املجلة الصحية لرشق املتوسط املجلد العرشون العدد الرابع

Editorial World Day 2014: Invest in the future. Defeat malaria Hoda Atta 1 and John Reeder 2

Every year, World Malaria Day (held therapies, or ACTs, which are the most rates. Pakistan has not managed to on 25 April) provides an opportunity effective treatment for uncomplicated mount a sufficiently robust response, to review regional and national efforts malaria [2] and a scale up of vector con- partly because its decentralised malaria to reduce the malaria burden, and to trol tools, such as long-lasting insecticidal programmes do not have adequate ca- reiterate political commitment for nets and indoor residual spraying [1]. pacities and resources. The country’s the control and elimination of this Changes in climate and ecology [3], response was also complicated by mosquito-borne disease. In the WHO urbanization and improved access to the 2010 floods, in which one-fifth of Eastern Mediterranean Region, almost health care have also contributed to pro- Pakistan’s territory came under water, 300 million people are at risk of malaria, gress and improved outcomes. During affecting over 20 million people. The and transmission occurs in eight coun- this period, the epidemiology of malaria slow progress in Pakistan has a nega- tries. In 2012, there were an estimated has changed considerably. In countries tive impact on other countries’ malaria 13 million malaria cases and 18 000 with Afrotropical malaria (Djibouti, So- efforts: the movement of populations deaths [1]. malia, Sudan, Yemen), malaria transmis- from endemic areas, mostly workers Two countries – Sudan and Paki- sion was substantially reduced, with fewer seeking new opportunities, is leading stan – account for more than 80 % of people living in areas with moderate to to outbreaks in malaria-free countries all estimated cases, while Afghanistan, high transmission [4,5]. However, sur- in the Arabian Peninsula and also in ar- Djibouti, Somalia and Yemen also have veillance systems – across most of the en- eas outside the Eastern Mediterranean high transmission rates. In the Islamic demic countries of the Region – do not Region [1,8]. Republic of Iran and Saudi Arabia, ma- capture all cases so we cannot accurately Gains in the fight against malaria laria transmission is spatially limited, measure progress in all countries [1]. are fragile in all regions of the world. If and in Iraq the last two locally transmit- There have been tangible results in interventions are not sustained – or are ted cases reported were in 2008. In some countries with low transmission abandoned due to conflict, humanitar- Afghanistan, Islamic Republic of Iran rates. Egypt, Oman, Iraq and the Syr- ian disasters, or a lack of political com- and Pakistan, most malaria cases are due ian Arab Republic have eliminated the mitment – resurgences are certain to to vivax, while in all other disease, although a few local cases occur. countries P. falciparum is the dominant following importation in areas of high Cautionary tales are abundant: in parasite species. P. falciparum is respon- receptivity may occur. The Islamic Re- Afghanistan, the 1970s war led to ma- sible for the large majority of severe and public of Iran and Saudi Arabia have jor epidemics, erasing the gains of the deadly forms of malaria. limited malaria transmission to a few country’s eradication programme. This Since 2000, all malaria-endemic districts along the borders with Paki- resurgence contributed to a serious countries in the Region have scaled stan and Yemen respectively. The deterioration of the malaria situa­tion up malaria control and elimination United Arab Emirates and Morocco in neighbouring Pakistan, Iran and Ta- activities and most have reduced their were certified free of malaria in 2007 and jikistan. Or take the case of Iraq. Iraq disease burden, and the frequency and 2010, respectively [6,7]. The situa­tion managed to reduce its vivax cases below intensity of malaria epidemics. This has in Afghanistan is also encouraging; the 4000 per year by the end of the 1980s, been driven by expanded funding for country is projected to reduce its case but in the wake of the Gulf war, the malaria control, and by a strengthening of incidence by more than 75% by 2015, number of cases shot up to 100 000. malaria programmes at the national level. and is on track to cut local falciparum In the 1990s, the termination of the The expansion of efforts has resulted cases to zero [1]. 10-year Blue Nile Health Project in in improved access to WHO-recom- Progress has been somewhat slower Gezira, Sudan, triggered a major malaria mended -based combination in countries with higher transmission resurgence, with case incidence rates

1Regional Adviser, Malaria Control and Elimination, World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt. 2Director, Tropical Diseases Research, World Health Organization, Geneva, Switzerland.

