As WHO hails Sri Lanka’s eradication of malaria a ‘truly remarkable’ achievement” after no locally-transmitted cases of disease have been found for three-and-a-half years a few days ago, it is timely to celebrate the impressive eradication programme of our island nation. Sri Lanka is the second country in the WHO South-East Asia Region to eliminate malaria after the Maldives.

The Regional Committee has eleven member countries: Bangladesh, Bhutan, Democratic Peoples’, Republic of Korea, India, Indonesia, the Maldives, Myanmar, Nepal, Sri Lanka, Thailand  and Timor-Leste. It meets annually to discuss its programmes and budget which is hosted by a member country.

Sri Lanka’s road to elimination was tough and demanded well-calibrated responsive policies, the WHO said. The five-day WHO event from September 5 to 9 will also help to showcase Sri Lanka’s achievements in the health sector and the progress the country has made in socio-economic development while highlighting its tourism potential,
Sri Lankan officials said.

The dark past
Around AD 300, the former capital city of Sri Lanka, Anuradhapura, was devastated by an epidemic that was most likely malaria. Indigenous medical literature describes a fever that included “chills, rigor, goose pimples and headache” symptomatic of malaria. After a spleen survey carried out 1908 in then Ceylon, by 1921, the first Malariologist was appointed. Yet every three to five years epidemics occurred – a major one occurring from 1934–1935 with an estimated 5.5 million cases.The little island of Ceylon decided then to wage war on this scourge.

The attack was multi-pronged and unorthodox. In 1945, Sri Lanka became the first country in the region to develop a scheme for indoor residual spraying (IRS) using DDT by establishing mobile spray units. IRS was rapidly expanded to all malaria-prone areas. Simultaneously, “vigilance units” conducted parasitological and entomological surveillance focusing on active surveillance. By 1954, the results were visible – malaria was on the decline.IRS was reduced but was quickly redeployed to respond to rising malaria if necessary. In 1958, Sri Lanka joined the Global Malaria Eradication Programme.
By 1953, massive declines in malaria incidence were visible.  Surveillance and control measures were pared back while funding for malaria eradication programmes was relaxed. However as is the case with tropical countries with ideal breeding grounds for the malaria mosquito a resurgence occurred between 1967-1968. Major epidemics have since occurred in throughout the 1980s and early 1990s.

Winning the war
The National Malaria Control Programme is responsible for formulating the National strategy for malaria control in the country. The Anti-Malaria Campaign comes under the purview of the Ministry of Health of the Government of Sri Lanka. The Anti-Malaria Campaign carries out its functions through a decentralized mechanism and has twenty one regional offices in the districts.  What is impressive is the fact that even during the 30-year civil conflict, the war on malaria continued by using the following strategies:
Web-based surveillance: All fever cases were tested for malaria and each case notified with the Anti -‘Malaria Campaign at the ministry of health. People with a travel history to countries with malaria transmission were closely tracked for symptoms,   as were people in the armed forces on peacekeeping missions, immigrants, emigrants, tourists and pilgrims.

Rationing medicines: Anti-malarial medicines were only available with the AMC, which compelled the private health sector to notify all cases. With malaria cases sharply falling, it soon became unprofitable for the private sector to stock anti-malarial medicines.
24×7 hotline: AMC ran a 24-hour hotline to notify, track and treat the patient in isolation to stop further spread of infection.

Parasite-control strategy: In the early1990s, the AMC changed from vector-control (mosquito control) to parasite control strategy to contain infection.

Health access: A strong public health system, sanitation and roads lowered mosquito breeding and took treatment to people in the remotest of places. Early diagnosis and prompt treatment by trained health workers with focus on high-risk areas lowered disease and deaths.

Stakeholder partnerships: Intensive disease surveillance, integrated vector management, rigourous community engagement and research increased social, technical and financial support for eradication.

The most important factor in the programme’ success was its ability to be flexible and adapt to changing conditions. To protect hard-to-reach, displaced populations, public health workers deployed mobile clinics equipped with malaria diagnostics and antimalarial drugs, whenever it was safe to do so. Likewise, when it was impossible to routinely spray insecticides in homes in conflict zones, the malaria program distributed long-lasting insecticide-treated nets, engaging non-governmental partner organizations familiar with the areas to help with distribution.

The programme was able to sustain key prevention and surveillance activities in conflict areas through support from partner organizations and support from the public.

Hurdles in Malaria Control
Despite Sri Lanka adopting the highly- successful strategy of rigorously and consistently providing interventions to prevent malaria among high-risk populations; proper and prompt diagnosis and treatment of all confirmed malaria cases; and maintenance of an effective surveillance system to quickly detect and respond to spikes in cases, challenges still remain.

Today, even with the country’s rapid progress, Sri Lanka    continues to face hurdles in sustaining the success of its eradication program. Plasmodium vivaxmalaria infections — the more difficult to diagnose and treat form of malaria was most common in Sri Lanka. Another challenge is the shift in the population group at highest risk for malaria. In most of the world, children and pregnant women are most at risk; however following the success of Sri Lanka’s control programme in protecting and treating these populations, researchers found that the group most at risk today in Sri Lanka is adult men, particularly those exposed to malaria-carrying mosquitoes through their work, such as gem mining, military service and farming. Sri Lanka will no doubt develop new strategies to target these groups and maintain the success of their eradication programme.

“Sri Lanka is showing the world how to eliminate malaria,” said Sir Richard Feachem, KBE, FREng, DSc(Med), PhD, director of the Global Health Group said some years ago. As the dedicated health sector personnel work in tandem to prevent parasites re-entering the country, the anti-malaria campaign is working with local and international partners to maintain surveillance and screening.