From 80,000 deaths recorded between 1934-1935, which was the most devastating outbreak of malaria the country has experienced, to zero indigenous cases (local patients) of malaria recorded by 2012, is a national achievement in deed.
Through valiant efforts by our state health sector, notably the Anti-Malaria Campaign (AMC) of the Ministry of Health, we have steadily reduced the malaria burden from over 400,000 cases in 1991 to zero cases by November 2012 and by October this year we will be completing the fourth consecutive year with no indigenous malaria.
What is more significant is sustaining the malaria eradication campaign to date, despite the 30-year civil war which ravaged the country, making accessibility to the acute malaria vulnerable regions in the country a daunting task.
Imported malaria
“We are now eligible to apply for the World Health Organisation (WHO) Certification for a malaria-free Sri Lanka which is a milestone in the history of health and development of the country. However, we are burdened with imported malaria especially from India, Pakistan and African countries,” asserts Dr. H.D.B. Herath, Director, Anti-Malaria Campaign, Ministry of Health.
He also warns of the risk of resurgence of malaria due to abundant malaria mosquito(anopheles mosquito) found in the country and increased travelling to and from malaria endemic countries, introducing the malaria parasite to the country.
Prevention strategies
Malaria prevention and control has had its evolution since the beginning of the last century. The word malaria is derived from Medieval Italian: mala aria or ‘bad air’ presuming that the disease was caused by ‘bad air’ or mal-air several millennia ago. However as Dr. Hearth explains, when it was realized that what caused malaria was not actually bad air but a parasite propagated through a mosquito, the 
global focus was on the control of the breeding of anopheles mosquito through draining of marshes and other measure. With the discovery of DDT, mosquito breeding was arrested to a large extent. Even locally, by 1963 the case load was reduced to 17 patients. A near malaria elimination was experienced during the Global Malaria Eradication Programme of the 1960s which failed causing the return of malaria in 1967.
However, with the emergence of DDT-resistance, Malathion and several more methods were introduced from time to time to control the density of the mosquitoes.
A complete overhaul of malaria-prevention strategy was adopted in1990s when parasite-controlling was launched. Locally this was initiated by the health workers reaching out to the community level in areas most susceptible to malaria and taking blood samples and initiating treatment even before the onset of symptoms.
"According to WHO, globally an estimated 3.2 billion people are at risk of malaria and in 2015 there were an estimated 214 million cases of malaria and an estimated 438,000 deaths. Major proportion of these deaths occurs in Sub-Saharan Africa. This region was home to 88% malaria cases and 90% of malaria deaths. "
A preventable disease
Malaria has been one of the most devastating diseases of mankind. Transmitted from one person to another through an infected anopheles mosquito bite, it is an entirely a preventable and treatable disease. The anopheles mosquito found locally is generally a ‘rural mosquito’. Illustrates Dr. Herath who adds that in case of India, another variety of this mosquito is found which an ‘urban mosquito’ is as well. “This is one of the reasons why malaria is largely reported from rural areas. The climatic conditions are also conducive to its breeding, the reason why anopheles mosquito is largely consecrated in the North West and North East of the country.” However as he warns, this does not necessarily mean that rest of the regions are not at risk although they are less vulnerable to malaria.
According to WHO, globally an estimated 3.2 billion people are at risk of malaria and in 2015 there were an estimated 214 million cases of malaria and an estimated 438,000 deaths. Major proportion of these deaths occurs in Sub-Saharan Africa. This region was home to 88% malaria cases and 90% of malaria deaths. In areas with high transmission of malaria, children under five are particularly susceptible to infection, illness and death; more than two thirds (70%) of all malaria deaths occur in this age group. Between 2000 and 2015, the under-five malaria death rate fell by 65% globally, translating into an estimated 5.9 million child lives saved between 2001 and 2015.Scaled up interventions carried out between 2000 and 2015 have reduced malaria incidence rates by 37% globally.
According to Anti-Malaria Campaign’s data, the South East Asian region is now facing the threat of multi-drug resistant malaria. In the SAARC region, Pakistan and India carry the largest disease burden. Only Sri Lanka and Maldives have already eliminated malaria. The strides taken by us in achieving a malaria-free nation deserve credit as it is the first time as the Director, Anti-Malaria Campaign explains, a major tropical country is achieving this status.
