Epidemiological Definitions

WHO 2016

Malaria Terminology : WHO, 2016

These definitions and indices are important in epidemiological surveillance and in planning the control strategy for malaria.

Endemic Malaria: Constant incidence over a period of many successive years in an area.

Epidemic Malaria: Periodic or occasional sharp increase of malaria in a given indigenous community.

Stable Malaria: Amount of transmission is high without any marked fluctuation over years though seasonal fluctuations occur.

Unstable Malaria: Amount of transmission changes from year to year.

Vulnerability: Either proximity to malarious areas or liability to frequent influx of infected people or anophelines.

Receptivity: Habitual presence of vector anophelines or existence of ecological factors.

Clinical Cure: Relief of symptoms without complete elimination of parasites.

Radical Cure: Elimination of parasites actually responsible for attack of malaria.

Recrudescence: Renewed clinical activity seen during the first 8-10 weeks after primary attack (short term relapse).

Recurrence: Renewed clinical activity seen around 30th – 40th week following primary attack (long term relapse)

Clinically Latent: Symptom less phase between primary attack and relapse with splenomegaly, no parasite seen in peripheral smear.

Insecticidal Resistance: Development of resistance i.e. ability in strains of insects to tolerate doses of toxicants which would prove lethal to the majority of the insect population of the same species.

Epidemiological Indices:

Annual Blood Examination Rate (A.B.B.R.) = Smears examined in a year X 100 / Total population.

Annual Parasitic Incidence (A.P.I.) = Total no. of positive slides for parasite in a year x 1000 / Total population.

Annual Falciparum Incidence = Total positive PF in a year x 1000 / Total population.

Slide Positivity Rate (S.P.R.) = Total positive x 100 / Total slides examined.

Slide Falciparum Rate (S.F.R.) = Total positive PF x 100 / Slides examined.

P. falciparum Percentage (PF %) = Total positive for P. falciparum x 100 / Total positive for MP

Entomological parameters:

Adult vector density – Man hour hand captures (per man hour density) = No. of mosquitoes collected/ No. of man hours spent in search

Sporozoite Rate (%) for each species = (No. of positive for sporozoites/ No. dissected) x 100

(I sincerely thank Dr. P.P. Venugopalan, Former Medical Superintendent, Attavar Hospital and Professor and Head of Community Medicine, Kasturba Medical College, Mangalore for his contribution)

©malariasite.com ©BS Kakkilaya | Last Updated: June 7, 2016

Malaria in Mangaluru

Mangaluru (formerly Mangalore) is a picturesque city in Southern India, on the shore of the Arabian Sea. It is the headquarters of Dakshina Kannada district with a population of 4,55,217 (2001 Census). Known for hundreds of rivers and rivulets and plenty of coconut and areca nut gardens and paddy fields, the district is home for many world-known educational and financial institutions. The people of the district are generally considered as intelligent, educated and peace loving. The district has been witnessing a great spurt in construction activities in the recent years, owing to rapid industrialization. And this has brought the dreaded disease, malaria, to this peaceful land. A disease that was unknown in Mangaluru until 1990 has already killed more than 300 people in the district in the past 15 years. And it has now spread, not only to all the villages of this district, but also to the neighbouring districts of Udupi and Kasaragod (in the state of Kerala).

See Malaria in India, Karnataka and Dakshina Kannada

Incidence of Malaria in India, Karnataka State and Mangalore

YearAll IndiaKarnatakaMangalore
19902.02 million7401219
19912.12 million44565198
19922.13 million81057707
19932.21 million1964663907
19942.51 million2666823131
19952.93 million2858835245
19963.04 million2191989874
19972.66 million1814477862
19982.22 million1186856475
19992.28 million961563415
20002.03 million1079991798
20012.09 million1963063309
20021.84 million1326093739
20031.87 million1002189138
20041.92 million8131416321
20051.82 million8318120083
20061.79 million6286415664
20071.51 million4935510930
20081.53 million473445915
20091.56 million365595154
20101.49 million441226335
20111.31 million242375724
20121.06 million164665327
20130.881 million133024714
20141.10 million1914811714
20151.16 million1627410910
20161.09 million110786209

Annual Incidence of Malaria in Mangalore (1990-2016)

YearP. vivaxP. falciparumTotal Deaths
1990190190
199119531980
1992692157070
199338961139070
19943124731310
19954374871524526
19968324155098745
1997700186178624
1998589657964751
1999314626934151
200017128617980
2001296534433092
2002296277737395
20037189194991382
2004121104211163213
2005140166067200834
20061076149031566411
200786262304109308
2008*525566059150
2009451164351541
2010538495163350
2011511560957240
2012496436353270 (>14#)
2013435136347140 (>20 #)
201410781933117142
201510105805109100
20165189102062090

[Table legend: *New CHO appointed, New NVBDCP Officer appointed; Data tweaked by stopping collection from private hospitals; #Official figures show no deaths, but >14 deaths in 2012 and >20 deaths in 2013 have been reported to NVBDCP, Mangalore.]

