Malaria continues to be a major life-threatening disease caused by five species of Plasmodium malaria parasites transmitted through the bite of an infected female Anopheline mosquito. There are two highly effective intervention opportunities for control and prevention of malaria. First, the treatment of safe, effective, and affordable drugs (case management). Second, using bednets, indoor insecticide spraying, and other measures directed to reduce or eliminate human-to-mosquito contact (vector control).
The World Health Organization’s (WHO) 2022 World Malaria Report reported an estimated 247 million cases of malaria and an estimated number of 619,000 deaths due to malaria worldwide in 2021, of which African countries carry a disproportionately high burden of cases (95%) and deaths (96%).
The WHO’s South-East Asia region has reported an 8.4% increase (2021 data). India contributed to 29% malaria burden in the region in 2021.
The WHO’s Western Pacific region reversed their upward trend from 2020, seeing a 14% drop in malaria cases down to near 2019 levels. Papua New Guinea, however, still carried the largest burden with 87% of cases, followed by 11% of cases in Solomon Islands. The WHO’s Mediterranean region reduced malaria by 38% between 2000 and 2015, before increasing by 44% between 2015 and 2021. In 2021, 18% of the cases in this region were due to P. vivax, mainly in Afghanistan and Pakistan bearing 4.5% and 11% of regional malaria burden, respectively.
On April 24, 2023, the Ministry of Health and Family Welfare, Government of India hosted the Asia Pacific Leaders’ Conclave on Malaria Elimination in partnership with the Asia Pacific Leaders Malaria Alliance to review the progress of malaria elimination and renew the commitment to eliminate malaria from the region by 2030. In the context of malaria, I would like to first share with you two historical facts about malaria.
First, the pre-independence India Nobel Prize malaria connection and then a note about malaria elimination in the United States of America.
About 965 miles from Delhi, in the city of Secunderabad in South India, a British medical doctor, Sir Ronald Ross, born on May 13, 1857, in Almora, India, made the discovery that mosquitoes transmit malaria.
About 7,950 miles from the April 24 Leaders’ Conclave in Delhi, and about 20 years prior to the discovery by Sir Ronald Ross, the malaria situation in the United States was grave. In 1882, nearly three fourth of the country was designated as probable malaria endemic. By 1934-35, the map of malaria in the United Stated had shrunk to transmission restricted to the South and Southeastern part of the country. In 1951, Dr. Frederick L. Hoffman, who served as the statistician for the Prudential Insurance Company made the first suggestion that the disease can be eradicated. Malaria was eliminated from the United States in 1951.
The global map of malaria has gradually shrunk over the past few decades. From 1955-2023, 41 countries and one territory has eliminated malaria using available tools. In the same period, malaria in another 61 countries disappeared without specific intervention or never existed. In the Asia Pacific region, Sri Lanka, Maldives, Singapore, Brunei, and China have eliminated indigenous malaria. In the Asia Pacific region, of the 48 countries, 20 still have endemic malaria, and aggressive and targeted interventions in these countries can end malaria.
Public health professionals, Ministries of Health of endemic countries, and many global institutions (such as the Global Fund, World Health Organization, Bill and Melinda Gates Foundation, US President’s Malaria Initiative, Roll Back Malaria Partnership to End Malaria, Asia Pacific Leaders Malaria Alliance, African Leaders Malaria Alliance, South Africa Development Community Malaria Elimination Eight Initiative, Global Institute for Disease Elimination, End Malaria Council, Medicine for Malaria Ventures, Innovative Vector Control Consortium and the US Centers for Disease Control and Prevention) have engaged in an unprecedented collaborative manner to eliminate malaria.
Bhutan, Nepal, Republic of Korea, Thailand, Timor-Leste, Vanuatu, Democratic People’s Republic of Korea, and Malaysia have been identified as countries with the potential to eliminate malaria by 2025. Some other countries in this region, including India, are expected to eliminate malaria by 2030. There is, however, a concern that few countries in the region could miss the 2030 elimination target. The presence of P. vivax as the major parasite species poses a challenge due to multi-day treatment but the introduction of tafenoquine now holds a great promise for a single dose treatment.
