Technical and operational underpinnings of malaria elimination from Sri Lanka

Abstract

Malaria was eliminated from Sri Lanka in 2012, and the country received WHO-certification in 2016. The objective of this paper is to describe the epidemiology of malaria elimination in Sri Lanka, and the key technical and operational features of the elimination effort, which may have been central to achieving the goal, even prior to schedule, and despite an ongoing war in parts of the country. Analysis of information and data from the Anti Malaria Campaign (AMC) of Sri Lanka during and before the elimination phase, and the experiences of the author(s) who directed and/or implemented the elimination programme or supported it form the basis of this paper. The key epidemiological features of malaria on the path to elimination included a steady reduction of case incidence from 1999 onwards, and the simultaneous elimination of both Plasmodium falciparum and Plasmodium vivax. Against the backdrop of a good health infrastructure the AMC, a specialized programme within the Ministry of Health operated through a decentralized provincial health system to implement accepted strategies for the elimination of malaria. Careful planning combined with expertise on malaria control at the Central level with dedicated staff at all levels at the Centre and on the ground in all districts, for several years, was the foundation of this success. The stringent implementation of anti-relapse treatment for P. vivax through a strong collaboration with the military in whose cadres most of the malaria cases were clustered in the last few years of transmission would have supported the relatively rapid elimination of P. vivax. A robust case and entomological surveillance and investigation system described here enabled a highly focused approach to delivering interventions leading to the interruption of transmission.

Keywords: Anti-relapse treatment; Case surveillance; Entomological surveillance; Malaria elimination; Sri Lanka.

Fig. 1

Reported malaria cases and insecticide usage by AMC, 1990–2015. In inset data for the period 2008 to 2015 at a higher magnification (Data for 1994 was not available)

Fig. 2

The relative proportions of Plasmodium vivax and Plasmodium falciparum in indigenous and imported malaria infections, 1999–2015. Infections were classified as imported from 2008 onwards. From 2013 onwards there were no local cases

Fig. 3

Map of Sri Lanka showing districts, which were served by Regional Malaria Officers. Districts are colour coded on the basis of population per RMO. Districts depicted in white had no RMOs since they were not endemic for malaria. The red dots represent Government health institutions which served as diagnosis and treatment centres for malaria

Fig. 4

Sequence of events that follow when a suspected malaria patient presents at a health institution in either the public private sector. The boxes shaded in colours represent actions, in pink at the health care institutions; in blue at the AMC headquarters and in yellow at the RMO offices. Boxes in white represent outcomes

Fig. 5

Map of Sri Lanka showing entomological surveillance sites. Circles represent entomological surveillance sites. District boundaries are in black lines and major waterways are represented by blue lines