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. 2012;7(8):e43162.
doi: 10.1371/journal.pone.0043162. Epub 2012 Aug 29.

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

Rabindra R Abeyasinghe  1 , Gawrie N L Galappaththy, Cara Smith Gueye, James G Kahn, Richard G A Feachem
Affiliations

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

Rabindra R Abeyasinghe et al. PLoS One. 2012.

Abstract

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.

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Conflict of interest statement

Competing Interests: The authors have read the journal's policy and have the following conflicts: RRA is currently supported by the World Health Organization. During the period of case study data collection and write up, RRA was supported by the Anti-Malaria Campaign, Ministry of Health, Sri Lanka. GNLG is supported by the Anti-Malaria Campaign, Ministry of Health, Sri Lanka. GNLG represents Sri Lanka in the Asia Pacific Malaria Elimination Network (APMEN) and RRA chaired the APMEN Advisory Board. RRA is a member of the Malaria Elimination Group. RGAF is the Director of the UCSF Global Health Group, chair of the Malaria Elimination Group and is also the Network Chair of APMEN. CSG is Program Coordinator at the UCSF Global Health Group and provides assistance to the APMEN Joint-Secretariat. The Global Health Group provides support to eliminating countries, such as Sri Lanka, and is funded by the Bill & Melinda Gates Foundation. The Global Health Group also received funding from ExxonMobil during the period of this study. APMEN is funded through a grant from the Australian Agency for International Development (AusAID). JGK is a professor of health policy at UCSF. This case study is a component of a collaboration between the UCSF Global Health Group and the WHO Global Malaria Programme to document country experience with malaria elimination.

Figures

Figure 1
Figure 1. Timeline of reported cases and major events in Sri Lanka, 1911–2011.
Figure 2
Figure 2. Map of Annual Parasite Incidence (API) (confirmed infections/1,000 population at risk) by district, 2000, 2005, and 2010.
API per 1,000/population at risk. The costing analysis was conducted in Anuradhapura and Kurunegala districts. Key informant interviews were conducted with representatives from Ampara, Anuradhapura, and Kurunegala districts. The Malaria Atlas Project (MAP) and the Sri Lanka Ministry of Health provided the base district-level map of Sri Lanka. MAP is committed to disseminating information on malaria risk, in partnership with malaria endemic countries, to guide malaria control and elimination globally.
Figure 3
Figure 3. Organizational diagram of the Sri Lanka Anti-Malaria Campaign.
Figure 4
Figure 4. Total confirmed infections from Active and Passive Case Detection, Sri Lanka, 1995 to 2011.
Figure 5
Figure 5. Annual percentage of confirmed infections for 1999, 2002, 2006 and 2011.
All percentages represent total cases, indigenous and imported cases combined.
Figure 6
Figure 6. Costs per person at risk in 2004 and 2009 by intervention category, in $USD, two districts.
See this image and copyright information in PMC

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