaquine for eight weeks was little different over nine months follow-up compared to 14-day self-administered primaquine in one small study (RR 2.97, 95% CI 0.34 to 25.87; one trial, 129 participants, very low quality evidence). Primaquine regimens compared to no primaquineThe number of people that relapsed was similar between people given five days of primaquine or given placebo or no primaquine (four trials, 2213 participants, high quality evidence; follow-up six to 15 months); but lower with 14 days of primaquine (RR 0.6; 95% CI 0.48 to 0.75; ten trials, 1740 participants, high quality evidence; follow-up seven weeks to 15 months).No serious adverse events were reported. Treatment-limiting adverse events were rare and non-serious adverse events were mild and transient. Trial authors reported that people tolerated the drugs.We did not find trials comparing higher dose primaquine regimens (0.5 mg/kg/day or more) for five days or more with the 14-day regimen. AUTHORS' CONCLUSIONS: The analysis confirms the current World Health Organization recommendation for 14-day primaquine (15 mg/day) to prevent relapse of vivax malaria. Shorter primaquine regimens at the same daily dose are associated with higher relapse rates. The comparative effects with weekly primaquine are promising, but require further trials to establish equivalence or non-inferiority compared to the 14-day regimen in high malaria transmission settings.

Irregular Migration as a Potential Source of Malaria Reintroduction in Sri Lanka and Use of Malaria Rapid Diagnostic Tests at Point-of-Entry Screening.

Background. We describe an irregular migrant who returned to Sri Lanka after a failed people smuggling operation from West Africa. Results. On-arrival screening by Anti-Malaria Campaign (AMC) officers using a rapid diagnostic test (RDT) (CareStart Malaria HRP2/PLDH) indicated a negative result. On day 3 after arrival, he presented with fever and chills but was managed as dengue (which is hyperendemic in Sri Lanka). Only on day 7, diagnosis of Plasmodium falciparum malaria was made by microcopy and CareStart RDT. The initially negative RDT was ascribed to a low parasite density. Irregular migration may be an unrecognized source of malaria reintroduction. Despite some limitations in detection, RDTs form an important point-of-entry assessment. As a consequence of this case, the AMC is now focused on repeat testing and close monitoring of all irregular migrants from malaria-endemic zones. Conclusion. The present case study highlights the effective collaboration and coordination between inter-governmental agencies such as IOM and the Ministry of Health towards the goals of malaria elimination in Sri Lanka.

Knowledge, attitudes and practices relevant to malaria elimination amongst resettled populations in a post-conflict district of northern Sri Lanka.

BACKGROUND: Malaria-related knowledge, preventative methods and treatment-seeking behaviours were investigated in a post-conflict district of Sri Lanka in order to guide the development of components of malaria interventions and to support future programme evaluation. METHODS: A structured questionnaire was used to collect data from a random sample of 300 households in four Divisional Secretariat Divisions (DSD) of the district where internally displaced populations were being resettled after a 30-year civil war. RESULTS: The surveyed community had a good overall level of knowledge of malaria. There was high bednet ownership (94.0%), although only 48.0% of households in the study had long-lasting insecticide-treated nets (LLIN). Most respondents reported rapid treatment-seeking behaviour (71.0%) and easy access to malaria diagnostic facilities (67.0%). The Tamil population living in Manthai West and Madhu DSDs who were displaced to refugee camps had better malaria-related knowledge and practices, probably due to the malaria control activities focused on these camps by the government. CONCLUSIONS: Although knowledge and practices regarding malaria amongst resettled populations in Mannar District were high, continued malaria surveillance, case management, vector control including distribution of LLINs, education and information campaigns are important not only amongst the communities affected by the conflict but the entire district.

The importance of accuracy in diagnosis of positive malaria cases in a country progressing towards malaria elimination.

BACKGROUND: With Sri Lanka aiming towards malaria elimination by 2015, the National Anti Malaria Campaign has stressed on the importance of identification of the species of Plasmodium either by examination of stained blood smears for malaria parasites or by Rapid Diagnostic Tests for malaria antigens before the initiation of treatment. This study aims at confirmation of the accuracy of clinical and/or microscopical malaria diagnosis using serology. MATERIALS AND METHODS: Study population comprised 51 individuals diagnosed with malaria either microscopically or clinically during the first half of 2011. ELISA for detection of the two significant blood antigens (AMA-1 and MSP1-19) was carried out in these individuals, 14-28 days after being diagnosed as being positive for malaria microscopically. RESULTS: ELISA confirmed the microscopic diagnosis in all 47 of the patients including two mixed infections which flagged positive for both parasite antigens. However, four individuals diagnosed clinically as being positive for P. vivax by Health Care Providers were negative for malaria antibodies by ELISA. CONCLUSIONS: With 175 cases of malaria reported in 2011, a formidable challenge exists to diagnose malaria positive blood smears due to the large number of negative blood smears being seen daily. After routine cross checking of positive slides, it is heartening to note that there were no false positives detected through serological assays amongst patients who were diagnosed as malaria positive by microscopy. Presumptive treatment of febrile patients with anti-malarials can lead to waste of resources and adversely impact the condition of the patient if the fever is not due to malaria.

Malaria control and elimination in Sri Lanka: documenting progress and success factors in a conflict setting.