"Sri Lanka is now free of malaria and the country is eligible to apply for the World Health Organisation (WHO) Certification for a malaria-free nation. Although the country has been free of indigenous cases for the last four years, there is a threat of imported malaria and the mosquito vector is abundantly prevalent here coupled with a loss of natural immunity of the population to the disease"
High risk groups
Imported malaria especially from India, Pakistan and African countries stands a threat before us making malaria no longer a ‘poor man’s disease’ as it is conventionally known to be. It is not only the rural farmer who is at the risk of the bite at dawn and dusk anymore but even a high profile businessman frequently travelling to malaria burdened countries is equally as risk. AMC identifies the following high risk groups among imported malaria cases:
1) Sri Lankan businessman/traders who travel frequently to India and other neigbouring countries
2) Sri Lankans engaged in gem business in African countries (especially: Madagascar and Mozambique)
3) Sri Lankan military personnel returning from peace-keeping missions in African region
4) Lankans returning from work or leisure trips abroad, mainly from Africa and East and South Asia
5) Tourists arriving here travelling through other countries in Asia or Africa
6) Migrant workers from neighbouring countries working here in industrial and development projects. Ex: ports/dockyard etc
7) Immigrants from neighbouring countries including illegal and irregular immigrants
8) Refugees including those from Pakistan, Myanmar and Afghanistan.
Preventive treatment
Lankans travelling to malaria-prone countries are strongly advised to take preventive treatment before leaving the shores. Such preventive medicine is available free of charge at AMC Headquarters, Regional Malaria offices. As Dr. Hearth points out, this preventive treatment needs to be started one week before leaving for a malarial area. “However, these drugs are available at the medical centre at the Bandaranaike International Airport for those who have failed to start preventive treatment early.”Among the other encouraged precautionary methods are to sleep under mosquito nets, use of mosquito repellent creams and avoidance of outdoor visits during the nights as much as possible and if such visits are unavoidable, to wear long garments which will cover the body. Upon the return, blood testing for malaria is strongly advised. “Such testing is available in all major state hospitals as well as in private hospitals and if fever or fever and chills are developed at any point of time after an overseas trip, seeking immediate medical advice is very important,” asserts Dr. Herath.
Economic burden
Dr. Kamini Mendis, an international expert on malaria and formerly senior official of the World Health Organization, Geneva warns, a resurgence of malaria today could cost the country as much as an estimated 25 billion Sri Lankan rupees (169 million USD) – accounted for by excess health care costs, poor productivity, and income loss, premature deaths and out-of-pocket expenditure on the part of families affected by malaria. Keeping the country malaria-free would require only a fraction of it, which amounts to a return on investment to the government of about 13 to 1 – a staggering cost saving. Sustaining malaria-free status through adequate funding of the national malaria elimination programme would, thus be one of best investments that the Sri Lankan Government could make, she observes,
“Working with counterparts in the University of California, San Francisco, which hosts a Malaria Elimination Group headed by Sir Richard Feachem, we estimate that the country saved 653 million SLR (4.4 billion USD) during the period 2008 – 2014 through reduced expenditure by the Anti-Malaria Campaign on account of reduced disease incidence and its eventual elimination. This is a good opportunity for Sri Lanka to break donor dependence and invest to keep this a country free of malaria, which would enhance trade, commerce, economic development, tourism, security, and the livelihoods of all Sri Lankans,” says Dr. Mendis who cites the Singapore experience. Singapore eliminated malaria several decades ago, but the country invests heavily on sustaining surveillance for malaria which is necessary to sustain its malaria-free status. “They do so knowing well that its economy would not be what it is today if malaria returned.”
Challenges ahead
The recent widespread claim that Indian and other migrant workers bring malaria back to the country is very true but as Prof. Rajitha Wickremasinghe, Professor of Public Health and former Dean of the Faculty of Medicine, Kelaniya observes, today, in an increasingly connected and interdependent world, we cannot close our doors to international traffic. “But we can and must take adequate and strategic steps to remove the risk of malaria being re-introduced, by having a comprehensive migration health policy, better regulation on migrant labour, providing adequate information to migrant labour and all travellers, including Sri Lankans travelling abroad, who also bring malaria back, on what steps they should to take if they develop fever while in Sri Lanka.
