Communicable diseases department (CDS)
Comment
8
9
10
New Zealand Ministry of Health. New Zealand Suicide Prevention Strategy
2006–2016. 2006. https://www.health.govt.nz/system/files/documents/
publications/suicide-prevention-strategy-2006–2016.pdf
(accessed July 30, 2016).
Clifford AC, Doran CM, Tsey K. A systematic review of suicide prevention
interventions targeting indigenous peoples in Australia, United States,
Canada and New Zealand. BMC Public Health 2014; 14: 201.
Wexler LM, Gone JP. Culturally responsive suicide prevention in
indigenous communities: unexamined assumptions and new
possibilities. Am J Public Health 2012; 102: 800–06.
11
12
Chachamovich E, Kirmayer LJ, Haggarty JM, Cargo M, Mccormick R,
Turecki G. Suicide among Inuit: results from a large, epidemiologically
representative follow-back study in Nunavut. Can J Psychiatry 2015;
60: 268–75.
Kirmayer LJ, Brass G. Addressing global health disparities among
Indigenous peoples. Lancet 2016; 388: 105–06.
Against the odds, Sri Lanka eliminates malaria
Ministry of Health, Nutrition and Indigenous Medicine , Government of Sri Lanka
Published Online
September 5, 2016
http://dx.doi.org/10.1016/
S0140-6736(16)31572-0
1038
Sri Lanka’s achievement in eliminating malaria, certified
by WHO on Sept 5, 2016, is an inspiring public health
success story.1 With its population of about 22 million,
this Indian Ocean island is the largest lower-middleincome country in the malaria-endemic tropics to
achieve elimination.2,3 Income per person in Sri Lanka is
still below the level at which countries typically succeed
in eliminating malaria.2 More than 80% of Sri Lanka’s
population live in rural areas, providing ideal ecosystems
for Anopheles culicifacies, one of the main vectors for
malaria in the region. And, remarkably, the groundwork
for elimination was laid during a period of internal
armed conflict.4
The elimination of malaria brings to an end one
of Sri Lanka’s most devastating health burdens. Of
the country’s 25 districts, only six had low to no risk
for malaria.4,5 Epidemics and endemic transmission
intensified in the 19th and 20th centuries as
plantation, irrigation, and agricultural projects—
undertaken by the British colonial administration and
then by the independent government—opened up
forested areas.5 Major epidemics occurred every few
years. The 1934–35 epidemic killed over 1·5% of the
population.5
In 1945, Sri Lanka was a regional pioneer in
introducing indoor residual spraying (IRS) with
dichlorodiphenyltrichloroethane (DDT).4,5 The dramatic
results led to IRS being used across the country, and in
1958 Sri Lanka joined WHO’s Global Malaria Eradication
Programme. By 1963, there were just 17 cases of malaria
reported in Sri Lanka, of which 11 were imported.5,6
Elimination seemed certain. But the subsequent scaling
back of IRS led to the resurgence of malaria, with about
1·5 million cases in Sri Lanka during 1967–69.2–6 For the
next 30 years, Sri Lanka did its best to control malaria
but with little success.
Then in the late 1980s technical leadership by
Sri Lanka’s Anti-Malaria Campaign (AMC) Directorate
led to the jettisoning of single vector-control
methods, such as IRS, in favour of integrated vector
management. This integrated approach relied on
several carefully selected interventions, including
vector control in major irrigation and agriculture
projects, rigorous entomological surveillance leading
to targeted spraying in high-risk areas, new classes of
insecticides for IRS, insecticide-treated nets and larval
control, and strengthened parasitological surveillance
for active case detection combined with rapid
response.5
Despite these efforts, major epidemics occurred
during the 1980s and 1990s. In the country’s 1986–87
epidemic there were more than 600 000 cases of malaria,
while in 1999 the number of confirmed cases of malaria
was 264 549.4,5 Fortunately, mortality was limited by
wide access to quality treatment and because most
infections were Plasmodium vivax malaria rather than
www.thelancet.com Vol 388 September 10, 2016
Comment
P falciparum, with a peak of 115 malaria-related deaths
recorded in Sri Lanka in 1998.4,5
A turnaround began in 1999–2000.4–7 The Sri Lankan
Government’s commitment to tackling malaria was
renewed by the advocacy and technical support of
the Roll Back Malaria Partnership.5 Across the country,
malaria vector control, surveillance, and treatment
interventions were ratcheted up. In subsequent years
malaria incidence fell substantially in Sri Lanka—
there was a 68% reduction in 2000–01 alone.5 By
2007, with further expansion of these interventions
made possible by grants from the Global Fund to
