Sri Lanka

Sri Lanka, Long a Hotbed of Malaria, Is Eliminating Indigenous Cases Through Diligence, Education

Sri Lanka, an island nation that has been afflicted with malaria outbreaks for at least 17 centuries, has an uneven history of battling the potentially fatal illness. Now able to boast no indigenous malaria cases in more than two years, Sri Lanka must consolidate its progress and maintain vigilance to win the World Health Organization’s coveted malaria-free certification.

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Sri Lanka, Long a Hotbed of Malaria, Is Eliminating Indigenous Cases Through Diligence, Education

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ANURADHAPURA, SRI LANKA – Punchibandage Rathnapala has been working in a small vegetable plot in his garden for about five hours today. It has taken him almost three days to weed the plot, he says. The uprooted weeds lie in a pile under the scorching sun. But now he’s too tired to clear the pile.

Not so long ago, Rathnapala could have tackled a chore like this in a few hours, he says.

“I used to be a robust fellow,” he says. “It was malaria which made me sickly and weak.”

Rathnapala, 43, first contracted malaria, a mosquito-borne disease, in the late 1990s. Over the next six or seven years, Rathnapala, his wife and four children continued to fall ill with malaria every few months.

Rathnapala used to work daily as a laborer, hauling rocks from the quarry near his house in Nallamudawa in Anuradhapura district. But after he first contracted malaria, he was no longer able to do such heavy labor, he says.

Rathnapala contracted Plasmodium falciparum, which is considered the deadliest of the four parasite species that cause malaria in humans. Although he does not have medical evidence to prove it, Rathnapala believes his fatigue was caused by his repeated bouts of malaria.

He has not had steady income since he first fell ill. He hires on as a temporary laborer when he can, but he is often too tired to work. When Rathnapala and his wife were both unable to work regularly, the family slid into debt.

“During this ordeal, there were times that we didn’t even have food to eat as everyone was sick and couldn’t work to earn a living,” Rathnapala says.

Field officers of the state-sponsored Anti Malaria Campaign, a special unit of the Ministry of Health and Indigenous Medicine, determined the family was infected with a malaria-causing parasite that is resistant to chloroquine, the standard treatment for malaria caused by the Plasmodium vivax parasite. The officers prescribed sulfadoxine/pyrimethamine, a compound found to be effective against the less common but more virulent Plasmodium falciparum parasite.

The officers insisted Rathnapala and his wife ingest their first doses of the tablets, which he recalls bore the imprint of a mosquito.

“They wouldn’t leave us until we took the medicine,” he says.

Rathnapala and his family have not contracted malaria since 2005.

“With the grace of God I have not had malaria since then,” he says.

While Rathnapala continues to struggle with the aftereffects of malaria, the rest of the family has fully recovered.

Sri Lanka has been a malaria hotbed for many centuries; it endured several devastating epidemics in the 20th century. In recent years, however, the intensive, wide-ranging efforts of the Anti Malaria Campaign are proving successful.

The last case of indigenous malaria in Sri Lanka was diagnosed in October 2012.

If no more indigenous cases are diagnosed by October 2015, the Sri Lankan government will be eligible to apply for malaria-free status from the World Health Organization. It will always be possible for a person with malaria to bring the disease to Sri Lanka from another country.

While eliminating indigenous malaria is considered a major achievement for a country, experts warn the health sector to be vigilant in ensuring that malaria strains imported into the island nation do not spread.

In Sri Lanka, malaria is endemic in two-thirds of the country, says Dr. Risintha Premaratne, an epidemiologist and director of the Anti Malaria Campaign.

Malaria is caused by any of a genus (Plasmodium) of unicellular parasites that spread through the bites of infected Anopheles mosquitoes. These mosquitoes, called “malaria vectors,” bite mainly between dusk and dawn.

Sri Lankan historians record that Anuradhapura, the ancient captial city of Sri Lanka, was devastated by a pestilence, most likely maleria, in 300 AD and again in 1300 AD, according to a report entitled “Malaria Control and Elimination in Sri Lanka: Documenting Process Factors in a Conflict Setting.”

“In the more recent past, the country has struggled with the disease for over five decades,” Premaratne says.

Thanks to health authorities’ extensive surveillance and malaria control activities, Sri Lanka nearly eliminated malaria more than a half-century ago, reducing the number of indigenous and foreign cases from 91,990 in 1953 to 17 in 1963, Premaratne says.

The country was the first in South Asia to start an indoor residual spraying campaign using the pesticide DDT; it established mobile spray units in all malaria-prone areas. At the same time, vigilance units conducted surveillance of mosquito populations and parasite spread. Sri Lanka also joined the Global Malaria Eradication Program, whose global unit continues to help fund Sri Lankan anti-malaria campaigns.

However, cutbacks in funding for these preventive activities permitted a dramatic increase in the incidence of malaria, Premaratne says.

More than 1.5 million cases of malaria occurred during the two-year period of 1967-1968, the Ministry of Health and Indigenous Medicine estimates. Since then, epidemics have broken out in 1987 and 1991 in areas of the country where malaria is endemic.

After 1998, when 118 Sri Lankans died of malaria, the number of malaria cases, both lethal and nonlethal, declined. In 2011, only 124 cases of indigenous malaria were diagnosed.

Since October 2012, no one has been diagnosed with indigenous malaria, Premaratne says.

Globally, 3.3 billion people in 97 countries and territories are at risk of being infected with malaria, according to the World Health Organization. In 2013, there were an estimated 198 million malaria cases worldwide.

