Where we stand in the battle to eliminate malaria

Jenny Liu and colleagues, writing in the Lancet, report some significant good news in the battle to eradicate malaria: 

The malaria map is rapidly shrinking. In 1900, endemic malaria was present in almost every country. Nowadays, the disease has been eliminated in 111 countries and 34 countries are advancing towards elimination.1 Elimination is defined as the absence of transmission in a defined geography—typically a country.2 Successful malaria control programmes in the remaining 64 countries with ongoing transmission have helped to reduce global incidence by 17% and mortality by 26% since 2000.3 For the 34 eliminating countries, the reductions were 85% in incidence and 87% in mortality.1 This progress is encouraging, but is worldwide eradication of human malaria possible? If so, is it a worthwhile goal and should we commit to it?

There is plenty of bad news as well, however: 

First, despite progress, the burden of malaria is still great and it is widespread. In 2010, an estimated 219 million cases of malaria were reported and 660 000 people died in 98 countries.3 Second, drug and insecticide resistance are on the rise. In Burma, Cambodia, China, Thailand, and Vietnam, resistance of Plasmodium falciparum, the major human malarial parasite species, to artemisinin, the most widely used first-line drug, has been detected and could be spreading despite efforts to contain it.3, 4 Resistance to pyrethroid insecticides can happen quickly and has emerged after large-scale distributions of bednets in several regions.5 Although new drugs and insecticides are being sought, none are expected to be available in the near future. Third, increased mobility of people not only makes containment of resistance difficult, but also threatens the introduction or reintroduction of malaria parasites to receptive areas. Fourth, outside sub-Saharan Africa, Plasmodium vivax, the second major human malarial parasite species, is the main challenge. P vivax is much less researched than is P falciparum. P vivax is harder to diagnose and failure to successfully treat its dormant liver stage results in relapses that can fuel onward transmission. Furthermore, in Borneo and neighbouring regions, evidence now exists of human infection by a monkey parasite species, Plasmodium knowlesi. Zoonotic reservoirs challenge all campaigns for eradication of human infection. Fifth, extreme events, such as wars or natural disasters, greatly disrupt malaria control and elimination activities, and can lead to substantial resurgence. When accompanied by large population movements, these events can introduce malaria into previously malaria-free areas. Sixth, as malaria becomes rare, persuasion of governments to allocate finances to maintain effective elimination or post-elimination programmes is increasingly difficult. Since 1930, 75 resurgences of malaria have been recorded and nearly all are linked to the scaling back of programmes.

Policy recommendations here: 

The practical policy option, and the one that will be less costly in the long term, is to pursue a global policy of progressive elimination, aggressive control in the high-burden areas, and eventual eradication. This policy is even more appealing in consideration of recent evidence showing that malaria elimination could be an inherently stable state, unlike sustained control.7, 8 No-one can know when malaria will be eradicated. Our estimate is perhaps 2050 or 2060. The last battles will likely be waged in wet, tropical, and poor areas: against P falciparum in sub-Saharan Africa and P vivax in Melanesia. Continued vigilance will be needed against zoonotic malaria arising from close human—macaque contact in Borneo and neighbouring areas.9 Special measures will need to be designed and implemented to control such malaria.

And then there is this bold claim: 

Of the ten leading causes of death in the developing world, malaria is the only one with a real prospect for eradication.