In the year 2006, a total of 62864 cases of malaria were reported from Karnataka state and Mangaluru accounted for 15664 (24%) of these cases. Of the 16446 cases of P. falciparum malaria reported from Karnataka in the same year, 4903 (29%) cases were from Mangaluru. And among 29 malaria related deaths from Karnataka, 11 were from Mangaluru. Whereas the incidence of malaria is showing a downward trend in Karnataka, it is continuing in Mangaluru, and in 2013, of the 13302 cases reported from Karnataka, 4714 (35%) were from Mangaluru and in 2014, of the 12335 cases from Karnataka, 7360 (59%) were from Mangaluru. Although only 2 deaths have been officially reported, the actual number of deaths may be 8-10 times more as all the cases are not reported and even among the reported deaths, all cannot be confirmed for want of evidence in the form of a preserved blood smear of the victim. Alarmed by this trend, the Karnataka State Government has intensified the malaria control drive in Mangaluru.

Graph showing Malaria in Mangalore (1990-2007)

Graph showing Malaria in Mangalore (1990-2007)

There was a sudden rise in the cases of P. falciparum in the year 1995-96 that resulted in more than 100 deaths due to malaria (26 in 1995 as per official figures). The high mortality was probably related to delayed diagnosis and treatment due to lack of awareness among the general public as well as doctors. Alarmed by these events, a voluntary initiative for malaria control was started by private medical practitioners in association with the local medical college, Mangaluru City Corporation (MCC) and District Administration; Malaria Control Action Committee (MCAC) was thus constituted. Due to the concerted efforts and also decline in the construction activities, the annual incidence declined by the year 2000, with only 1798 cases reported. However, by 2001 the incidence again showed an upward trend. Despite strengthening the anti-malaria drive under MCAC, the cases have continued to rise, largely due to resurgence in construction activities.

In June 2003, a Malaria Cell was started with financial aid from the city based Corporation Bank. It has a co-ordinator, a computer operator and more than 30 field staff, including supervisors, ANMs, spray workers and Guppy distributors divided into six teams. Logistical support is provided by the MCC and DHO. These teams are carrying out active surveillance with special emphasis on migrant workers, construction workers, hotel workers and inmates of orphanages. The teams also carry out door-to-door surveys, IEC activities, source reduction, anti larval and anti adult spray operations, fogging, distribution of Guppy fish besides administering treatment to positive cases. [See Malaria Control in Mangaluru]

Monthwise Incidence of Malaria in Mangalore (Jan 2003-Dec 2007)

MonthP. vivaxP. falciparumTotal
Jan03451108559
Feb0326271333
Mar0334480424
Apr0327067337
May0331849367
Jun0350069569
Jul03793162955
Aug0310462921338
Sep038562421098
Oct037243171041
Nov038352591094
Dec037902331023
Jan04581172753
Feb0435595450
Mar04486141627
Apr04665134799
May04796157953
Jun0414604491909
Jul0416286132241
Aug0411715641735
Sep0412244971721
Oct0412274421669
Nov0411464661612
Dec0413714811852
Jan058172871104
Feb058552531108
Mar05714221935
Apr05740259999
May0510613351396
Jun0515294421971
Jul0520226982720
Aug 0514567262182
Sep0512318092040
Oct 0512727652037
Nov0512557702025
Dec0510645021566
Jan069234041327
Feb06647220867
Mar06513203716
Apr06526245771
May067644171181
Jun069393911330
Jul0610855661651
Aug0613066101916
Sep0611555731728
Oct068913041195
Nov0610484701518
Dec069645001464
Jan077962961092
Feb07479112591
Mar0736795462
Apr0733266398
May0749099589
Jun079051391044
Jul0712292811510
Aug0711193381457
Sep078592361095
Oct078192741093
Nov07635238873
Dec07590130720

Monthwise Malaria Cases in Mangalore

Monthwise Malaria Cases in Mangaluru

Water logging at construction site

Water logging at construction site

Month-wise mosquito density

Month-wise mosquito density and malaria cases (2003-2004)

Month-wise larval density and malaria cases (2003-2004)

Month-wise larval density and malaria cases (2003-2004)

The teams of Malaria Cell visit construction sites, hotels, orphanages, apartments and other high risk areas on a regular basis. Active surveillance and treatment of migrant workers staying in open areas is regularly conducted during early hours of the morning and evenings.

