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      Malaria Control and Elimination in Sri Lanka: Documenting Progress and Success Factors in a Conflict Setting


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          Sri Lanka has a long history of malaria control, and over the past decade has had dramatic declines in cases amid a national conflict. A case study of Sri Lanka's malaria programme was conducted to characterize the programme and explain recent progress.


          The case study employed qualitative and quantitative methods. Data were collected from published and grey literature, district-level and national records, and thirty-three key informant interviews. Expenditures in two districts for two years – 2004 and 2009 – were compiled.


          Malaria incidence in Sri Lanka has declined by 99.9% since 1999. During this time, there were increases in the proportion of malaria infections due to Plasmodium vivax, and the proportion of infections occurring in adult males. Indoor residual spraying and distribution of long-lasting insecticide-treated nets have likely contributed to the low transmission. Entomological surveillance was maintained. A strong passive case detection system captures infections and active case detection was introduced. When comparing conflict and non-conflict districts, vector control and surveillance measures were maintained in conflict areas, often with higher coverage reported in conflict districts. One of two districts in the study reported a 48% decline in malaria programme expenditure per person at risk from 2004 to 2009. The other district had stable malaria spending.


          Malaria is now at low levels in Sri Lanka – 124 indigenous cases were found in 2011. The majority of infections occur in adult males and are due to P. vivax. Evidence-driven policy and an ability to adapt to new circumstances contributed to this decline. Malaria interventions were maintained in the conflict districts despite an ongoing war. Sri Lanka has set a goal of eliminating malaria by the end of 2014. Early identification and treatment of infections, especially imported ones, together with effective surveillance and response, will be critical to achieving this goal.

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          Most cited references 43

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          Malaria resurgence: a systematic review and assessment of its causes

          Background Considerable declines in malaria have accompanied increased funding for control since the year 2000, but historical failures to maintain gains against the disease underscore the fragility of these successes. Although malaria transmission can be suppressed by effective control measures, in the absence of active intervention malaria will return to an intrinsic equilibrium determined by factors related to ecology, efficiency of mosquito vectors, and socioeconomic characteristics. Understanding where and why resurgence has occurred historically can help current and future malaria control programmes avoid the mistakes of the past. Methods A systematic review of the literature was conducted to identify historical malaria resurgence events. All suggested causes of these events were categorized according to whether they were related to weakened malaria control programmes, increased potential for malaria transmission, or technical obstacles like resistance. Results The review identified 75 resurgence events in 61 countries, occurring from the 1930s through the 2000s. Almost all resurgence events (68/75 = 91%) were attributed at least in part to the weakening of malaria control programmes for a variety of reasons, of which resource constraints were the most common (39/68 = 57%). Over half of the events (44/75 = 59%) were attributed in part to increases in the intrinsic potential for malaria transmission, while only 24/75 (32%) were attributed to vector or drug resistance. Conclusions Given that most malaria resurgences have been linked to weakening of control programmes, there is an urgent need to develop practical solutions to the financial and operational threats to effectively sustaining today’s successful malaria control programmes.
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            Treatment seeking for malaria: a review of recent research.

             S C McCombie (1996)
            A review of literature on treatment seeking for malaria was undertaken to identify patterns of care seeking, and to assess what is known about the adequacy of the treatments used. There is considerable variation in treatment seeking patterns, with use of the official sector ranging from 10-99% and self-purchase of drugs ranging from 4-87%. The majority of malaria cases receive some type of treatment, and multiple treatments are common. The response to most episodes begins with self-treatment, and close to half of cases rely exclusively on self-treatment, usually with antimalarials. A little more than half use the official health sector or village health workers at some point, with delays averaging three or more days. Exclusive reliance on traditional methods is extremely rare, although traditional remedies are often combined with modern medicines. Although use of antimalarials is widespread, underdosing is extremely common. Further research is needed to answer the question of what proportion of true malaria cases get appropriate treatment with effective antimalarial drugs, and to identify the best strategies to improve the situation. Interventions for the private and public sector need to be developed and evaluated. More information is needed on the specific drugs used, considering resistance patterns in a particular area. In order to guide future policy development, future studies should define the nature of self-treatment, record multiple treatments and attempt to identify the proportions of all cases who begin treatment with antimalarials at standardized time intervals. Hypothetical questions were found to be of limited usefulness in estimating rates of actual treatments. Whenever possible, studies should focus on actual episodes of illness and consider supplementing retrospective surveys with prospective diary-type methods. In addition, it is important to determine the specificity of local illness terms in identifying true malaria cases and the extent to which local perceptions of severity are consistent with clinical criteria for severity and symptoms of complicated malaria.
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              Genetic diversity among Plasmodium falciparum field isolates in Pakistan measured with PCR genotyping of the merozoite surface protein 1 and 2

