Sri Lanka is yet malaria-free, but can it remain so?

By A Health Watcher

We in Sri Lanka celebrated World Malaria Day (WMD) just a few days ago on April 25 for having eliminated malaria in 2012. When the World Health Organization certified Sri Lanka as a malaria-free country the event was hailed worldwide as a major milestone in global public health history. The good news is that Sri Lanka is still malaria-free.

This year’s WMD commemorations in Sri Lanka were, however, marred by two very unfortunate events. One was misinformation on malaria in Sri Lanka in the local print media which alarmed stakeholders the world over. A prominent local English newspaper reported that 10 malaria cases were reported in Sri Lanka this year – which is correct. But its print version stated in a headline that nine of them were indigenous cases, meaning that these patients contracted malaria in this country implying that malaria has returned to Sri Lanka.

The other version reported that 10 cases of malaria have been reported in Sri Lanka despite the disease having being eliminated from the country. Both these reports imply that malaria has been re-established in Sri Lanka, which is blatantly incorrect. All cases of malaria reported this year and almost all reported since the disease was eliminated in Sri Lanka have been imported cases, meaning that they are travelers who contracted the disease overseas in other malaria endemic countries but were diagnosed and treated after their arrival in Sri Lanka.

It is to be noted that imported malaria cases are reported from all countries of the world where there is no malaria, including the UK, USA, Europe and elsewhere, and Sri Lanka is no exception. The occurrence of imported malaria is by no means synonymous with malaria returning to the country. Only, and only if the mosquito in Sri Lanka begins to transmit malaria from one person to another that malaria would have returned to the country, and to date, it has not.

Misinformation in the print media has damaging consequences, and is a reflection of extremely poor national standards. It may not be attributable to irresponsible journalism alone. One of the articles mentioned above quoted the spokesperson of a professional medical body, who seem to either be unaware that the occurrence of imported malaria does not mean that malaria has returned to the country, or in an enthusiastic bid to raise awareness on malaria has used exaggerated and scaremongering language. Either of these reasons amounts to poor reporting, and even worse, to a shocking lack of knowledge and professionalism.

The other very unfortunate event this year is that a person died of malaria on April 15, the first malaria death in the country since 2007. The deceased, a Sri Lankan national, contracted malaria in an African country, and on his return to Sri Lanka developed symptoms of malaria for which he sought treatment. Malaria was unfortunately not diagnosed early enough to save his life. Imported malaria in countries that have no malaria is known to be associated with a relatively high mortality rate for the simple reason that being a rare disease doctors fail to test for malaria soon enough, and thus, treatment is often delayed. Sri Lanka is now in that category of countries where malaria is a rarely encountered disease. Consequently, malaria being not among the common causes of fever such as dengue, influenza and viral fevers which are highly prevalent in the country, doctors fail to place malaria high on their list for testing.

The clue to management of fevers in this country should be to elicit from a patient the history of travel to other countries, of which the Anti Malaria Campaign keeps reminding members of the medical profession, but not always with effect, as evident in this particular case. Malaria is a disease which is both preventable and treatable, and a death due to malaria is entirely avoidable and regrettable. In this unfortunate instance of the recent malaria death in this country we have failed in both. These events call for introspection.

The national malaria control programme of Sri Lanka, the body which successfully spearheaded the elimination of malaria has still a lot of work to do to prevent malaria deaths, and to prevent the disease returning because the mosquito that transmits malaria is prevalent in the country. The malaria control programme which is a special programme within the Ministry of Health has an active, year round, 24/7 programme which alerts physicians on the need to test for malaria, and which screens groups of people who return from malaria endemic countries for malaria. The staff of the programme actively seek travelers to malaria endemic countries (and I was one of them), and advise them on reducing the risk of contracting malaria while overseas. They even provide travelers with preventive medicines to be taken while being exposed to malaria overseas. Why then, could this death not have been prevented?

More questions than answers emerge from both these unfortunate events. Does the national malaria programme receive the necessary budgetary and administrative support that it should, to keep Sri Lanka malaria-free? Does the national malaria programme have the necessary technical capacity and commitment to do its work? And why aren’t there mechanisms to review the performance of public sector institutions such as the national malaria programme? Are the medical schools current in teaching travel health and medicine to the graduating doctors? Are clinical practitioners in Sri Lanka up-to-date with demands of the rapidly changing world of international travel health?

The unfortunate events relating to malaria this year cannot be reversed, but it is imperative on our part to prevent further occurrences of this nature. People of this country and the tax payer expect the relevant health authorities and institutions to be held accountable for preventing malaria deaths and the return of malaria to this country. If they fail, malaria could return, and if it does, it could cause devastation on a scale not seen before, in a population that now lacks immunity.