Imagine an Asia Pacific Region where women, children and men live without the fear of malaria.
No one dies of malaria.
No one gets sick due to malaria.
Children do not miss school and their education is uninterrupted.
Women have safer malaria-free pregnancies, and heathy babies are born.
Women and men do not miss work and provide for their families in an uninterrupted manner.
Nations don’t have to spend on malaria control and treatment programs perpetually.
Now is the time for India and other countries in the Asia Pacific to renew their commitment at the political level to eliminate malaria. There would be collateral benefits through impact on other important vector-borne diseases (such as dengue, chikungunya, and filariasis).
The recent success of malaria elimination in Sri Lanka, Maldives, and China provides us the optimism that malaria can be eliminated from other Asia Pacific nations. However, there are concerns to share as well. Challenges such as civil conflicts, political instability, natural disasters, weak health systems, and the inability to absorb external aid are some of the pressing threats to the malaria elimination efforts in Myanmar, Pakistan, Afghanistan, Papua New Guinea, and the Solomon Islands.
The re-introduction of malaria through travel from neighbouring countries because of tourism or trade-related travel presents a risk to the gains made by Sri Lanka and Maldives.
From India, there are now experiences to share from a comprehensive malaria elimination demonstration project in Madhya Pradesh. This project has provided valuable information that can be used for sub-national, national, and regional elimination programs.
This partnership project was conducted in the tribal district of Madhya Pradesh to demonstrate the indigenous transmission of malaria can be eliminated. Mandla was chosen because it presented varying complexities of demographic (forest malaria, hard-to-reach areas, transportation, tribal malaria etc.) and epidemiology (both major species of malaria parasites, multiple mosquito vectors, seasonality of transmission, dependence on practitioners of alternative medicine and faith-based healers, sub-microscopic and sub-RDT infections, and asymptomatic malaria).
The key learnings of the Mandla project are:
- Oversight at management, technical, operational, and financial levels for checks on quality of human resources and supply chain systems
- Independent review by public health experts
- Analysis of data in real-time
- Regular briefing at national and sub-national levels; and
- sharing data through peer-reviewed publications.
I argue that a Malaria-Free India and most nations in Asia Pacific region is feasible by 2030. There is one top-line request for the leaders of the Asia Pacific Nations that if implemented would help convert the desirable into feasible.
The expansion of an advocacy campaign on ‘A Malaria Free Nation Starts with Me’ from Africa to Asia Pacific would provide a much-needed boost. It would be desirable for this campaign to be initiated by the Prime Ministers, led by the Ministers for Health, the Chief/Provincial Ministers, National Secretaries and from the Principal Health Secretaries of the State to the District Collectors and Chief Medical and Health Officers at the district level.
For the malaria elimination goal to be realized in a timely manner, a Malaria Free Asia Pacific Region must be everyone’s goal. The leaders must commit. The Policy makers must deliver on leaders’ commitment, and the Program managers must see the program through the lens of a “Decade of Collaboration” with an all-hands-on-deck strategy.
Now let me take you back to the three observations I have made above.
First, a Malaria-Free Asia Pacific is feasible by 2030, because safe, effective, and affordable diagnostics tests, drugs and tools of vector control are available and made in the region.
Second, bringing the ‘A Malaria Free Nation Starts with Me’ campaign championed by political, government, business, civil society, and religious leaders.
Third, unless the entire region is free of malaria, it would be difficult to sustain malaria elimination from those that have achieved it. This challenge can be overcome by a meaningful cross-border collaboration, by invoking “Nation as a Whole” and “Region as a Whole” approach.
Therefore, now is the time to seize the moment for an all-hands approach to end malaria forever in all Asia Pacific countries through collective leadership and the investment of resources by national governments and by targeted and sustained external support by donor agencies.