Challenges of Malaria Elimination

Dec. 9, 2013, 5:42 p.m.

Andrew A Lover, Richard J Coker

We share Chris Cotter and colleagues' (Sept 7, p 900)1 concerns regarding the challenges ahead in strategic research for malaria control; however, we believe several issues demand closer attention, especially within historical context.

Foremost, the factors that contribute to the successful elimination of malaria remain obscure; indeed, debate has scarcely progressed in almost 90 years.2 Without realistic consideration of this fundamental gap, the potential for resurgence remains. Although the epidemiological situation has changed dramatically, the massive Plasmodium vivax epidemic in Sri Lanka in 1968, caused by programme changes, population movements, and undetected low-level infections remains a stark reminder of malaria's truly explosive potential for resurgence.3

The increasing focus on hot-pops, forested areas, and migration is not new; the issues raised in a WHO report4 more than 20 years ago are essentially unchanged, aside from trading one type of resistance (chloroquine) for another (artemisinin). Without transnational cooperation to address parasite persistence within these populations in southeast Asia, these same issues will appear in Reviews in another few decades' time.

Finally, we were gratified to see renewed focus on local control as a priority in Cotter and colleagues' Review.1 Wisdom expressed 75 years ago resonates clearly, cautioning against premature generalisable solutions and stating that although no royal road for malaria control exists, research can provide solutions to the multitude of diverse local problems.5

Comprehensive assessment of the microepidemiology was and should remain the crucial consideration in control and elimination of malaria.

We declare that we have no conflicts of interest.

1 Cotter C, Sturrock HJ, Hsiang MS, et al. The changing epidemiology of malaria elimination: new strategies for new challenges. Lancet 2013; 382: 900-911. Summary | Full Text | PDF(2617KB) | CrossRef | PubMed

2 James SP. The disappearance of malaria from England. Proc R Soc Med 1929; 23: 71-87. PubMed

3 Gramiccia G, Beales P. The recent history of malaria control and eradication. In: Wernsdorfer WH, Gregor IM, eds. Malaria: principles and practice of malariology. Edinburgh, New York: Churchill Livingstone, 1988.

4 WHO. Regional Office for South-East Asia. Forest-related malaria in countries of the South-East Asia Region: report of the informal consultative meeting, New Delhi, 18—22 February 1991. New Delhi: World Health Organization, South-East Asia Region, 1991.

5 Swellengrebel NH. Presidential address at the opening of the Third International Malaria Congress. Acta Conv Tertii Malarias Morbis 1938; 2: 19-23. PubMed


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