Last week, National Malaria Day (NMD) was observed at Adi Guadad, Central Region, under the theme, “Integrated Effort for Eradicating Malaria.” During the event, a variety of activities were conducted and the region’s progress in the fight against malaria was reviewed. In addition to the many considerable insights it offered, the recent observance of NMD at the regional level provides a useful opportunity to discuss malaria generally, with a focus on Eritrea’s national progress and efforts toward prevention and control.
Malaria is a severe, life-threatening disease caused by Plasmodium parasites, which are spread to people through the bites of infected female Anopheles mosquitoes. Despite being readily preventable and treatable, malaria remains a massive global public health problem and it occurs in more than 100 countries and territories worldwide. About half of the world’s population is at risk, with large areas of Africa and South Asia, along with parts of Central and South America, the Caribbean, Southeast Asia, the Middle East, and Oceania, considered areas where malaria transmission occurs.
Globally, Africa remains the region with the greatest burden of malaria. According to the latest edition of the World Malaria Report (published last year), in 2020, of the world’s 241 million malaria cases and approximately 627,000 malaria deaths, the region was home to 95 percent of global cases and 96 percent of global deaths.
However, over the past two decades the world has achieved tremendous progress in the fight against malaria, with the incidence of malaria deaths reduced by over a half and malaria cases by nearly a third. Progress in reducing the global burden of the disease has been driven through a combination of prevention and control tools and strategies, including effective vector control (such as the distribution of long-lasting insecticide-treated nets (LLIN), indoor residual spraying (IRS), and larval source management). In brief, vector control encompasses a range of measures that are directed against a vector of disease, aiming to completely interrupt local transmission and eliminate all transmission foci. Indoor residual spraying, a core vector control intervention that can rapidly reduce malaria transmission, involves the application of a residual insecticide to internal walls and ceilings of housing structures where malaria vectors may come into contact with the insecticide. Another key vector control intervention is the use of insecticide-treated nets. These form a protective barrier around people sleeping under them. Finally, larval source management refers to the management of water bodies that are potential habitats for mosquito larvae in order to prevent completion of development of the immature stages.
Alongside vector control, malaria is fought with the use of safe and cost-effective preventive antimalarial drugs, appropriate case management (which involves rapid diagnosis and proper treatment), and community mobilization, awareness, and behavioral change mechanisms. More recently, important landmarks in malaria vaccine development were achieved last year, offering further hope in the collective fight to prevent and control the disease. In particular, after many years of global efforts seeking to develop an effective malaria vaccine, there were promising results in a number of separate clinical trials. Then, in a historic milestone in global health, on 6 October the World Health Organization (WHO) recommended the widespread use of the RTS,S/AS01 (RTS,S) malaria vaccine among children in Sub-Saharan Africa and in other regions with moderate to high malaria transmission.
In Eritrea, malaria has been a longstanding challenge and the risk of malaria remains moderate to high within large swathes of the country. The Gash Barka and Debub regions account for the vast majority of the national malaria burden, while a significant percentage of the population resides in malaria-endemic areas. Historically, malaria has been a formidable threat to several vulnerable population groups, such as pregnant women and children. (Young children are vulnerable as they have not developed immunity to malaria and pregnant women are vulnerable as their immunity has been decreased by pregnancy.)However, since independence, and particularly following the establishment of the National Malaria Control Program in 1995, Eritrea has made major inroads against the disease. Through the combination of an array of control and prevention interventions, which has included the mass distribution of LLINs, IRS, drainage and larval source management, effective case management and surveillance, and strong community mobilization, awareness, and reception, the national malaria burden has been significantly reduced.
Between 1998 and 2016, malaria incidence in Eritrea dropped significantly, declining from 157 to 34 cases per 1,000 people. Following further reductions to 18 cases per 1,000 in 2018, there has been a slight increase in cases in recent years, to 30 cases per 1,000 in 2020. Reported malaria deaths have also fallen, dropping from 405 in 1998 to 23 in 2016 and 6 in 2021 (an overall reduction of approximately 99 percent).
These overall reductions are among the best in the region and anywhere in the world. For relative context, Africa is not on track to achieve its ambitious goal of eliminating malaria on the continent by 2030. To achieve its objective, the African Union (AU) set a 2020 target of reducing malaria incidence and mortality by 40 percent compared to 2015. However, according to estimates from the WHO, malaria incidence only declined by 1 percent and malaria mortality increased by 1 percent between 2015 and 2020.
Notably, Eritrea’s rapid and substantial progress also made it one of a small number of countries to achieve the United Nations Millennium Development Goals target related to malaria (Goal 6, which it met ahead of the 2015 target date). In 2016, during the 26th Summit of the AU, it even received an award from the African Leaders Malaria Alliance in recognition of its, “commitment, innovation, and progress in the fight against malaria.” (The African Leaders Malaria Alliance is a coalition of AU Heads of State and Government established to drive accountability and action for results against malaria and neglected tropical diseases, and to promote reproductive, maternal and child health.)
Looking ahead, despite a recent small rise in cases in some areas of the country, Eritrea is steadily transitioning from pre-elimination toward elimination of malaria, with the long-term goal of ultimately eliminating and preventing the reintroduction of malaria by 2030. (The path to malaria-free status is characterized by four distinct programmatic phases: control, pre-elimination, elimination, and prevention of reintroduction. Subsequently, once a country has proven, beyond a reasonable doubt, that the chain of local malaria transmission by Anopheles mosquitoes has been interrupted nationwide for at least three consecutive years, it is then granted a certification of malaria-free status from the WHO.)
Encouragingly, entomology laboratories for research have been established in Elabered and Tesseney, helping in identification of species and parasites, while last year a total of approximately 1.9 million LLINs were distributed nationwide. Moreover, efforts continue to ensure early diagnosis and treatment, as it prevents deaths and contributes to reducing transmission.