219 EMHJ • Vol. 20 No. 4 • 2014 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale

soaring and exceeding those at the start malaria programmes need to have countries can progress towards elimina- of the project [9]. strong capacity at all levels, together tion, or will have to witness and respond The future of malaria control and with strong district information and to major resurgences and outbreaks. elimination depends greatly on the diagnostic systems. Programmes need With the support of the Malaria Policy larger enabling environment for disease to strengthen diagnostic testing, quali- Advisory Committee, WHO will con- control (including the absence of con- ty-assured treatment and surveillance, tinue to regularly review evidence and flict and humanitarian emergencies), in line with WHO’s T3: Test. Treat. update its policy recommendations to the degree of political commitment, the Track initiative [11]. Improvement of help countries reduce their malaria bur- availability of funding, and the structure cross-border and regional collabora- den, and save more lives. and capacity of national malaria control tion is imperative. Ministries of health We have an important opportunity programmes. Given the political unrest need to invest more in operational to win this battle and eliminate malaria in many parts of the Region, such as the research, and pay close attention to from this Region. But we must push ongoing armed conflict in the Syrian emerging drug and insecticide resist- hard if we want to take this disease over Arab Republic, there is a real threat that ance. Collaborative efforts should be the edge and consign it to history. malaria will resurge and spread to areas expanded to facilitate the engagement where the disease had been brought of sectors outside of health to ensure Acknowledgements under the control. With the lack of epi- a genuine multi-sectoral response We are grateful to Dr Ghasem Zamani demiological and entomological sur- to the complex challenges posed by of WHO-EMRO for his review and veillance in the Syrian Arab Republic malaria. insightful comments which helped and the movement of refugees, malaria This is a critical juncture for the glob- enhance the editorial. We thank the transmission may spread to neighbour- al malaria partnerships and for endemic National Malaria Programmes in Min- ing areas of Turkey and Iraq. countries in the Eastern Mediterranean istries of Health of EMR countries who To move towards elimination and Region. The political and funding allo- provided the malaria data used in the fulfil the regional commitment [10], cation decisions will determine whether article.

References

1. World malaria report 2013. Geneva, World Health Organiza- 8. Snow RW et al. The malaria transition on the Arabian Peninsu- tion, 2013 (http://www.who.int/malaria/publications/world_ la: progress toward a malaria-free region between 1960–2010. malaria_report/en/, accessed 20 March 2014). Advances in Parasitology, 2013, 82:205–251. 2. Abdelgader TM et al. Progress towards implementation of 9. Emerging and resurgent diseases in the Eastern Mediterranean Re- ACT malaria case-management in facilities in gion with special reference to malaria. Technical paper present- the Republic of Sudan: a cluster-sample survey. BMC Public ed at the Forty-fifth Session of the WHO Regional Committee Health, 2012, 12. for the Eastern Mediterranean, 1998 (EM RC 45) (http://ap- 3. McMichael AJ, Woodruff RE, Hales S., Climate change plications.emro.who.int/docs/em_rc45_9_en.pdf, accessed and human health: present and future risks. Lancet, 2006, 20 March 2014). 367(9513):859–869. 10. Malaria elimination in the Eastern Mediterranean Region: vi- 4. Noor AM et al The changing risk of sion, requirements and strategic outline. Technical discussion malaria infection in Africa: 2000–10: a spatial and temporal paper presented at the Fifty-fifth Session of the WHO Regional analysis of transmission intensity. Lancet, 2014. doi: 10.1016/ Committee for the Eastern Mediterranean, 2008 (EM/RC55) S0140-6736(13)62566-0 (Epub ahead of print). (http://applications.emro.who.int/docs/EM_RC55_tech_ disc_2_en.pdf, accessed 20 March 2014). 5. Atta H, Zamani G. The progress of Roll Back Malaria in the Eastern Mediterranean Region over the past decade. Eastern 11. T3: Test. Treat. Track. Scaling up diagnostic testing, treatment and Mediterranean Health Journal, 2008, 14(Suppl.):S82–S88. surveillance. Geneva, World Health Organization, 2012 (http:// www.who.int/malaria/publications/atoz/test_treat_track_ 6. United Arab Emirates certified malaria-free.Weekly Epidemio- brochure.pdf, accessed 20 March 2014). logical Record, 2007, 82(4):30–32. 7. Morocco certified malaria-free. Weekly Epidemiological Record, 2010, 85(24):235–236.

220