              Background The genetic diversity of Plasmodium falciparum has been extensively studied in various parts of the world. However, limited data are available from Pakistan. This study aimed to establish molecular characterization of P. falciparum field isolates in Pakistan measured with two highly polymorphic genetic markers, i.e. the merozoite surface protein 1 (msp-1)and 2 (msp-2). Methods Between October 2005 and October 2007, 244 blood samples from patients with symptomatic blood-slide confirmed P. falciparum mono-infections attending the Aga Khan University Hospital, Karachi, or its collection units located in Sindh and Baluchistan provinces, Pakistan were collected. The genetic diversity of P. falciparum was analysed by length polymorphism following gel electrophoresis of DNA products from nested polymerase chain reactions (PCR) targeting block 2 of msp-1 and block 3 of msp-2, including their respective allelic families KI, MAD 20, RO33, and FC27, 3D7/IC. Results A total of 238/244 (98%) patients had a positive PCR outcome in at least one genetic marker; the remaining six were excluded from analysis. A majority of patients had monoclonal infections. Only 56/231 (24%) and 51/236 (22%) carried multiple P. falciparum genotypes in msp-1 and msp-2, respectively. The estimated total number of genotypes was 25 msp-1 (12 KI; 8 MAD20; 5 RO33) and 33 msp-2 (14 FC27; 19 3D7/IC). Conclusions This is the first report on molecular characterization of P. falciparum field isolates in Pakistan with regards to multiplicity of infection. The genetic diversity and allelic distribution found in this study is similar to previous reports from India and Southeast Asian countries with low malaria endemicity.

                Author and article information

                Role: Editor
                PLoS One
                PLoS ONE
                PLoS ONE
                Public Library of Science (San Francisco, USA )
                29 August 2012
                : 7
                : 8
                [1 ]Country Office, World Health Organization, Port Moresby, National Capital District, Papua New Guinea
                [2 ]Anti-Malaria Campaign, Ministry of Health, Colombo, Western Province, Sri Lanka
                [3 ]Global Health Group, University of California San Francisco, San Francisco, California, United States of America
                [4 ]Institute for Health Policy Studies, University of California San Francisco, San Francisco, California, United States of America
                Tulane University School of Public Health and Tropical Medicine, United States of America
                Author notes

                Competing Interests: The authors have read the journal's policy and have the following conflicts: RRA is currently supported by the World Health Organization. During the period of case study data collection and write up, RRA was supported by the Anti-Malaria Campaign, Ministry of Health, Sri Lanka. GNLG is supported by the Anti-Malaria Campaign, Ministry of Health, Sri Lanka. GNLG represents Sri Lanka in the Asia Pacific Malaria Elimination Network (APMEN) and RRA chaired the APMEN Advisory Board. RRA is a member of the Malaria Elimination Group. RGAF is the Director of the UCSF Global Health Group, chair of the Malaria Elimination Group and is also the Network Chair of APMEN. CSG is Program Coordinator at the UCSF Global Health Group and provides assistance to the APMEN Joint-Secretariat. The Global Health Group provides support to eliminating countries, such as Sri Lanka, and is funded by the Bill & Melinda Gates Foundation. The Global Health Group also received funding from ExxonMobil during the period of this study. APMEN is funded through a grant from the Australian Agency for International Development (AusAID). JGK is a professor of health policy at UCSF. This case study is a component of a collaboration between the UCSF Global Health Group and the WHO Global Malaria Programme to document country experience with malaria elimination.

                Conceived and designed the experiments: RRA GNLG CSG JGK RGAF. Performed the experiments: RRA GNLG CSG JGK RGAF. Analyzed the data: CSG. Contributed reagents/materials/analysis tools: RRA GNLG CSG JGK RGAF. Wrote the paper: RRA GNLG CSG JGK RGAF. Developed the malaria costing tool: JGK.


                This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                Page count
                Pages: 14
                This case study was funded by a grant from the Bill & Melinda Gates Foundation. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
                Research Article
                Viral Transmission and Infection
                Viral Vectors
                Global Health
                Infectious Diseases
                Parasitic Diseases
                Plasmodium Vivax
                Tropical Diseases (Non-Neglected)
                Vectors and Hosts
                Public Health
                Behavioral and Social Aspects of Health
                Preventive Medicine
                Social and Behavioral Sciences
                Public Finance
                Government Spending and Taxation



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