Active Surveillance among high risk population in Mangalore

Risk Group20042005 (Up to March)Total
SmearsVivaxFalciparumTotalSmearsVivaxFalciparumTotalSmearsTotal PositiveSPR
Total62523605141115151404818877655997.71
Construction workers8251781919748510035135131033225.34
Hotel workers580751590691872564911517.71
Orphanages, hostel inmates72050106054639774698.91
Moving labourers412757764907163195032831.64

Monthwise Adult Anopheles Mosquito Density, Larval Density and Malaria Cases

MonthAdult Mosquito DensityLarval DensityTotal Cases
Jan032.33559
Feb032.22.6333
Mar0322.6424
Apr0322.5337
May0334367
Jun0346569
Jul034.26.4955
Aug0346.71338
Sep033.261098
Oct03351041
Nov03341094
Dec032.831023
Jan042.42.6753
Feb042.22.6450
Mar042.22.3627
Apr0422.4799
May042.63.8953
Jun0445.81909
Jul044.16.22241
Aug043.96.51735
Sep043.15.81721
Oct04351669
Nov042.641612
Dec042.53.11852

See Guide to malaria treatment in Mangaluru

Drug Resistance Pattern in Mangaluru

Mangaluru is identified to have chloroquine resistance in P. falciparum. Accordingly, Mangaluru was one of the first cities in India to have switched over to artemisinin based combination for the treatment of P. falciparum malaria. Resistance to other antimalarial drugs is not known. NVBDCP now recommends Artesunate Plus Pyrimethamine-sulfadoxine for the treatment of all cases of P. falciparum in Mangaluru. P. vivax remains sensitive to chloroquine and therefore must be treated with chloroquine alone.

Travel to Mangaluru- Recommendations for Chemoprophylaxis

Mangaluru has now become endemic for malaria and as the figures above clearly indicate, nearly 10% of cases of malaria are caused by P. falciparum infection. And, resistance to chloroquine, of various degrees, has been noticed in Mangalore. Therefore, all travelers planning to visit Mangaluru are recommended the following chemoprophylaxis regimen:

Tablet Doxycycline 100 mg once daily (1.5mg/kg body weight for children above 8 years), (start 2 days before, continue during the stay at Mangaluru and for 4 weeks thereafter); alternatively, Tablet Mefloquine can be used at a dose of 250mg (5mg/kg body weight) weekly, starting 2 weeks before travel, continued during and for 4 weeks after travel.

For further details and dosage in children, see Chemoprophylaxis

©malariasite.com ©BS Kakkilaya | Last Updated: Apr 28, 2015

Malaria in India

Malaria endemic areas in India

Malaria endemic areas in India

Malaria has been a problem in India for centuries. Details of this disease can be found even in the ancient Indian medical literature like the Atharva Veda and Charaka Samhita. In the 30’s there was no aspect of life in the country that was not affected by malaria. During the latter parts of nineteenth and early twentieth centuries, nearly one-fourth of India’s population suffered from malaria, particularly in the states like Punjab and Bengal.[1] The economic loss due to the loss of man-days due to malaria was estimated to be at Rs. 10,000 million per year in 1935.

At the time of independence in 1947, of a population of 330 million, about 75 million people were estimated to be infected with malaria every year, and the direct mortality due to the disease was estimated at 0.8 million per annum.[2,3] To combat this menace, the Govt. of India launched the National Malaria Control Programme in April 1953. The programme proved highly successful and the number of malaria cases significantly declined to about 2 million by 1958.[4] Encouraged by this, the programme was changed to a more ambitious National Malaria Eradication Programme in 1958. By 1961 the incidence dropped further to a mere 49151 cases, with no deaths.[5]

But since then the programme suffered repeated set-backs due to technical, operational and administrative reasons and the cases started rising again.[3] Early setbacks in malaria eradication coincided with DDT shortages. Later in the 1960s and 1970s malaria resurgence was the result of technical, financial and operational problems. In the late 1960s malaria cases in urban areas started to multiply, and upsurge of malaria was widespread. As a result in 1976, 6.45 million cases were recorded by the National Malaria Eradication Programme (NMEP), highest since resurgence.

