COUNTRY BRIEFING Eliminating malaria in SAUDI ARABIA

Saudi Arabia has experienced a 99 percent decrease in reported malaria cases between 2000 and 2013 and is on track to achieve elimination by 2015.

Overview At a Glance1 Saudi Arabia is in the malaria elimination phase as classified 34 Local cases of malaria by the World Health Organization (WHO) and reported just 1 (100% P. falciparum) 34 local cases in 2013. The malaria burden has been quite low since 2000, with the majority of cases, both local and 0 Deaths from malaria imported, occurring in Asir and Jazan provinces along the (Last deaths reported in 2011) southwestern border with Yemen. Despite a considerable 0.1 % population living in areas of number of imported cases originating in Yemen, India, and active transmission Pakistan in recent years—2,479 were reported in 2013—only (total population: 28.8 million) four malaria-related deaths have been reported in Saudi Arabia since 2000. All local cases in 2013 were Plasmodium 0.001 Annual parasite incidence falciparum infections, although imported cases in recent (cases/1,000 total population/year) years have been increasingly P. vivax.1 The primary vector 0.003 % slide positivity rate for malaria transmission is Anopheles arabiensis, prevalent mostly in the southwestern part of Saudi Arabia at altitudes below 2,000 meters. Secondary vectors include An. sergentii, An. stephensi, An. superpictus, and An. multicolor.2,3 Because Malaria Transmission Limits most of the Arabian Peninsula is a desert climate, malaria Plasmodium falciparum transmission in Saudi Arabia is focal, primarily occurring along rivers and in oases, and the malaria program focuses its efforts in these areas.2 Transmission typically occurs between November and March.4

Water P. falciparum free Unstable transmission (API <0.1) Stable transmission (≥0.1 API)

Transmission was defined as stable Pf( API ≥ 0.1 per 1,000 people p.a.), unstable (Pf API < 0.1 per 1,000 people p.a.) and no risk using medical intelligence data. The limits were further refined using temperature and aridity data Data from International travel and health guidelines (ITHG) were used to zero risk defined areas.

0 500 1,000 1,500 Kilometres

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Eliminating malaria in SAUDI ARABIA

Financing for malaria elimination activities in Saudi Arabia is provided entirely by the government, and coverage of vector Progress Toward Elimination control and surveillance activities within the remaining foci Malaria in Saudi Arabia was first documented shortly after of transmission are high.1 The biggest challenge to malaria the Kingdom was established in 1932, when oil exploration elimination in Saudi Arabia is the steady influx of imported brought an influx of workers into receptive areas along the cases across the Yemeni border. In response to this threat, Gulf Coast. In the 1940s, the estimated malaria attack rate in a regional partnership was formed in 2007 when the goal this area was 160 per 1,000 population and malaria caused an of a malaria-free Arabian Peninsula by 2015 was outlined estimated 12 percent of all deaths among Saudi employees in a strategic plan approved by all peninsular countries.6 of the Arabian American Oil Company, prompting the initia- 7,8 Saudi Arabia has intensified its cross-border collaboration tion of concerted malaria control efforts. From 1948–1953, with Yemen, including coordinated malaria surveillance and the oil company conducted aggressive indoor residual spray- long-lasting insecticide-treated bed net (LLIN) distribution, ing (IRS) with DDT, and later dieldrin, in order to control local 2,8 staff training exercises, and standardization of malaria drug malaria. The success of these efforts prompted the Saudi policy between the countries.5 While Yemen still has areas of government to create a national malaria program, called high transmission and is unlikely to eliminate in 2015, Saudi the Malaria Control Service (MCS), in 1956. The MCS was Arabia is on track to eliminate malaria by the end of this year, designed to target malaria endemic areas throughout the provided that strong political commitment is maintained and country with a particular focus on protecting pilgrims visiting 7,8 cross-border collaboration continues. Mecca and Medina in the west.

Goal:7 Eliminate malaria by the end of 2015.

Reported Malaria Cases*

40 000 35 000 30 000 25 000 20 000 15 000

Number of cases 10 000 69 82 34 5 000 cases cases cases 0 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012

After a serious epidemic caused malaria cases to spike in 1998, Saudi Arabia intensified its vector control and surveillance activities. Since 2000, the country has maintained a low local case burden despite regular importation from neighboring Yemen. *Graph shows local cases only Source: World Health Organization, World Malaria Report 2014

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Eliminating malaria in SAUDI ARABIA

