The story so far
Malaria is as old as the Egyptian civilization, and the fight against it spans nearly 100 years in Egypt. Egypt recently achieved a monumental feat by receiving WHO certification for eliminating the disease on October 20, 2024. Egypt is the third country in the WHO Eastern Mediterranean region and the 44th overall to be awarded the malaria elimination certification. The WHO certification confirms not only the interruption of local transmission, but also Egypt’s preparedness to prevent the reintroduction of the disease. Meanwhile, India is on its journey toward malaria elimination, aiming for zero indigenous cases by 2027 and full certification by 2030.
What is the process for WHO certification?
The Sustainable Development Goal (SDG) Target 3.3 aims to end malaria and other epidemics by 2030, a global commitment India has aligned with through its policies. India’s aims to eliminate malaria by 2030, emphasising universal access to healthcare and disease prevention.
The WHO certification for malaria elimination is an extensive process designed to ensure that malaria transmission has been interrupted within a country for a sustained period, and that systems are in place to prevent reintroduction. A country begins the certification process after reporting zero indigenous cases for at least three consecutive years, supported by a robust national surveillance system that can detect and respond to any imported cases.
The process starts with a formal request to WHO through the country’s Ministry of Health. Following this, the country prepares a National Elimination Report that outlines detailed evidence of its success in eliminating malaria. The report includes surveillance data, vector control activities, healthcare facility capabilities, and measures for preventing re-establishment. WHO’s Malaria Elimination Certification Panel (MECP) reviews the report and conducts field visits to verify its findings. If the panel is satisfied, it submits a recommendation to the WHO Director-General, who decides whether to grant the country malaria-free certification.
What was Egypt’s journey to malaria-free certification?
By 2001, Egypt had malaria under control, and aimed for elimination through targeted measures. In 2014, a small outbreak in Aswan was successfully managed through early detection, treatment, vector control, and public education. Over the last decade, Egypt expanded access to health services, with 95% of the population living near primary care facilities and offered free malaria treatment. In 2016, Egypt formed a High Committee for Integrated Vector Management to address vector-borne diseases. The country also strengthened cross-border partnerships, especially with Sudan, to prevent the re-establishment of malaria and provided essential services to migrants, including those affected by the 2023 conflict.
What is India’s strategy for malaria elimination?
India’s approach to eliminating malaria is rooted in several coordinated strategies aimed at controlling and ultimately eradicating the disease. A key focus is on strengthening surveillance systems, transforming them into an essential part of malaria control by improving data reporting and response mechanisms. Another crucial aspect is ensuring that every suspected case of malaria is tested, treated, and tracked to prevent further transmission.
Vector control remains central to these efforts, with the widespread use of insecticide-treated bed nets and indoor residual spraying. The government has placed special emphasis on high-transmission areas such as tribal regions, forested zones, and border areas, where malaria remains a challenge. Additionally, India encourages research and innovation to adapt its strategies and prevent the re-establishment of malaria, while also fostering cross-border cooperation to tackle imported cases.
India has made remarkable strides in reducing malaria, with reported cases dropping over the years. As of 2022, India has made significant progress in malaria elimination across its districts. A total of 128 districts are in Category 0 (prevention of re-establishment) with zero indigenous malaria cases; 603 districts are in Category 1 (elimination phase) with an Annual Parasite Incidence (API) of less than 1 per 1,000 population. Under Category 2 (pre-elimination phase), where the API is between 1 and 2, there are 9 districts. Finally, 18 districts remain in Category 3 (intensified control phase), with an API exceeding 2 per 1,000 population. This reflects a substantial reduction in malaria transmission compared to previous years.
What is India’s preparation for the WHO certification?
For larger countries like India, which have varying levels of malaria transmission across regions, subnational verification is crucial. In such cases, parts of the country that have successfully interrupted malaria transmission can undergo subnational verification. This allows countries to assess regional targets and reinforce efforts in high-transmission areas. Subnational verification follows the same rigorous criteria as national certification, with independent national and international experts reviewing reports and conducting field visits. This process helps India drive progress toward its national elimination goals by encouraging healthy competition between States and districts. Districts that achieve zero cases for three consecutive years can apply for subnational verification, which includes field visits, document reviews, and validation by independent national and international experts. After districts or states pass the verification process, they must continue implementing robust surveillance and vector control measures to prevent reintroduction.
According to the National Strategic Plan for Malaria Elimination (NSPME) 2023-2027, the process for WHO certification requires proof that local malaria transmission has been interrupted nationwide for at least three consecutive years. In addition, India must have a fully functional surveillance and response system capable of preventing re-establishment of malaria. The certification process involves close collaboration with WHO’s Malaria Elimination Certification Panel (MECP) and comprehensive documentation, including a national elimination report, epidemiological data, and detailed plans for ongoing surveillance.
What is the journey ahead?
Despite significant reductions in malaria-related mortality, India still has a long journey ahead in reducing the number of cases. The country’s diverse landscape presents unique challenges, requiring tailored strategies to combat malaria in urban areas, forest regions, tribal communities, and among migrant populations. Additionally, during and after the elimination process, India must remain vigilant against the potential impact of climate change, which could facilitate the resurgence of Plasmodium parasites and create favourable conditions for mosquito vectors. As climate change alters environmental patterns, it threatens malaria elimination programmes, underscoring the need for robust, long-term surveillance and adaptive vector control strategies to ensure continued progress in India’s fight against malaria. However, India has made substantial progress in reducing malaria mortality, with the number of deaths falling to 83 in 2022 (NSPME).
Egypt, along with other countries that have eliminated malaria, must also remain vigilant as climate change could increase the risk of malaria re-emergence. Changes in temperature and rainfall patterns may create favourable conditions for mosquito breeding, raising the potential for malaria transmission even in areas that have achieved elimination.
As a global phenomenon, climate change can heighten the risk of imported cases and local outbreaks. Therefore, Egypt and other malaria-free nations need to continuously strengthen surveillance systems and vector control efforts to prevent the re-establishment of malaria, ensuring long-term disease elimination despite these environmental challenges.
(Dr. C. Aravinda is an academic and a public health physician. aravindaaiimsjr10@hotmail.com)
Published – October 30, 2024 04:35 pm IST