Fight AIDS, Tuberculosis and Malaria, there were just
198 indigenous and imported malaria cases in the
country, representing a 99% reduction in incidence
from the 1999 level.5 In 2008, for the first time,
there were no indigenous malaria-related deaths in
Sri Lanka.4–7
Strikingly, these achievements were made despite
the challenges posed by the protracted armed conflict
between the government and the Liberation Tigers of
Tamil Eelam (LTTE), which began in the early 1980s.4,6,7
By 2000, Sri Lanka’s eight conflict-affected districts
accounted for most malaria infections, after a surge
in annual parasite incidence as anti-malaria efforts
and primary health services buckled from decades of
conflict in these districts.4,5,7 Integrated vector control
and treatment interventions were scaled up in the
conflict-affected districts by the AMC Directorate and
the regional malaria teams, often in partnership with
non-governmental organisations and the military.4,5
With their ranks affected by malaria, the LTTE assured
the AMC Directorate that they would support malaria
control measures.4
The at-risk population protected by IRS in conflict
districts increased from 23·5% in 1995 to 52·2% in
2000, higher than the corresponding coverage of
43·7% in non-conflict districts.4,7 The introduction
of insecticide-treated nets, and then long-lasting
insecticidal nets, also reduced transmission.4 By 2005,
long-lasting insecticidal nets were used by 38·1% of
the at-risk population in districts affected by conflict,
distributed by the AMC, Sarvodaya (a Sri Lankan nongovernmental organisation), UNICEF, and WHO.4
Access to diagnosis and treatment services, often
provided by mobile malaria clinics, was stepped up
www.thelancet.com Vol 388 September 10, 2016
through the combined efforts of health staff, the
Sri Lanka Red Cross, the International Committee of
the Red Cross, and Médecins Sans Frontières.4,5 By 2005
annual parasite incidence rates in both the conflict and
non-conflict districts had equalised to a fraction of
earlier levels.4,7 And in October, 2012—just a few years
after the armed conflict had ended in May, 2009—
Sri Lanka had recorded its last case of indigenous
malaria.4–7
Inevitably, difficult challenges still remain. These
range from preventing the reintroduction of malaria
from imported cases to the pressing need to tackle
the threats posed by Aedes and Culex mosquitoes,
including the burden of dengue, chikungunya, and
Japanese encephalitis, and the potential threat of Zika
virus disease and even yellow fever.5–8 These challenges
will be resolutely addressed because Sri Lanka is
committed to combating and eliminating mosquitoborne and other infectious diseases as a key part of
the country’s pledge to achieving the Sustainable
Development Goals for 2030. The elimination of
malaria is a first milestone in reaching the SDG health
goals in Sri Lanka.
Rajitha Senaratne, *Poonam Khetrapal Singh
Ministry of Health, Nutrition and Indigenous Medicine,
Government of Sri Lanka, Colombo , Sri Lanka (RS); and WHO
Regional Office for South-East Asia, New Delhi 110002, India (PKS)
[email protected]
RS is the Minister of Health, Nutrition and Indigenous Medicine, Government of
Sri Lanka; PKS is Regional Director of WHO Regional Office for South-East Asia.
We declare no competing interests.
© 2016. World Health Organization. Published by Elsevier Ltd/Inc/BV. All rights
reserved.
1
2
3
4
5
6
7
8
WHO Regional Office for South-East Asia. WHO certifies Sri Lanka malariafree. Sept 5, 2016. http://www.searo.who.int/en/ (accessed Sept 5, 2016).
Feachem RGA, Phillips A, Hwang J, et al. Shrinking the malaria map:
progress and prospects. Lancet 2010; 367: 1566–78.
WHO. World malaria report 2015. Geneva: World Health Organization, 2015.
Abeyasinghe RR, Galappaththy GN, Smith Gueye C, Kahn JG, Feachem RG.
Malaria control and elimination in Sri Lanka: documenting progress and
success factors in a conflict setting. PLoS One 2012; 7: e43162.
Ministry of Health, Nutrition and Indigenous Medicine, Government of
Sri Lanka. Malaria elimination in Sri Lanka: national report for WHO
certification. Colombo: Government of Sri Lanka, 2016.
Premaratne R, Ortega L, Navaratnasingham J, Mendis KN. Malaria
elimination from Sri Lanka: what it would take to reach the goal.
WHO South East Asia J Public Health 2014; 3: 85–89.
Ministry of Health Sri Lanka, WHO, Global Health Group of University of
California, San Francisco. Eliminating malaria: case-study 3 progress
towards elimination in Sri Lanka. Geneva: World Health Organization, 2012.
Dissanayake C. Maintaining momentum in Sri Lanka to ensure that malaria
is gone—but not forgotten. WHO South East Asia J Public Health 2016;
5: 79–81.
1039
8
9
10
New Zealand Ministry of Health. New Zealand Suicide Prevention Strategy
2006–2016. 2006. https://www.health.govt.nz/system/files/documents/
publications/suicide-prevention-strategy-2006–2016.pdf
(accessed July 30, 2016).
Clifford AC, Doran CM, Tsey K. A systematic review of suicide prevention
interventions targeting indigenous peoples in Australia, United States,
Canada and New Zealand. BMC Public Health 2014; 14: 201.
Wexler LM, Gone JP. Culturally responsive suicide prevention in
indigenous communities: unexamined assumptions and new
possibilities. Am J Public Health 2012; 102: 800–06.
11
12
Chachamovich E, Kirmayer LJ, Haggarty JM, Cargo M, Mccormick R,
Turecki G. Suicide among Inuit: results from a large, epidemiologically
representative follow-back study in Nunavut. Can J Psychiatry 2015;
60: 268–75.
Kirmayer LJ, Brass G. Addressing global health disparities among
Indigenous peoples. Lancet 2016; 388: 105–06.
Against the odds, Sri Lanka eliminates malaria
Ministry of Health, Nutrition and Indigenous Medicine , Government of Sri Lanka
Published Online
September 5, 2016
http://dx.doi.org/10.1016/
S0140-6736(16)31572-0
1038
Sri Lanka’s achievement in eliminating malaria, certified
by WHO on Sept 5, 2016, is an inspiring public health
success story.1 With its population of about 22 million,
this Indian Ocean island is the largest lower-middleincome country in the malaria-endemic tropics to
achieve elimination.2,3 Income per person in Sri Lanka is
still below the level at which countries typically succeed
in eliminating malaria.2 More than 80% of Sri Lanka’s
population live in rural areas, providing ideal ecosystems
for Anopheles culicifacies, one of the main vectors for
malaria in the region. And, remarkably, the groundwork
for elimination was laid during a period of internal
armed conflict.4
The elimination of malaria brings to an end one
of Sri Lanka’s most devastating health burdens. Of
the country’s 25 districts, only six had low to no risk
for malaria.4,5 Epidemics and endemic transmission
intensified in the 19th and 20th centuries as
plantation, irrigation, and agricultural projects—
undertaken by the British colonial administration and
then by the independent government—opened up
forested areas.5 Major epidemics occurred every few
years. The 1934–35 epidemic killed over 1·5% of the
population.5
In 1945, Sri Lanka was a regional pioneer in
introducing indoor residual spraying (IRS) with
dichlorodiphenyltrichloroethane (DDT).4,5 The dramatic
results led to IRS being used across the country, and in
1958 Sri Lanka joined WHO’s Global Malaria Eradication
Programme. By 1963, there were just 17 cases of malaria
reported in Sri Lanka, of which 11 were imported.5,6
Elimination seemed certain. But the subsequent scaling
back of IRS led to the resurgence of malaria, with about
1·5 million cases in Sri Lanka during 1967–69.2–6 For the
next 30 years, Sri Lanka did its best to control malaria
but with little success.
Then in the late 1980s technical leadership by
Sri Lanka’s Anti-Malaria Campaign (AMC) Directorate
led to the jettisoning of single vector-control
methods, such as IRS, in favour of integrated vector
management. This integrated approach relied on
several carefully selected interventions, including
vector control in major irrigation and agriculture
projects, rigorous entomological surveillance leading
to targeted spraying in high-risk areas, new classes of
insecticides for IRS, insecticide-treated nets and larval
control, and strengthened parasitological surveillance
for active case detection combined with rapid
response.5
Despite these efforts, major epidemics occurred
during the 1980s and 1990s. In the country’s 1986–87
epidemic there were more than 600 000 cases of malaria,
while in 1999 the number of confirmed cases of malaria
was 264 549.4,5 Fortunately, mortality was limited by
wide access to quality treatment and because most
infections were Plasmodium vivax malaria rather than
www.thelancet.com Vol 388 September 10, 2016
Comment
P falciparum, with a peak of 115 malaria-related deaths
recorded in Sri Lanka in 1998.4,5
A turnaround began in 1999–2000.4–7 The Sri Lankan
Government’s commitment to tackling malaria was
renewed by the advocacy and technical support of
the Roll Back Malaria Partnership.5 Across the country,
malaria vector control, surveillance, and treatment
interventions were ratcheted up. In subsequent years
malaria incidence fell substantially in Sri Lanka—
there was a 68% reduction in 2000–01 alone.5 By
2007, with further expansion of these interventions
made possible by grants from the Global Fund to
Fight AIDS, Tuberculosis and Malaria, there were just