The MCS partnered with WHO in 1963 to launch an Saudi Ministry of Health re-expressed its goal for national ambitious pre-elimination program that involved malaria malaria elimination. In 2003, the National Malaria Strategy risk stratification and intensive IRS using DDT and dieldrin. 2004–2007 was developed to inform pre-elimination activities, When resistance to both insecticides was detected in some with a focus on improved case management with artemis- areas, IRS was replaced with larvicides, including Paris Green inin-based combination therapy (ACT), quality-assured lab and temephos, as well as mass drug administration with confirmation of all cases, geographical information systems chloroquine.2,8 By the 1970s, local malaria transmission had to guide vector and larval control activities, and ongoing been eliminated in the east and north, with only limited cooperation with Yemen. The Saudi government showed its transmission remaining in the southwest along the border support for this strategy by committing substantial funds and with Yemen.5,7 This stronghold of malaria led to a re-eval- publicly promoting the efforts of the malaria program.8 uation of the malaria elimination goals, and ultimately the In 2007, Saudi Arabia signed the Malaria-Free Arabian program switched its focus back to control in 1977 when it Peninsula Initiative, a project aimed at eliminating malaria was decided that local elimination would not be feasible.8 In in the entire peninsula by 2015 and funded by countries of 1979, the rising number of imported cases in the southwest the Gulf Cooperation Council.6,11 At this time, the second led to a collaboration between Saudi Arabia and Yemen, and phase of the country’s elimination strategy (2007–2010) was strengthened control activities began in 1980 in the Jazan implemented, emphasizing prompt detection and treatment and Najran provinces.9 The Saudi national malaria program of every single malaria case in the remaining foci of transmis- began distinguishing between local and imported cases be- sion. From 2007–2009, elimination efforts were intensified ginning in 1990, and it became apparent that most reported and included distribution of LLINs, active case detection and cases were in fact imported from Yemen, highlighting the case investigation, and entomological surveillance.8 Saudi importance of continued cross-border collaboration.7 Arabia’s efforts toward elimination have yielded considerable During the 1990s, support for malaria control in Saudi Arabia success to date. Malaria cases have been on a steady decline waned and portions of the malaria control effort were inte- since 2000, with imported cases outnumbering local by an grated into the larger health system, which led to reduced increasing margin: in 2000, imported cases accounted for quality and coverage of interventions. In addition, chloro- about a quarter of the total reported, while in 2013, 99% of quine resistance began to emerge, with treatment failure reported cases were imported.1,5 In response to these trends, rates reaching 12 percent.8 Several localized outbreaks the current malaria elimination strategy has four primary occurred during this period, peaking in 1998 with more than components: 1) targeted vector control in remaining high- 40,000 cases, the majority reported in Jazan Province.1,8 In risk areas in the southwest; 2) rapid diagnosis and treatment response to these outbreaks, the government refocused using microscopy or rapid diagnostic tests (RDTs) and ACTs efforts to get malaria back under control, with a particular plus primaquine; 3) reactive case detection; and 4) active emphasis on the porous border with Yemen, which accounted case detection at the border with Yemen.7 for more than 15 percent of cases. A cross-border meeting was held in 1996 to coordinate surveillance, train health 12–14 personnel on malaria control, and identify target border Eligibility for External Funding areas.8 In 1999, Saudi Arabia, along with neighboring countries in the Eastern Mediterranean Region of WHO, The Global Fund to Fight AIDS, Tuberculosis and No partnered with Roll Back Malaria to further strengthen Malaria intersectoral and cross-border collaboration.10 U.S. Government’s President’s Malaria Initiative No In 2001, the collaboration with Yemen evolved into biannual cross-border meetings to strengthen control activities, share World Bank International Development Association No information, and promote communication, advocacy and health education among border populations. At this point, the financing and surveillance mechanisms for a robust na- tional malaria control program were already in place and the

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Eliminating malaria in SAUDI ARABIA

Economic Indicators15 and around 150,000 cases are reported within the country annually, although reporting is known to be incomplete 1,16 GNI per capita (US$) $26,260 due to political instability and security disruptions. This instability has led to increased human movement into Saudi Country income classification High income Arabia in recent years. The risk of importation is further exacerbated by the regular influx of oil workers and religious Total health expenditure per capita (US$) $795 pilgrims from malaria endemic countries.4

Total expenditure on health as % of GDP 3 Conclusion Private health expenditure as % total 34 For more than a decade, Saudi Arabia has demonstrated a health expenditure strong political and financial commitment to malaria elimina- tion, despite the ongoing challenge of controlling imported cases across its borders. Saudi Arabia continues to work Challenges to Eliminating in collaboration with the other countries of the Arabian Peninsula on cross-border initiatives and intensification of Malaria control efforts within Yemen. While the goal of a malaria-free Cross-border importation Arabian Peninsula may not be immediately achievable due The risk of imported malaria from Yemen into Saudi Arabia to the high transmission in Yemen, with continued vigilance presents the greatest threat to elimination. Nearly 70 percent at the border and sustained financial commitments, Saudi of Yemen’s population lives in areas of malaria transmission Arabia will be able to achieve national elimination by 2015.

