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Malaria in Eritrea: Marching Towards Elimination

Yesterday, World Malaria Day was commemorated worldwide under the theme, “Time to deliver zero malaria: invest, innovate, implement.”

Malaria is one of the most common endemics in the world. For a long time, it has been one of the most frequent causes of death worldwide.

But with time, many developed countries have managed to control or eliminate it. Currently, the world is marching toward a total eradication of the disease by helping developing countries to apply preventive and treatment systems.

According to the 2023 World Health Organization (WHO) report on malaria; Malaria occurs primarily in tropical and subtropical countries. The vast majority of malaria cases and deaths are found in the African Region, with nearly all cases caused by the Plasmodium falciparum parasite. This parasite is also dominant in other malaria hotspots, including the regions of South-East Asia, Eastern Mediterranean and Western Pacific. In the Americas, the Plasmodium vivax parasite is predominant, causing 75% of malaria cases.

The threat of malaria is highest in sub-Saharan Africa, and 4 countries in the region accounted for nearly half of all malaria deaths worldwide in 2021: Nigeria (26.6%), the Democratic Republic of the Congo (12.3%), Uganda (5.1%), and Mozambique (4.1%).

Globally, the elimination net is widening, with more countries moving towards zero indigenous cases: in 2018, 49 countries reported fewer than 10,000 such cases, up from 46 countries in 2017 and 40 countries in 2010. The number of countries with fewer than 100 indigenous cases – a strong indicator that elimination is within reach – increased from 17 countries in 2010 to 25 countries in 2017 and 27 countries in 2018.

On the one hand, if malaria case incidence and mortality rate remained the same as those in 2000, globally there would be 320 million cases and nearly 1 million malaria deaths in 2018. Instead, there were an estimated 228 million malaria cases and 405,000 malaria deaths in 2018. These represent about 30% fewer cases and 60% fewer deaths in 2018 than would have been the case had levels of malaria incidence and malaria death remained similar to those in 2000. While the gains to date are impressive, the global malaria challenge remains enormous, and the rate of progress is slowing down.

The Ministry of Health of Eritrea (MoH) has targeted malaria as one of the diseases that must be eliminated, being the serious public health problem it has been for a long time. To do so, the National Malaria Control Program (NMCP) and other partners have been following steady prevention and treatment mechanisms to stop the spread of the disease using different techniques, such as vector control, insecticide-treated mosquito nets, indoor residual spraying (IRS) of insecticides and Larval source management. Based on these achievements, the WHO Global Technical Strategy for Malaria 2016–2030 lays the foundation for further significant reductions in mortality and incidence by at least 90% over the coming 15 years, with elimination of malaria projected for a further 35 countries.

Since 1998, Eritrea has shown unstable cases and deaths of malaria. But generally, it has so far succeeded to show a major loop toward malaria elimination. Technically, the earliest stage of the fight against the disease is to control the surge of morbidity and mortality due to malaria. After it is controlled and the cases are reduced greatly, both spatially and numerically, the country or zone is said to be marching to elimination, that is, pre-elimination stage, where cases are further reduced in some areas or zones, also known as sub-national elimination. This stage is where Eritrean Fight against malaria is currently passing through to the advanced stage, which is, scoring zero local cases. Moreover, the global elimination of the disease, as targeted by WHO, is called eradication — encountering no malaria-related cases at all. In order to claim that a subzone, zone or a country has eliminated malaria, it has to show a zero malaria morbidity and mortality for 36 months in a row. Nevertheless, in case there are imported cases, a prevention of re-introduction is carried out across border towns and villages. That is why we say Eritrea has controlled it and gone all the way near elimination but it has not been announced as a free country either.

Moreover, the Eritrean NMCP, established in 1995, has managed to achieve a great deal of malaria cases decline from 1997 onward. In 1998, the Roll Back Malaria (RBM) partnership was launched aiming to reduce malaria by half by 2010. Similarly, the NMCP developed a national 5 year plan (2000-2004) to reduce malaria morbidity and mortality by 80%. According to the 2016 MDGs report, a remarkable progress has been made in reducing both the incidence of and death from malaria. Malaria cases declined from 53 per 1,000 people in 1998 to 5 per 1,000 in 2004, but increased to 13 per 1000 in 2013. During the period 1998-2013 the incidence of malaria declined by an average of 9.4% per year. Due to this trend, it was projected to further decline to 12 per 1,000 at the end of 2015. Similarly, malaria deaths declined from 20% in 1998 to 0.004% in 2013 and declined to 0.002 at the end of 2015. This ranked Eritrea as one of Africa’s exemplary countries in malaria control. In 2016, Eritrea received the African Leaders Malaria Alliance award for its success in achieving millennium development goals.

According to the NMCP, Eritrea has a three-tier health care delivery system.

1. Primary level, constituting of community-based health services, health stations, health centers and community hospitality.

2. Secondary level, constituting Zoba and sub zebra hospitals.

3. Tertiary level encompasses national referral hospitals which also serve as national centers of excellence for specialized training, education and research.

The health sector is composed of public and private health care providers. There are 28 hospitals, 13 community hospitals, 35 health centers and 186 health stations. As for the specific organization of malaria control program,

Eritrea has set a strategic development plan (2017-2021), which is organized at several layers of sub-organizations — national, zonal, sub zonal and community levels. Each has designated functions in the system, complementing one another.

When inclined to elimination, the core intervention that must be implemented in addition to the former interventions and treatments is surveillance followed by further treatment. Despite upsurges in some sub-zones, Eritrea has made a commendable progress and is further striving up the ladder through the pre-elimination stage to achieve a score of zero local transmissions.

The local activities of larval source management on community basis and the awareness-raising discourses need to be reinforced every now and then. Though the larval management can be done by spraying relevant insecticides on puddles, the effects of the current situation may arise later because as Mr. Selam said, “people tend to stop taking the cautious malaria guidelines as they observe major cases decline.”

Therefore, though Eritrea has succeeded to control the malaria endemic, it is no time to relax. It is actually now that we need to work harder to preserve the achieved results and keep streaming in the lane of successfully eliminating the disease.

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