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A sticky situation: the unexpected stability of malaria elimination.

A sticky situation: the unexpected stability of malaria elimination.
A sticky situation: the unexpected stability of malaria elimination.
Malaria eradication involves eliminating malaria from every country where transmission occurs. Current theory suggests that the post-elimination challenges of remaining malaria-free by stopping transmission from imported malaria will have onerous operational and financial requirements. Although resurgent malaria has occurred in a majority of countries that tried but failed to eliminate malaria, a review of resurgence in countries that successfully eliminated finds only four such failures out of 50 successful programmes. Data documenting malaria importation and onwards transmission in these countries suggests malaria transmission potential has declined by more than 50-fold (i.e. more than 98%) since before elimination. These outcomes suggest that elimination is a surprisingly stable state. Elimination's 'stickiness' must be explained either by eliminating countries starting off qualitatively different from non-eliminating countries or becoming different once elimination was achieved. Countries that successfully eliminated were wealthier and had lower baseline endemicity than those that were unsuccessful, but our analysis shows that those same variables were at best incomplete predictors of the patterns of resurgence. Stability is reinforced by the loss of immunity to disease and by the health system's increasing capacity to control malaria transmission after elimination through routine treatment of cases with antimalarial drugs supplemented by malaria outbreak control. Human travel patterns reinforce these patterns; as malaria recedes, fewer people carry malaria from remote endemic areas to remote areas where transmission potential remains high. Establishment of an international resource with backup capacity to control large outbreaks can make elimination stickier, increase the incentives for countries to eliminate, and ensure steady progress towards global eradication. Although available evidence supports malaria elimination's stickiness at moderate-to-low transmission in areas with well-developed health systems, it is not yet clear if such patterns will hold in all areas. The sticky endpoint changes the projected costs of maintaining elimination and makes it substantially more attractive for countries acting alone, and it makes spatially progressive elimination a sensible strategy for a malaria eradication endgame.
0962-8436
20120145
Smith, David L.
5c918948-ded2-42d8-82c1-a746a4bc3b6e
Cohen, Justin M.
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Chiyaka, Christinah
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Johnston, Geoffrey
a6ab21bc-1a51-4bbb-81e4-da330f8176a8
Gething, Peter W.
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Gosling, Roly
47c8c28a-7ba0-4b8d-8f20-dc90ac338af8
Buckee, Caroline O.
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Laxminarayan, Ramanan
ace97662-6b0d-4dd1-9c51-7d3b13bc2fd1
Hay, Simon I.
471d3ae4-a3c1-4d29-93e3-a90d44471b00
Tatem, Andrew J.
6c6de104-a5f9-46e0-bb93-a1a7c980513e
Smith, David L.
5c918948-ded2-42d8-82c1-a746a4bc3b6e
Cohen, Justin M.
7de99049-a4c3-4fa1-8ff8-cc1bc5dcdfc9
Chiyaka, Christinah
69ff3d0d-8e33-4cb1-8b95-b393fcdfa41a
Johnston, Geoffrey
a6ab21bc-1a51-4bbb-81e4-da330f8176a8
Gething, Peter W.
6afb7d8c-8816-4c03-ae73-55951c8b197f
Gosling, Roly
47c8c28a-7ba0-4b8d-8f20-dc90ac338af8
Buckee, Caroline O.
f4bc891c-4f42-46a6-822d-03fc1f9cd55b
Laxminarayan, Ramanan
ace97662-6b0d-4dd1-9c51-7d3b13bc2fd1
Hay, Simon I.
471d3ae4-a3c1-4d29-93e3-a90d44471b00
Tatem, Andrew J.
6c6de104-a5f9-46e0-bb93-a1a7c980513e

Smith, David L., Cohen, Justin M., Chiyaka, Christinah, Johnston, Geoffrey, Gething, Peter W., Gosling, Roly, Buckee, Caroline O., Laxminarayan, Ramanan, Hay, Simon I. and Tatem, Andrew J. (2013) A sticky situation: the unexpected stability of malaria elimination. Philosophical Transactions of The Royal Society B Biological Sciences, 368 (1623), 20120145. (doi:10.1098/rstb.2012.0145). (PMID:23798693)

Record type: Article

Abstract

Malaria eradication involves eliminating malaria from every country where transmission occurs. Current theory suggests that the post-elimination challenges of remaining malaria-free by stopping transmission from imported malaria will have onerous operational and financial requirements. Although resurgent malaria has occurred in a majority of countries that tried but failed to eliminate malaria, a review of resurgence in countries that successfully eliminated finds only four such failures out of 50 successful programmes. Data documenting malaria importation and onwards transmission in these countries suggests malaria transmission potential has declined by more than 50-fold (i.e. more than 98%) since before elimination. These outcomes suggest that elimination is a surprisingly stable state. Elimination's 'stickiness' must be explained either by eliminating countries starting off qualitatively different from non-eliminating countries or becoming different once elimination was achieved. Countries that successfully eliminated were wealthier and had lower baseline endemicity than those that were unsuccessful, but our analysis shows that those same variables were at best incomplete predictors of the patterns of resurgence. Stability is reinforced by the loss of immunity to disease and by the health system's increasing capacity to control malaria transmission after elimination through routine treatment of cases with antimalarial drugs supplemented by malaria outbreak control. Human travel patterns reinforce these patterns; as malaria recedes, fewer people carry malaria from remote endemic areas to remote areas where transmission potential remains high. Establishment of an international resource with backup capacity to control large outbreaks can make elimination stickier, increase the incentives for countries to eliminate, and ensure steady progress towards global eradication. Although available evidence supports malaria elimination's stickiness at moderate-to-low transmission in areas with well-developed health systems, it is not yet clear if such patterns will hold in all areas. The sticky endpoint changes the projected costs of maintaining elimination and makes it substantially more attractive for countries acting alone, and it makes spatially progressive elimination a sensible strategy for a malaria eradication endgame.

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Published date: 24 June 2013
Organisations: Global Env Change & Earth Observation, WorldPop, PHEW – P (Population Health), Population, Health & Wellbeing (PHeW)

Identifiers

Local EPrints ID: 354522
URI: https://eprints.soton.ac.uk/id/eprint/354522
ISSN: 0962-8436
PURE UUID: f30dbd02-9c8c-46e3-b5af-4c98aba0f2cf
ORCID for Andrew J. Tatem: ORCID iD orcid.org/0000-0002-7270-941X

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Date deposited: 12 Jul 2013 08:27
Last modified: 15 Aug 2019 00:36

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Contributors

Author: David L. Smith
Author: Justin M. Cohen
Author: Christinah Chiyaka
Author: Geoffrey Johnston
Author: Peter W. Gething
Author: Roly Gosling
Author: Caroline O. Buckee
Author: Ramanan Laxminarayan
Author: Simon I. Hay
Author: Andrew J. Tatem ORCID iD

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