Malaria eradication

We share the aspirations of the Lancet Commission on Malaria Eradication for attaining eradication worldwide within a generation.¹ Nevertheless, we would like to stress the risks arising from setbacks and the importance of regional actions and long-term plans for achieving malaria elimination, as experienced in the Amazon basin.

The WHO’s 2018 World Malaria Report² showed a remarkably heterogeneous scenario in Latin America. Paraguay was certified as malaria-free, whereas in 11 countries cases increased by more than 10% compared to 2014.² Political instability, decentralisation, high staff turnover in National Malaria Control Programs (NMCPs), competing epidemics, and mass migration had an important negative impact on malaria control achievements at country and regional levels. While important progress can be obtained with hard work, it can also be lost quickly.

In the past 20 years, two major multicountry efforts were implemented in the Amazon basin. The US Agency for International Development-funded Amazon Malaria Initiative (2001–16) supported building NMCPs’ capacities and addressed country-specific, regionally shared malaria control needs in 11 countries, six from the Amazon basin and five from central America.³ Complementary to this initiative, PAMAFRO (2005–10), a Global Fund-sponsored project, supported the scaling up of comprehensive control interventions in Venezuela, Colombia, Ecuador, and Peru.⁴ Despite success, achievements attained were not sustained after efforts ceased and by 2016 incidence rates had regressed to pre-PAMAFRO levels.⁵

Long-term country plans are also critical to establish context-specific agendas and targets—eg, Brazil’s Malaria Elimination Plan (2015), a municipal-level initiative focused on Plasmodium falciparum elimination, and Peru’s Malaria Cero Plan (2017), a focalised effort using a community-based, intercultural approach, addressing all malaria species. Both plans respond to the highly heterogeneous micro-epidemiology of malaria in the Amazon basin.

Furthermore, malaria-endemic countries in South America are middle-income economies that rely primarily on internal funding for malaria control. Political commitment to securing the sustainability of NMCPs’ efforts through multi-year, long-term horizon regional programmes improves the chances of success for malaria elimination. Conversely, short-term initiatives or single-country projects could be counterproductive.

Eradication is a critical global goal and elimination an imperative objective for the Americas, but both might be achievable only in the long term. Arguably, the Americas still need to focus on consolidating the progress achieved and preventing malaria re-emergence. Aiming at eradication in the current scenario could prevent addressing the risks still faced by NMCPs and jeopardise their achievements. Recent challenges and setbacks suggest caution and demand commitment to long-term goals and plans for malaria elimination.