The implementation of urban malaria scheme (UMS) in 1971-72 and the modified plan of operation (MPO) in 1977 improved the malaria situation for 5-6 years. Malaria cases were reduced to about 2 million. The impact was mainly on vivax malaria. Easy availability of drugs under the MPO prevented deaths due to malaria and reduced morbidity. The P. falciparum containment programme (PfCP) launched in 1977 helped reduce falciparum malaria in the areas where the containment programme was operated but its general spread could not be contained. P. falciparum showed a steady upward trend during the 1970s and thereafter. Rising trend of malaria was facilitated by developments in various sectors to improve the national economy under successive 5 year plans.

Malaria, at one time a rural disease, diversified under the pressure of developments into various ecotypes. These ecotypes have been identified as forest malaria, urban malaria, rural malaria, industrial malaria, border malaria and migration malaria; the latter cutting across boundaries of various epidemiological types. Further, malaria in the 1990s has returned with new features not witnessed during the pre-eradication days. These are the vector resistance to insecticide(s); pronounced exophilic vector behaviour; extensive vector breeding grounds created principally by the water resource development projects, urbanization and industrialization; change in parasite formula in favour of P. falciparum; resistance in P. falciparum to chloroquine and other anti-malarial drugs; and human resistance to chemical control of vectors.[6]

Proportion of P. falciparum distribution in India [6]

Proportion of P. falciparum distribution in India [6]

According to the World Malaria Report 2014, 22% (275.5m) of India’s population live in high transmission (> 1 case per 1000 population) areas, 67%  (838.9m) live in low transmission (0–1 cases per 1000 population) areas and 11% (137.7m) live in malaria-free (0 cases) areas.[7] In 2013, 0.88 million cases have been recorded, with 128 million tests being conducted on the suspected cases, with P. falciparum causing 53% and P. vivax causing 47% of the infections. The incidence of malaria in India accounted for 58% of cases in the South East Asia Region of WHO.[7]

At present, official figures for malaria in India, available at NVBDCP,[8] indicate 0.7–1.6 million confirmed cases and 400-1,000 deaths annually[3,8].

Study Contradicts NVBDCP and WHO Data: A study conducted by teams from the office of the Registrar General of India, Centre for Global Health Research at St Michael’s Hospital and University of Toronto, Canada, published in The Lancet on 20 November 2010 has reported that malaria causes 205 000 malaria deaths per year in India before age 70 years (55 000 in early childhood, 30 000 at ages 5—14 years, 120 000 at ages 15—69 years) with a 1.8% cumulative probability of death from malaria before age 70 years. The report says that 90 per cent of the deaths were recorded in rural areas, of which 86 per cent occurred at home without any medical attention. It also found that Orissa reported the highest number of deaths — 50,000, followed by Chhattisgarh, Jharkhand and Assam. The study, which began in 2002, covered 6,671 areas, each with about 200 households.[9-11] However, WHO has rebutted these estimates.[12]

Yet other study on the global malaria mortality between 1980 and 2010 by Murray at al, published in The Lancet in Feb 2012, estimated the malaria mortality in India in 2010 at 46,800.[13]

According to the estimates of a 16-member committee set up by the National Vector Borne Disease Control Programme (NVBDCP) to assess India’s actual malaria death burden, the total annual number of cases in India may be about 9.7 million, with about 30,014 – 48,660 deaths (40,297 on an average).[14]

Another paper estimates the malaria burden in India at India at 180 million, with as many as 90 million cases of P. falciparum malaria per year.[15]

malaria-india-graph

All Malaria and P. falciparum malaria Cases Reported from India from 1995-2007 [14]

malaria-india-towns

Map Showing High Risk Towns for Malaria in India [16]

Malariaa Deaths in India

Malaria Deaths in India 2011-2014 [Source]

The biggest burden of malaria in India is borne by the most backward, poor and remote parts of the country, with >90-95% cases reported from rural areas and <5-10% from urban areas; however, the low malaria incidence in urban areas may be due to almost non-existing surveillance. The state of Orissa, with a population of 36.7 million (3.5%), contributes about 25% of the total annual malaria cases, more than 40% of P. falciparum malaria cases and nearly 20–30% of deaths caused by malaria in India, followed by Meghalaya, Mizoram, Maharashtra, Rajasthan, Gujarat, Karnataka, Goa, southern Madhya Pradesh, Chhattisgarh, and Jharkhand that also report significant number of malaria cases and deaths.[3,17] The proportion of P. vivax and P. falciparum varies in different parts of India; P. falciparum accounts for 30–90% of the infections in the forested areas inhabited by ethnic tribes and <10% of malaria cases in mostly indogangetic plains and northern hilly states, northwestern India, and southern Tamil Nadu.[3]

