Towards Zero Malaria: The Greater Mekong Subregion’s Path to 2030 Elimination Targets

The Greater Mekong Subregion has made significant strides in malaria elimination through coordinated efforts, innovative strategies, and substantial international support, exemplified by China's successful elimination of malaria. However, ongoing challenges like drug resistance and reaching mobile populations require sustained vigilance and collaboration to achieve the 2030 goal.

Malaria remains a persistent challenge globally, especially for vulnerable communities despite considerable progress in reducing malaria-related deaths and cases. The Greater Mekong Subregion (GMS), which includes Cambodia, China's Yunnan province, Laos, Myanmar, Thailand, and Vietnam, has long been the epicenter for antimalarial drug resistance. The World Health Organization (WHO), in collaboration with research institutes such as the Yunnan Institute of Parasitic Diseases, the National Institute of Malariology, Parasitology and Entomology in Vietnam, and the National Center for Parasitology, Entomology and Malaria Control in Cambodia, has been at the forefront of combating this threat, focusing on the emergence of Plasmodium falciparum artemisinin partial resistance and multi-drug resistance.

Strategy for Malaria Elimination

The GMS has seen substantial progress due to the Strategy for Malaria Elimination in the Greater Mekong Subregion (2015-2030), coordinated by the WHO Mekong malaria elimination program. This strategy has resulted in a 77% reduction in malaria cases and a 97% reduction in malaria deaths across the region between 2012 and 2022. A significant milestone was achieved in 2021 when China was certified malaria-free by the WHO, highlighting the success of these efforts. Critical to this progress has been the strong ownership and accountability exhibited by each GMS country, with each outlining its priorities in strategic and annual work plans.

Surveillance and Collaboration

One of the central components of the success in the GMS has been the development of strong networks for antimalarial drug resistance surveillance and epidemiological surveillance. Harmonizing policies and guidelines has enhanced collaboration, ensuring that activities are evidence-driven. However, challenges persist, particularly in Myanmar, where security concerns have hampered recent progress. An intensification and acceleration plan is in place to regain momentum in these areas.

Innovative Strategies and Community Involvement

The GMS countries have adopted innovative strategies to reduce malaria. These include high-quality case management and investigation with real-time epidemiological surveillance, decentralization of malaria services to the community level, increased testing capacity, and targeted chemoprevention. By 2022, these interventions had delivered a significant reduction in malaria cases and deaths, with the goal of eliminating Plasmodium falciparum by 2025 and all human malaria by 2030.

Triumph Over Malaria: China's Strategy and GMS's Path Forward

China’s successful elimination of malaria was attributed to strong political commitment, substantial domestic funding, free access to affordable malaria diagnosis and treatment, and effective multi-sector collaboration across thirteen government ministries. The implementation of the '1-3-7' strategy, which mandates the reporting of malaria diagnoses within one day, case confirmation and risk assessment within three days, and appropriate measures to prevent further spread within seven days, played a crucial role in this achievement.

The GMS's journey towards malaria elimination has been marked by strategic adaptations to the local epidemiological context. Despite the progress, the primary challenge remains the continued threat of drug resistance. In particular, the emergence of artemisinin partial resistance in the GMS required urgent action and regional collaboration. The validation of molecular markers for artemisinin and partner drug resistance has enabled detailed molecular surveillance of its evolution and spread across the region. These efforts are crucial for ensuring the continued efficacy of antimalarial therapies.

Efforts to combat malaria in mobile and migrant populations (MMPs) have been a key focus, given these populations' high risk of contracting malaria. Innovative approaches have been developed to provide effective malaria services to these groups, including the establishment of community malaria action teams responsible for distributing insecticide-treated nets, conducting surveillance, and providing tailored information and education communication activities.

Surveillance, monitoring, and evaluation have been core activities supported by sustained funding from international donors. High-quality surveillance data are essential for verifying case reporting, monitoring treatment efficacy, and making informed decisions about intervention strategies. Drug resistance surveillance, through therapeutic efficacy studies (TES) and integrated drug efficacy surveillance (iDES), has provided key evidence supporting national treatment guidelines and has been crucial for tracking the emergence and spread of resistance.

Harmonization of procedures, such as laboratory methods and microscopy, ensures data quality and allows for effective comparison between countries. WHO guidance and policies have been central to developing national malaria work plans, though countries must adapt these guidelines to their specific contexts. Implementing changes in malaria treatment guidelines involves securing necessary commodities and resources, managing logistical challenges, and ensuring community acceptance of new interventions.

The GMS countries have shown remarkable progress in reducing malaria transmission through coordinated efforts and substantial investment in malaria control and elimination programs. The success in containing artemisinin partial resistance and partner drug resistance, coupled with the significant reduction in malaria cases and deaths, underscores the effectiveness of these strategies. Moving forward, the region must continue to address the remaining challenges, maintain robust surveillance systems, and sustain collaborative efforts to achieve the goal of malaria elimination by 2030.