Progress Stalling on Malaria Elimination

Judy Stone, MD

May 05, 2021

In its final report on the E-2020 initiative, the World Health Organization (WHO) touted its progress on its goal of eliminating malaria throughout the world. But critics are charging that progress has stalled.

The E-2020 initiative supported the efforts of twenty-one countries in eliminating malaria. In a remarkable achievement, especially during the COVID-19 pandemic, eight E-2020 member countries reported zero cases of malaria in 2020. The WHO's next target is the elimination of malaria in 20 of those countries by 2025.

Dr Nicholas White

While applauding these successes, in an interview with Medscape Medical News, Sir Nicholas J. White, professor of tropical medicine, Mahidol University, Salaya, Thailand, and Oxford University, Oxford, United Kingdom, also put those successes in perspective. For one thing, the original 2020 goal was the elimination of malaria in 10 countries. White acknowledged that there had been very "substantial reductions in global morbidity and mortality" from 2000 to 2015, but he pointed out that those advances have not been sustained.

White added, "There has never been a really good, detailed inquiry as to why progress has stalled" in the high-burden countries.

White also provided important historical context, explaining that "100 years ago, malaria was pretty much a global disease. There were few places in the world which did not have malaria. You had malaria up to the Arctic Circle. You had malaria in the United States, particularly in the Tennessee Valley in the southeastern part of the United States. The Centers for Disease Control was formed specifically to counter malaria and malaria interfering with the building of the Erie and Ottawa canals."

Kim Lindblade, PhD, malaria elimination team lead of the WHO's Global Malaria Program, addressed those concerns with Medscape Medical News. "It's not completely clear why [progress] has stalled," she said. "There are lots of potential reasons for it, including stagnating funding."

Lindblade added that high-burden countries are "facing big challenges. [Since 2015] there's this stagnation. We're fighting against population growth, and countries need to get back on track to continue to decrease their malaria burden. So that's the big focus right now, to reorganize efforts to help countries achieve the goals of the World Health Assembly."

Asked how these countries might approach the problem differently, Lindblade told Medscape Medical News that in the recent past, there was "almost a one-size-fits-all strategy. Now we're looking much more carefully at conditions at the district level or provincial level and saying, What is it that this particular district or province needs?... It's becoming much more tailored to the environment and to the specific epidemiological situation...and I think that's gotten a lot of people very excited."

Because of travel restrictions and lockdowns because of COVID-19, the number of imported cases of malaria has declined. That's the good news. But the pandemic has made elimination more difficult in other ways. For example, the delivery of insecticide-treated bed nets has been delayed in some areas, as has targeted indoor spraying. People in many areas have put off seeking medical care. Diagnostic capabilitites have been reduced because of healthcare personnel having been diverted to address the COVID-19 crisis.

Still, some of the successes in eliminating malaria have been striking. Iran, for example, reduced its cases from about 98,000 in 1991 to 12,000 just 10 years later. Since then, Iran has established rapid response teams equipped with insecticide-impregnated nets, rapid diagnostic tests, and antimalarials. A network of more than 3700 community health volunteers has been trained and deployed throughout the country.

A key element of Iran's success — and that of some of the other countries — is the political will to tackle malaria. This translates to funding. Notably, the most successful countries provide free primary healthcare to everyone, regardless of their legal or residency status. Volunteer migrant workers are trained to diagnose malaria and to educate fellow migrants about the disease and prevention strategies.

Malaysia and China are examples of two countries at risk of importing malaria through their many people who work abroad in malaria-endemic regions. They have had to increase their surveillance.

Although Malaysia has eliminated most malaria species — those transmitted through people — they still have problems with the malaria parasite hosted by monkeys.

The WHO report stresses the lessons learned through their E-2020 program. Two key criteria are political commitment and associated funding. Next are surveillance and efforts to reach everyone, even in geographically remote or marginalized communities. Close surveillance also enables strategies to be modified to local needs.

Countries need to cooperate, especially along border areas and in regard to communications. The WHO stressed the need for countries to have an integrated response in their approach to malaria, including accurate surveillance, diagnostic testing, treatment, and robust education in preventive measures.

Although these successes were not in some high-burden countries, White applauded their perseverance, noting, "It's quite difficult to sustain the political momentum.... That endgame to keep the motivation, keep the support, to getting rid of something is hard."

White and Lindberg have disclosed no relevant financial relationships.

WHO. Zeroing In on Malaria Elimination: Final Report of the E-2020 Initiative. Published online April 21, 2021. Full text

Judy Stone, MD, is an infectious disease specialist and author of Resilience: One Family's Story of Hope and Triumph Over Evil and of Conducting Clinical Research, the essential guide to the topic. You can find her at or on Twitter @drjudystone.

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