Unbridled urbanization, drought, migration of workers, and lax control efforts are all contributing to the resurgence of malaria in India and the problem is expected to exacerbate in the years to come. With increasing global warming, it is projected that in 2050s, malaria is likely to persist in Orissa, West Bengal and southern parts of Assam, bordering north of West Bengal, but may shift from the central Indian region to the south western coastal states of Maharashtra, Karnataka and Kerala. Also the northern states, including Himachal Pradesh and Arunachal Pradesh, Nagaland, Manipur and Mizoram in the northeast may become malaria prone.[18]

Incidence of Malaria in India (Sources 1,2) [For latest update, see http://nvbdcp.gov.in/malaria-new.html]

YearTotal casesP. falciparumDeaths
194775 million?8,00,000
196149151?
196259375?--
196387306?
1964112942?
196599667?--
1966148012?
1967278214
1968274634
1969347975
1970694017
19711322398
19721428649
19731930273
19743167658
19755166142
197664700000.75 million59
19774700000
19783600000
19793100000
19802800000
19812600000
19822182302
19832018605
19842.18 million0.65 million247
19851.86 million0.54 million213
19861.79 million0.64 million323
19871.66 million0.62 million188
19881.85 million0.68 million209
19892.05 million0.76 million268
19902.02 million0.75 million353
19912.12 million0.92 million421
19922.13 million0.88 million422
19932.21 million0.85 million354
19942.51 million0.99 million1122
19952.93 million1.14 million1151
19963.04 million1.18 million1010
19972.66 million1.01 million879
19982.22 million1.03 million664
19992.28 million1.14 million1048
20002.03 million1.05 million932
20012.09 million1.01 million1005
20021.84 million0.90 million973
20031.87 million0.86 million1006
20041.92 million0.89 million949
20051.82 million0.81 million963
20061.79 million0.84 million1707
20071.51 million0.74 million1311
20081.53 million0.77 million1055
20091.56 million0.84 million1144
20101.60 million0.83 million1018
20111.31 million0.67 million754
20121.07 million0.53 million519
20130.88 million0.46 million440
20141.07 million0.70 million535
Orissa, Chhattisgarh, West Bengal, Jharkhand and Karnataka contribute the most number of cases of malaria in India [6]

Orissa, Chhattisgarh, West Bengal, Jharkhand and Karnataka contribute the most number of cases of malaria in India [6]

Economic Burden: Sinton estimated a loss of Rupees 42 crores at 1935, based only on the financial loss in the community in terms of lost wages. In 1994, Shiv Lal and others estimated that, if there were no control activities and malaria was allowed to transmit from the 1947 level, there would have been an expenditure of Rupees 76,600 million (US$1,670 million) for medication, medical advise, hospitalization, and absenteeism. If the estimates of the Malaria Research Center, Delhi were taken into account for calculation of economic loss, the cost would have been Rupees 68,600 million (US$1,508 million) versus expenditures of Rupees 3,467.9 million (US$76.2 million) for control. Thus, the net savings due to malaria control was estimated at Rupees 65,132.1 million (US$1,431 million). These authors inferred that every Rupee invested in malaria control has produced a direct return of Rupees 19.70. The estimated man-days saved were 1,328.75 million per year.[3]

Realising the difficulties in controlling/eradicating malaria, the National Malaria Eradication Programme has been now renamed as National Anti Malaria Programme. (See National Vector Borne Disease Control Programme Website)

Malaria in Karnataka

Incidence of Malaria in Karnataka State and Dakshina Kannada District

YearTotal in Karnataka StateP. falciparum in Karnataka StateTotal in Dakshina Kannada DistrictP. falciparum in Dakshina Kannada District
199426668237934474421
19952858833970092211694
199621919832639124811749
19971814474651710057989
1998118685263698834685
199996156215234438295
2000107999279342653122
2001196306472004441449
2002132609296755069874
200310021823425102752051
20048131420579173474292
20058318121956210596135
20066286416446164734957
2007493551129586851768
20084734498646452675
20093655957235850682
20104412277717025984
2011242372648 6418651
2012164661278 6215422
201313302967 5660391
20141233510798240719