However, malaria mortality rates decreased by an impressive 47 percent between 2000 and 2013 globally, according to WHO’s 2014 World Malaria Report.

The Anti Malaria Campaign has virtually eliminated the disease through increased surveillance and extensive control activities, Premaratne says.

The campaign will continue to conduct random, door-to-door malaria testing in the endemic areas. The campaign launched mobile clinics that have tested, diagnosed and treated patients in villages and homes, and it introduced rigorous follow-up monitoring to ensure patients complete prescribed treatment.

To prevent further outbreaks, public health care system hospitals are prepared to trace the movements of any treated malaria patients.

The campaign is still in effect. Various malaria elimination activities were reoriented into a malaria control program and brought under the auspices of the campaign.

The national campaign covers all parts of the island nation, including areas in the Northern and Eastern provinces, where a military conflict raged for nearly 30 years.

Sunil Priyantha Upathissa, 51, started working for the Anti Malaria Campaign as a field officer in Anuradhapura district in December 1986. He had been treated for malaria 12 times and was still under treatment when he first began working for the campaign.

“Since we have been suffering from the disease, we were committed to combating it,” he says.

Malaria was a common disease in his village, Katiyawa, in Anuradhapura district, Upathissa says. All nine members of his family have had malaria at least once.

As a prefect – an older student with disciplinary authority – Upathissa helped his school control an outbreak in the 1980s.

“One of my duties as a prefect was to take the students who had fever to the hospital to get treatment,” he says. “Every day, about 50 students would be taken to the hospital and treated for malaria.”

Upathissa was involved in the extensive house-to-house educational campaigns carried out in the malaria-endemic areas of the country. Representatives of the program taught Sri Lankans about the nature and transmission of malaria and stressed the need to be diagnosed and treated.

Many malaria patients stopped taking their prescribed medicine when the symptoms of the disease, including fever and headaches, abated, so the campaign also highlighted the importance of faithfully following medical advice, Upathissa says.

In addition to promoting diagnosis and treatment, the campaign has sought to prevent breeding of the malaria vector through insecticide spraying, fumigation, and introducing fish that consume mosquito larvae to small ponds and stagnant water holes in high-risk areas.

The multifaceted approach to eliminating indigenous malaria has borne results: Only 23 malaria cases were diagnosed in Sri Lanka in 2012 – the last of them in October of that year, Premaratne says.

“A developing country achieving this is very significant,” says Dr. Navaratnasingam Janakan, national professional officer for communicable diseases at the Sri Lanka office of the World Health Organization. “It is not an easy task. The achievement becomes even more prominent when the history of malaria in the country is considered.”

Sri Lanka could become the first South Asian country to obtain this status, Premaratne says.

However, experts warn that Sri Lanka is not out of the woods.

Malaria could spread anew after being reintroduced to the island by a traveler, Premaratne says.

“The entire country is at risk,” he says. “However, certain parts of the country are at higher risk due to high receptivity and vulnerability in those areas.”

These are the dry areas in the north, central and eastern parts of the country.

Ravindra Jayanetti, the campaign’s regional malaria officer in Anuradhapura district, confirms that dry weather is most favorable to the breeding of anopheles culicifacies, the major vector of malaria in Sri Lanka.

“The paddy and other dry fields in the dry zone are ideal for breeding this mosquitoes, and has high prevalence of the vector, especially during dry weather conditions in the year,” he says.

The campaign is gearing up to combat foreign malaria, Jayanetti says.

The nationwide malaria monitoring system aims to keep tabs on all Sri Lankans who have traveled overseas and all foreign visitors who seek medical attention for malaria symptoms.

Premaratne is concerned that the apparent elimination of indigenous malaria in Sri Lanka will lull health care professionals into dropping their guard. A doctor who fails to immediately test for malaria when symptoms are present may delay a diagnosis, he says. Worse, inexperienced laboratory technicians may be unfamiliar with the disease.

Dr. Jayantha Bandara, a physician working at the National Hospital of Sri Lanka in Colombo, the country’s largest teaching hospital, acknowledges that malaria is no longer among the first diseases doctors consider in making a diagnosis.

“We do general investigations, and we don’t immediately check for malaria, as it’s an unnecessary cost unless there are symptoms where we can suspect malaria,” he says. “I have not seen a malaria patient for a very long time.”

In response to this concern, the campaign is conducting awareness programs for both medical professionals and the public. A nationwide advertising campaign is underway. In addition, campaign teams in each district carry out community meetings and public events.

Because the country remains vulnerable to an outbreak, the campaign urges Sri Lankans to take anti-malaria medication before traveling abroad and to get tested if they fall sick while visiting or after returning from malaria-prone countries.

The campaign is partnering with travel agencies to improve the monitoring of Sri Lankans who travel to malaria-prone countries. It is also setting up a testing and treatment unit at Bandaranaike International Airport, Sri Lanka’s main international airport in Katunayake.

“The next major step for Sri Lanka is ensuring that the country has a foolproof system to ensure that malaria does not get reintroduced to the country,” Premaratne says.

Once the Sri Lankan health ministry applies for the certification, WHO will conduct a rigorous assessment of the nation’s strategies to prevent the reintroduction of malaria before granting malaria-free status, Navaratnasingam says.

The anti-malaria campaign has succeeded thanks to the hard work and dedication of everyone who has worked on awareness, treatment and prevention activities over the past three decades, Upathissa says.

“We used to work tirelessly during the epidemic times,” he says. “We all worked well past our official duty hours, and even went into conflict-prone areas.”

Chathuri Dissanayake, GPJ, translated some interviews from Sinhala.