Sri Lanka has won global acclaim since the World Health Organisation certified it as a Malaria free country in 2016. The daunting task of keeping Sri Lanka’s malaria free status in a country where the malaria vector is widely prevalent has been so far been successfully sustained for the past nine years by all those involved in fighting the disease spearheaded by the Anti Malaria Campaign . However, today, the challenge is to prevent it being re-established by local and foreign travellers who have returned after visiting Malaria high risk countries bringing the parasite with them. Around 50-60 imported malaria patients are being reported from Sri Lanka every year.
To prevent the disease from being re- established, and sustain our malaria free status the need of the hour is for more public funding to recruit more staff and carry out the many tasks of screening, keeping tabs on new cases .
The Sunday Observer spoke to a long and experienced malaria expert who has been instrumental in launching a global initiative to eliminate malaria when she was working with the World Health Organization In Geneva.
Here, Emeritus Professor Kamini Mendis tells us why more investment in fighting malaria can ensure both the health of the general public, but benefit the nation as a whole.
Excerpts…
Q. Today, 25 April is World Malaria Day. Sri Lanka does not have malaria any more, so why is this relevant to us?
A. There has been no malaria transmission in Sri Lanka since 2012, and the World Health Organization certified Sri Lanka as a malaria-free country in 2016 and won global acclaim. However, we have to keep Sri Lanka malaria-free, and that is a challenge.
This is because the mosquito vector that transmits malaria is prevalent in parts of the country, and we have malaria patients who bring the parasite that causes malaria. They acquire the infection abroad and develop the disease on their return to Sri Lanka, and if they transmit the parasite to the mosquito here, malaria can be re-established in the country.
Q. Sri Lanka has been kept free of malaria for the past 9 years, how was this done despite the risk of it returning.
A. Because the Anti Malaria Campaign conducts a robust programme of work throughout the year to ensure that every imported malaria patient who enters the country is detected without delay and treated so that he or she does not transmit the disease through a mosquitoe.
Q. So, do we have to keep working to ensure that malaria does not return, and does that cost the country much?
A. Yes, we must continue to work to ensure that malaria does not return, and there is a cost to sustaining a malaria-free country. However, that cost is very small compared to the expenditure we would have to incur if the disease returns to the country.
When malaria was highly endemic here, up to a third of the entire public health budget was spent on malaria control, mainly to purchase insecticides. Now that we are free of malaria we save all that money, which can therefore be spent on other diseases and health problems.
The cost of keeping Sri Lanka malaria-free is the cost of surveillance and response– that is, looking out for malaria cases, and keeping a tab on the mosquito vector both of which entails a great deal of hard work on the part of the Anti Malaria Campaign. But the cost of this is very small, compared to the past when we spent enormous amounts of money on simply controlling the disease.
It has been estimated that a return on an investment to keep malaria away is 13 to one – for every rupee that is spent the government will gain 13 rupees by way of savings on malaria control.
Q. Is it only the financial cost that we should be concerned about?
A. No, malaria was a devastating disease that cost the country dearly in many other ways for centuries. It caused illness and disability – beyond 400,000 episodes of malarial illness was reported yearly in Sri Lanka only a few decades ago. Each episode of illness keeps people away from work – farmers lost their livelihoods, and some lost their lives to malaria.
Malaria was highly prevalent in the areas which have a thriving tourist industry. If malaria was endemic in the country today doubt that tourism would have flourished the way it did in Sri Lanka. Studies done in Sri Lanka have shown that repeated malaria infections interfere with cognitive development of children, and this would have had an enormous toll on nation buidling. And the losses malaria causes to trade, commerce and tourism would have been substantial. Now all that is history.
Q. From where does Sri Lanka get imported malaria patients and who are they?
A. Around 50-60 imported malaria patients are being reported from Sri Lanka every year. Most of them acquire the disease either in India or in African countries. These patients are either Sri Lankan business travellers or pilgrims, or they are imported labour from those countries.
There is a considerable amount of imported labour force in the country today associate with development projects. Many Sri Lankans engage in the gem trade and travel frequently to African countries and India in connection with their business, and they are at very high risk of contracting malaria.
Another high-risk group are members of the armed forces, mainly members of the Security Forces and Air Force, and the Police Department who return from United Nations Peace Keeping Missions in malaria endemic countries. More rarely, foreign tourists who travel via malaria endemic countries and Sri Lankan leisure travellers have been among the imported malaria patients detected.