Source: NVBDCP Data Available at http://nvbdcp.gov.in/Doc/Malaria-situation-upto2011(P).pdf and data from District Malaria Officer, Mangalore and Malaria Cell, Mangalore City Corporation

Malaria in Dakshina Kannada District: Dakshina Kannada district is located on the western coast of Karnataka State. It was relatively free from malaria until early 1990 with only sporadic case reports. But since 1990, with a sudden spurt in industrialisation and construction activities, malaria has made a dramatic comeback here. The table below gives the details of the incidence as per the data available with the District Malaria Officer. The data is based on the study of only peripheral smears examined at the district laboratory and the primary health centres and it is generally a gross understatement. (QBC Technique is not accepted by the National Malaria Eradication Programme for diagnosis of malaria and hence data from private labs is not included).

Incidence of Malaria in Dakshina Kannada District [Source: District Malaria Officer, Mangalore]

YearPopulationSlides ExaminedTotalP. vivaxP. falciparumDeathsAPISlide Positivity RateP. falciparum percentage
19697370875750-0.100.00
1970617787570-0.120.00
19716884091910-0.130.00
1972859641671661-0.190.60
19731008791851841-0.180.54
19749682579781-0.081.27
19751182417517483-0.640.40
1976215378215480752255104114-2.433.382.18
197721537821544294004393074-1.862.591.85
19782031683548351137-1.751.04
19792276278184300291329058-1.281.580.27
19802303589178421233023237-1.011.310.30
19812303589180774163616360-0.710.900.00
198223475942066369819810-0.420.470.00
198321612622160884244240-0.200.200.00
198421612622135862402391-0.110.110.42
198521970852169941321320-0.060.060.00
198622195672435661751741-0.080.070.57
198721471492553901051050-0.050.040.00
19882151449265928867610-0.040.0311.63
198921669302890062792772-0.130.100.72
199025654002767851141104-0.040.043.51
199125825002871713403346-0.130.121.76
1992263810029865899296824-0.380.332.42
199326906003255124588458424-1.711.410.52
199427467003154934744472321-1.731.500.44
19952772800358312922175271694263.332.5718.37
199627926004181101248110732174954.472.9914.01
1997283450036912010057906898943.552.729.83
1998*16753002555068834814968515.273.467.75
199917169822144874438414329512.582.076.65
200017259802214792653253112201.541.204.60
200118886802666614441399244922.351.6710.11
200219266262829055069419587452.631.7917.24
20031955500325690102758224205135.253.1519.96
200419632782909471734713055429248.845.9624.74
2005196450032886221059149246135710.726.4029.13
2006196527828895016473115164957148.385.7030.09
20072084612281558868569171768114.173.0820.36
200820846122979546452577767503.102.1710.46
200921467463057195850516868212.731.9111.66
201021467463100077025604198413.272.2714.01
2011214674629992564185767651-2.992.1410.14
2012222063628743062155793422-2.802.166.79
201322206363055705660526939102.551.856.91
201422206363437588240752171923.712.408.73

* In 1998 the district was bifurcated into Dakshina Kannada and Udupi districts, hence the numbers; Most of these cases in Dakshina Kannada have occurred in the city of Mangalore, its head quarters.

Also see: Malaria in Mangaluru

Further Reading:

  1. Richard Tren. Malaria and Climate Change. Working Papers Series: Julian Simon Centre For Policy Research. October 2002. Full Text at http://www.libertyindia.org/pdfs/malaria_climatechange2002.pdf
  2. Shiv Lal, Sonal GS, Phukan PK. Status of Malaria in India. Journal of Indian Academy of Clinical Medicine. 2000;5(1):19-23. Full Text at http://medind.nic.in/jac/t00/i1/jact00i1p19.pdf
  3. Ashwani Kumar, Neena Valecha, Tanu Jain, Aditya P. Dash. Burden of Malaria in India: Retrospective and Prospective View. Am J Trop Med Hyg. 2007;77(6_Suppl):69-78. Full Text at http://www.ajtmh.org/cgi/reprint/77/6_Suppl/69
  4. PB Health. National Vector Borne Disease Control Progrmme. Available at http://pbhealth.gov.in/pdf/malaria.pdf
  5. Dash AP, Valecha N, Anvikar AR, Umar A. Malaria in India: Challenges and opportunities. J. Biosci. 2008;33:583–592. Available at http://www.ias.ac.in/jbiosci/nov2008/583.pdf
  6. Sharma VP. