Interview with Dr. Rajitha Wickremasinghe: Sri Lanka's malaria history - learning from the past and looking towards the future

Last week, as world malaria experts convened in Colombo for the ninth Malaria Elimination Group meeting, we had the pleasure of getting a firsthand account of Sri Lanka's journey to becoming malaria free. Dr. Rajitha Wickremasinghe, Professor of Public Health at the University of Kelaniya in Sri Lanka and lead author of Maintaining zero: An update to the Sri Lanka malaria elimination case study, sat down with us for an interview - first sharing Sri Lanka's history with elimination that included a devastating resurgence, and then looking ahead to the challenges that remain in maintaining a malaria-free future.

Q: Welcome Prof. Rajitha! Before we dive in, how did you start your career in malaria? A: I have always been interested in malaria and I specialize in epidemiology and biostatistics. In fact, my father worked in malaria control, which initially piqued my interest. After my postgraduate program, I returned to Sri Lanka to work on malaria with Dr. Kamini Mendis.

History of malaria in Sri Lanka

Q: Can you provide a brief overview of the last 100 years with malaria in Sri Lanka? A: Organized malaria control efforts started in 1911 with the establishment of the malaria control unit. In 1934-5, there was a massive epidemic where there was an estimated 1.5 million cases in a population of about 5 million with 80,000 deaths - all during a span of 9 months. In response, malaria control efforts were intensified with mass antimalarial distribution and indoor residual spraying (IRS) using DDT, and there was a big reduction in malaria in the early 1950s.

In 1958, Sri Lanka embarked on a national malaria elimination program. By 1963, there were only 17 recorded cases in Sri Lanka, of which, only 6 were indigenous. At about the same time the elimination program curtailed its use of IRS. This was one of the many factors that caused a devastating resurgence of malaria from 1967-69.

In 1984, the first case of chloroquine resistance was reported. From the 1980s to 2009, we also had several conflicts in the northern and eastern provinces and most of the public health infrastructure, including antimalarial distribution, was affected. Since 2001 there has been a gradual reduction. Sri Lanka started using ACTs as first line drug against uncomplicated malaria in 2007, and embarked on a pre-elimination program in 2008. Since 2007 we have had no deaths from indigenous malaria, and since October 2012, we have not had a single case of indigenous malaria.

Our concern now is preventing the reintroduction of malaria. We have about 100 imported malaria cases every year.

A Focus on Resurgence

Q: What do you believe were the main causes of resurgence in the 1960s? A: The elimination program in the 1960s had distinct phases: the preparatory phase, the attack phase, and once the number cases of cases reached a certain level, IRS coverage was gradually reduced. IRS was the main strategy at the time, so cessation of IRS may have been a factor that contributed to the resurgence. Another problem at that time was that they took funds away from malaria control, so certain activities were curtailed.

Also, there could have been pockets of areas such as rural jungle areas where cases were not detected and malaria was not controlled.

Q: After the unfortunate resurgence in the 1960s, what did it take to regain national and political support to work toward eliminating malaria? A: As the number of cases increased, the public pressured the politicians. They wanted the areas sprayed and thus the funds started coming back.

Q: Do you think the public and government remember the past and will be less likely to divert funding this time? A: It is a difficult question to answer because memory is always short. We also have a lot of competing issues like dengue, which is quite fatal. Given the funding constraints, administrators will have to balance the budget. We should also remember that things are different now.

Q: You have shown a compelling graphic that overlays the near elimination and insurgence of malaria cases in the 1960s with the gains in driving down cases that have been made in the past few years. It shows how Sri Lanka is in a pivotal moment where elimination can either be sustained or where you run the risk of having another resurgence. What do you think is required to ensure history is not repeated? Who are the people you need to convince that efforts in malaria control should be maintained? A: There are chances of outbreaks, definitely. The receptivity is high. We should make sure our workforce stays properly trained and competent. If everyone forgets about malaria control and if there are outbreaks, then we don't have anything to fall back on. This will be difficult because there is little money.

New challenges

Q: Has Sri Lanka seen episodes of drug resistance over the decades of fighting malaria? What is the role, if any, that elimination plays to stem drug resistance in the region? A: Our main concern is the introduction of drug resistant strains, which can come from anywhere. We don't have this problem, but a problem can come from counterfeit drugs. Fortunately, the Anti-Malaria Campaign is the only authority that is importing drugs in to Sri Lanka.

Q: Since indigenous malaria was eliminated in late 2012, all of Sri Lanka's malaria cases have been imported from other countries. Has Sri Lanka worked with other countries in the region to stem malaria? A: No we have not and this is probably because we are an island nation. I think it would be useful for the program director to get updates about resistance in the region so we can be ready with the necessary drugs.

Q: In your experience, how have interventions and attitudes toward malaria changed from the last pre-elimination period to this one? A: I must say the people have forgotten! Twenty years ago, if a person had a fever, they would think it was malaria, so they would get it treated as soon as they got the second fever spike. Now, people have forgotten because malaria is not common.

Another main difference between the 1960s and now is accessibility. Socioeconomic status and housing has improved. It has been shown that poor housing types are more likely to have mosquitoes.

Q: You mentioned keeping health workers engaged is a major issue – how would you try to keep them motivated to keep screening for cases? A: One thing would be to have regular training programs. We are also planning on having an accreditation system and have microscopists undergo continual training, with help from the Asia Pacific Malaria Elimination Network (APMEN).

The way forward

Q: What do you think is the most important element needed for Sri Lanka's elimination success? Are you optimistic that WHO certification will be awarded? A: I think we should be okay, provided we don't have any more outbreaks. I think this time we are far more confident than we were in the 1960s because our surveillance system is better and faster.

Q: Other than overseas travelers, are there any populations more at risk for malaria? A: Yes, mainly illegal immigrants and refugee groups. We also have foreign labor groups, such as Indian laborers, working in the north where the last cases of malaria were detected. Approximately one thousand Pakistani refugees were screened and we found 18 cases of vivax. Also, we screen security personnel who go on UN peace keeping missions. We work with the United Nations, the United Nations High Commissioner for Refugees and the International Organization for Migration, to try to mitigate imported cases.

Q: At the moment, the global roadmaps for malaria - the GTS and the GMAP2 - are being revised. How have global strategies and frameworks been helpful to your work in Sri Lanka? A: We adopt the strategies recommended by the WHO's Global Malaria Program as well WHO-SEARO. We use these documents to get support and commitment from the highest levels. We have convinced the Minister of Health and cabinet that malaria is important. For this year's World Malaria Day, our President even gave a message! We also get a lot of support from the WHO country office. Fortunately for us, elimination has been on our national agenda, which has helped a lot.

Lastly, and just for fun

Q: What is your favorite place in Sri Lanka? A: I'm from Colombo and I love it!