BACKGROUND: Sri Lanka has a long history of malaria control, and over the past decade has had dramatic declines in cases amid a national conflict. A case study of Sri Lanka's malaria programme was conducted to characterize the programme and explain recent progress. METHODS: The case study employed qualitative and quantitative methods. Data were collected from published and grey literature, district-level and national records, and thirty-three key informant interviews. Expenditures in two districts for two years--2004 and 2009--were compiled. FINDINGS: Malaria incidence in Sri Lanka has declined by 99.9% since 1999. During this time, there were increases in the proportion of malaria infections due to Plasmodium vivax, and the proportion of infections occurring in adult males. Indoor residual spraying and distribution of long-lasting insecticide-treated nets have likely contributed to the low transmission. Entomological surveillance was maintained. A strong passive case detection system captures infections and active case detection was introduced. When comparing conflict and non-conflict districts, vector control and surveillance measures were maintained in conflict areas, often with higher coverage reported in conflict districts. One of two districts in the study reported a 48% decline in malaria programme expenditure per person at risk from 2004 to 2009. The other district had stable malaria spending. CONCLUSIONS/SIGNIFICANCE: Malaria is now at low levels in Sri Lanka--124 indigenous cases were found in 2011. The majority of infections occur in adult males and are due to P. vivax. Evidence-driven policy and an ability to adapt to new circumstances contributed to this decline. Malaria interventions were maintained in the conflict districts despite an ongoing war. Sri Lanka has set a goal of eliminating malaria by the end of 2014. Early identification and treatment of infections, especially imported ones, together with effective surveillance and response, will be critical to achieving this goal.

Malaria control in Bhutan: case study of a country embarking on elimination.

BACKGROUND: Bhutan has achieved a major reduction in malaria incidence amid multiple challenges. This case study seeks to characterize the Bhutan malaria control programme over the last 10 years. METHODS: A review of the malaria epidemiology, control strategies, and elimination strategies employed in Bhutan was carried out through a literature review of peer-reviewed and grey national and international literature with the addition of reviewing the surveillance and vector control records of the Bhutan Vector-Borne Disease Control Programme (VDCP). Data triangulation was used to identify trends in epidemiology and key strategies and interventions through analysis of the VDCP surveillance and programme records and the literature review. Enabling and challenging factors were identified through analysis of socio-economic and health indicators, corroborated through a review of national and international reports and peer-review articles. FINDINGS: Confirmed malaria cases in Bhutan declined by 98.7% from 1994 to 2010. The majority of indigenous cases were due to Plasmodium vivax (59.9%) and adult males are most at-risk of malaria. Imported cases, or those in foreign nationals, varied over the years, reaching 21.8% of all confirmed cases in 2006. Strategies implemented by the VDCP are likely to be related to the decline in cases over the last 10 years. Access to malaria diagnosis in treatment was expanded throughout the country and evidence-based case management, including the introduction of artemisinin-based combination therapy (ACT) for P. falciparum, increasing coverage of high risk areas with Indoor Residual Spraying, insecticide-treated bed nets, and long-lasting insecticidal nets are likely to have contributed to the decline alongside enabling factors such as economic development and increasing access to health services. CONCLUSION: Bhutan has made significant strides towards elimination and has adopted a goal of national elimination. A major challenge in the future will be prevention and management of imported malaria infections from neighbouring Indian states. Bhutan plans to implement screening at border points to prevent importation of malaria and to targeted prevention and surveillance efforts towards at-risk Bhutanese and migrant workers in construction sites.

Malaria is an important differential diagnosis in visitors returning from Sri Lankan National Safari Parks.

Diagnostic confusion may occur between dengue and malaria when febrile patients with thrombocytopenia return from travel to previous malaria endemic areas. Laboratory tests should include blood smear examination for malaria parasites even though current malaria endemicity in Sri Lanka is low.

Trends in malaria research in 11 Asian Pacific countries: an analysis of peer-reviewed publications over two decades.

BACKGROUND: Quantitative data are lacking on published malaria research. The purpose of the study is to characterize trends in malaria-related literature from 1990 to 2009 in 11 Asian-Pacific countries that are committed to malaria elimination as a national goal. METHODS: A systematic search was conducted for articles published from January 1990 to December 2009 in PubMed/MEDLINE using terms for malaria and 11 target countries (Bhutan, China, North Korea, Indonesia, Malaysia, Philippines, Solomon Islands, South Korea, Sri Lanka, Thailand and Vanuatu). The references were collated and categorized according to subject, Plasmodium species, and whether they contained original or derivative data. RESULTS: 2,700 articles published between 1990 and 2009 related to malaria in the target countries. The annual output of malaria-related papers increased linearly whereas the overall biomedical output from these countries grew exponentially. The percentage of malaria-related publications was nearly 3% (111/3741) of all biomedical publications in 1992 and decreased to less than 1% (118/12171; p < 0.001) in 2009. Thailand had the highest absolute output of malaria-related papers (n = 1211), followed by China (n = 609) and Indonesia (n = 346). Solomon Islands and Vanuatu had lower absolute numbers of publications, but both countries had the highest number of publications per capita (1.3 and 2.5 papers/1,000 population). The largest percentage of papers concerned the epidemiology and control of malaria (53%) followed by studies of drugs and drug resistance (47%). There was an increase in the proportion of articles relating to epidemiology, entomology, biology, molecular biology, pathophysiology and diagnostics from the first to the second decade, whereas the percentage of papers on drugs, clinical aspects of malaria, immunology, and social sciences decreased. CONCLUSIONS: The proportion of malaria-related publications out of the overall biomedical output from the 11 target Asian-Pacific countries is decreasing. The discovery and evaluation of new, safe and effective drugs and vaccines is paramount. In addition the elimination of malaria will require operational research to implement and scale up interventions.