198 indigenous and imported malaria cases in the
country, representing a 99% reduction in incidence
from the 1999 level.5 In 2008, for the first time,
there were no indigenous malaria-related deaths in
Sri Lanka.4–7
Strikingly, these achievements were made despite
the challenges posed by the protracted armed conflict
between the government and the Liberation Tigers of
Tamil Eelam (LTTE), which began in the early 1980s.4,6,7
By 2000, Sri Lanka’s eight conflict-affected districts
accounted for most malaria infections, after a surge
in annual parasite incidence as anti-malaria efforts
and primary health services buckled from decades of
conflict in these districts.4,5,7 Integrated vector control
and treatment interventions were scaled up in the
conflict-affected districts by the AMC Directorate and
the regional malaria teams, often in partnership with
non-governmental organisations and the military.4,5
With their ranks affected by malaria, the LTTE assured
the AMC Directorate that they would support malaria
control measures.4
The at-risk population protected by IRS in conflict
districts increased from 23·5% in 1995 to 52·2% in
2000, higher than the corresponding coverage of
43·7% in non-conflict districts.4,7 The introduction
of insecticide-treated nets, and then long-lasting
insecticidal nets, also reduced transmission.4 By 2005,
long-lasting insecticidal nets were used by 38·1% of
the at-risk population in districts affected by conflict,
distributed by the AMC, Sarvodaya (a Sri Lankan nongovernmental organisation), UNICEF, and WHO.4
Access to diagnosis and treatment services, often
provided by mobile malaria clinics, was stepped up
www.thelancet.com Vol 388 September 10, 2016
through the combined efforts of health staff, the
Sri Lanka Red Cross, the International Committee of
the Red Cross, and Médecins Sans Frontières.4,5 By 2005
annual parasite incidence rates in both the conflict and
non-conflict districts had equalised to a fraction of
earlier levels.4,7 And in October, 2012—just a few years
after the armed conflict had ended in May, 2009—
Sri Lanka had recorded its last case of indigenous
malaria.4–7
Inevitably, difficult challenges still remain. These
range from preventing the reintroduction of malaria
from imported cases to the pressing need to tackle
the threats posed by Aedes and Culex mosquitoes,
including the burden of dengue, chikungunya, and
Japanese encephalitis, and the potential threat of Zika
virus disease and even yellow fever.5–8 These challenges
will be resolutely addressed because Sri Lanka is
committed to combating and eliminating mosquitoborne and other infectious diseases as a key part of
the country’s pledge to achieving the Sustainable
Development Goals for 2030. The elimination of
malaria is a first milestone in reaching the SDG health
goals in Sri Lanka.
Rajitha Senaratne, *Poonam Khetrapal Singh
Ministry of Health, Nutrition and Indigenous Medicine,
Government of Sri Lanka, Colombo , Sri Lanka (RS); and WHO
Regional Office for South-East Asia, New Delhi 110002, India (PKS)
[email protected]
RS is the Minister of Health, Nutrition and Indigenous Medicine, Government of
Sri Lanka; PKS is Regional Director of WHO Regional Office for South-East Asia.
We declare no competing interests.
© 2016. World Health Organization. Published by Elsevier Ltd/Inc/BV. All rights
reserved.
1
2
3
4
5
6
7
8
WHO Regional Office for South-East Asia. WHO certifies Sri Lanka malariafree. Sept 5, 2016. http://www.searo.who.int/en/ (accessed Sept 5, 2016).
Feachem RGA, Phillips A, Hwang J, et al. Shrinking the malaria map:
progress and prospects. Lancet 2010; 367: 1566–78.
WHO. World malaria report 2015. Geneva: World Health Organization, 2015.
Abeyasinghe RR, Galappaththy GN, Smith Gueye C, Kahn JG, Feachem RG.
Malaria control and elimination in Sri Lanka: documenting progress and
success factors in a conflict setting. PLoS One 2012; 7: e43162.
Ministry of Health, Nutrition and Indigenous Medicine, Government of
Sri Lanka. Malaria elimination in Sri Lanka: national report for WHO
certification. Colombo: Government of Sri Lanka, 2016.
Premaratne R, Ortega L, Navaratnasingham J, Mendis KN. Malaria
elimination from Sri Lanka: what it would take to reach the goal.
WHO South East Asia J Public Health 2014; 3: 85–89.
Ministry of Health Sri Lanka, WHO, Global Health Group of University of
California, San Francisco. Eliminating malaria: case-study 3 progress
towards elimination in Sri Lanka. Geneva: World Health Organization, 2012.
Dissanayake C. Maintaining momentum in Sri Lanka to ensure that malaria
is gone—but not forgotten. WHO South East Asia J Public Health 2016;
5: 79–81.
1039