Sources 1 Global Malaria Programme. World Malaria Report 2014. Geneva: World Health Organization; 2014. 2 Manguin S, Carnevale P, Mouchet J, editors. Biodiversity of Malaria in the World. London: John Liebbey Eurotext; 2008. 3 Abdoon AM, Alshahrani AM. Prevalence and distribution of anopheline mosquitoes in malaria endemic areas of Asir region, Saudi Arabia. East Mediterr Health J 2003; 9(3): 240–247. 4 Al-Hamidhi S, Mahdy MAK, Idris MA, Bin Dajem SM, Al-Sheikh AAH, Al-Qahtani A, et al. The prospect of malaria elimination in the Arabian Peninsula : A population genetic approach. Infect Genet Evol 2014; 27: 25–31. 5 Al-Seghayer SM. Malaria Control in Saudi Arabia. Kingdom of Saudi Arabia Ministry of Health, Directorate of Parasitic & Infectious Dis- eases; 2003. 6 Meleigy M. Arabian Peninsula states launch plan to eradicate malaria. BMJ 2007; 334(7585): 117. 7 Coleman M, Al-Zahrani MH, Coleman M, Hemingway J, Omar A, Stanton MC, et al. A Country on the Verge of Malaria Elimination—The Kingdom of Saudi Arabia. PLoS ONE 2014; 9(9): e105980. 8 Snow RW, Amratia P, Zamani G, Mundia CW, Noor AM, Memish ZA, et al. The Malaria Transition on the Arabian Peninsula: Progress toward a Malaria-Free Region between 1960–2010. Adv Parasitol 2013; 82: 205–251. 9 Al-Seghayer SM. Collaboration between Saudi Arabia and the Republic of Yemen on Malaria Control Activities at the Border Areas. Kingdom of Saudi Arabia Ministry of Health, Directorate of Parasitic & Infectious Diseases; 2001. 10 Atta H, Zamani G. The progress of Roll Back Malaria in the Eastern Mediterranean Region over the past decade. East Mediterr Health J 2008; 14: S82–S89. 11 World Health Organization Regional Office for Eastern Mediterranean. Progress report on control and elimination of malaria. Regional Committee for the Eastern Mediterranean: Fifty-eighth Session; 2011. [Available from: http://applications.emro.who.int/docs/RC_ technical_papers_2011_inf_doc_4_13995.pdf?ua=1]. 12 International Development Association. IDA Borrowing Countries. 2014. [Available from: http://www.worldbank.org/ida/borrowing- countries.html]. 13 President’s Malaria Initiative. PMI Focus Countries. 2014. [Available from: http://www.pmi.gov/where-we-work].

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14 The Global Fund to Fight AIDS, Tuberculosis and Malaria. 2014 Eligibility List. 2014. [Available from: www.theglobalfund.org/documents/ core/eligibility/Core_EligibleCountries2014_List_en/]. 15 The World Bank. World Development Indicators Database. 2014. [Available from: http://data.worldbank.org/data-catalog/world- development-indicators]. 16 World Health Organization Regional Office for Eastern Mediterranean. Report on the intercountry workshop on malaria surveillance, monitoring and evaluation. Sharm El Sheikh, Egypt: 2010. [Available from: http://applications.emro.who.int/docs/who_em_mal_359_ e_en_14383.pdf?ua=1].

Transmission Limits Map Sources Gething PW, Patil AP, Smith DL, Guerra CA, Elyazar IRF, Johnston GL, Tatem AJ, Hay SI. A new world malaria map: Plasmodium falciparum endemicity in 2010. Mal J 2011; 10: 378.

About This Briefing This Country Briefing was developed by the UCSF Global Health Group’s Malaria Elimination Initiative, in collaboration with WHO Regional Office for the Eastern Mediterranean. Malaria transmission risk maps were provided by the Malaria Atlas Project. This document was produced by Gretchen Newby; to send comments or for additional information about this work, please email [email protected].

m a l a r i a a t l a s p r o j e c t

The Global Health Group at the University of California, San Francisco The Malaria Atlas Project (MAP) provided the malaria transmission (UCSF) is an ‘action tank’ dedicated to translating new approaches maps. MAP is committed to disseminating information on malaria risk, into large-scale action that improves the lives of millions of people. in partnership with malaria endemic countries, to guide malaria control Launched in 2007, the UCSF Global Health Group’s Malaria Elimination and elimination globally. Find MAP online at: www.map.ox.ac.uk. Initiative works at global, regional and national levels to accelerate progress towards eradication by conducting operational research to improve surveillance and response, strengthening political and financial commitment for malaria elimination, and collaborating with country partners to shrink the malaria map.

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