Q. What is the work of the Anti Malaria Campaign which has been successful in keeping he country malaria-free?
A. The Anti Malaria Campaign conducts an extremely robust programme of work and this is done with Regional Malaria Officers who work within the Provincial Ministries of Health in the districts. The staff of the AMC and the RMOs, screen large numbers of people who are at risk of malaria by examining their blood for the malaria parasite.
These include occupational groups such as those engaged in the gem trade, members of the armed forces and police who return from missions, refugees from malaria endemic countries such as Pakistan, Myanmar who are temporarily resident here. When a malaria patient is detected, an enormous amount of work is carried out to ensure that the patient is hospitalised and treated until complete cure is achieved.
People in the neighbourhood of the patient are screened for malaria to see if they have contracted the disease via a mosquito bite. All the travel contacts of the patient are traced and tested for malaria – and they may be in different parts of the country,. Quite often the co-travellers of the patient have also been found to be infected with malaria because they have been exposed to the same risk as the patient, overseas.
The AMC also provides medicines and advice free of charge to people travelling to malaria endemic countries to prevent malaria, and they can be contacted 24 hours of the day seven days of the week in the event of any person requiring assistance with diagnosing malaria or if they require prophylactic medicines. It is only the AMC that is in possession of antimalarial medicines in the country and these medicines are not available in pharmacies or in private sector health institutions.
This is to ensure that every case of malaria in the country is notified to the AMC which then has to take many steps to ensure that onward transmission of the disease does not occur.
Q. Are other institutions and sectors involved in this task.
A. Yes, keeping the country free of malaria requires working across sectors beyond health and beyond the public sector, and this is what the AMC does.
It works closely with the Military and Police Departments who are extremely co-operative and provide the AMC with information when their officers return from overseas missions. The Ministry of Buddhasasana and Religious Affairs is an important collaborator because every year several buddhist pilgrims who return from India develop malaria, and measures to prevent them contracting malaria can only be implemented with their co-operation.
The Airports and Aviation authority is important because they control the entry and exit of persons who visit malaria endemic countries. The AMC has even malaria screening facilities at the airports. The private health sector is an important partner because many imported malaria patients are diagnosed in private laboratories and hospitals.
The AMC provides training to their laboratory staff on how to diagnose malaria, free and provides medicines and advice on the management of malaria patients. These collaborations are working very effectively.
Q. What would be the most important interventions a Government must make to ensure that we remain malaria-free?
A. We must sustain the Anti Malaria Campaign with the necessary funding and staff to perform the much needed work that it is doing now. There have been examples of other diseases which have been eliminated from Sri Lanka such as Leprosy in 1995, only to have it return to the country in concerning numbers.
This may be partly because the work of the Leprosy Campaign was handed over to the general health services too soon, and there was lack of oversight for conducting a post-elimination surveillance programme to prevent Leprosy coming back.
We cannot afford to have this happen with malaria. If malaria returns to the country it would be very grave situation. The population of the country lacks immunity to malaria now. And we have a new mosquitoe vector in the country called Anopheles stephensi, which has been inadvertently introduced, probably from India, where it is a very good transmitter of malaria in urban areas. If malaria returns to Sri Lanka it might therefore become endemic even in cities.
Q. Any other interventions you think important at this time around?
A. We must also impress on the Provincial Ministries of Health that it is important to invest resources and effort on malaria surveillance and response. Developing countries often work on the basis that when a disease is no longer prevalent, it can be forgotten, and that it is not necessary to invest funds or effort on that disease anymore.
It is often thought that funds are better spent on other more prevalent diseases. This is unwise, for then the effort of eliminating a disease would not have been worthwhile and the disease will surely return because the world is highly connected place today and human movement between countries is rampant. Government investment to ensure that the diseases we have eliminated are kept away is extremely important.
Q. This being World Malaria Day is there a message for our readers on how to minimize risks of exposure to Malaria ?
A. There is no risk of your acquiring malaria in Sri Lanka today, which is a great relief. however, if you travel overseas to a malara endemic country (most tropical countries including our neighbouring countries such as India, Pakistan and other Southeast Asian countries are highly malarious) you are at risk of acquiring malaria.
Prior to undertaking such a journey it would be important to contact the anti malaria campaign and obtain advice on how you could reduce the risk of getting malaria, and also obtain prophylactic medicines to protect yourself from getting malaria. these medicines are given free-of-charge by the amc.
Most importantly, on your return to the country if you develop a febrile illness keep in mind that it could be malaria, and tell your doctor that you have travelled to a malaria endemic country and request a test for malaria. Remember that malaria is a potentially fatal disease if not treated early. So for your own sake and that of the country, it would be important to protect yourself from getting malaria when you travel overseas and to be vigilant and aware on your return that you may develop symptoms of malaria.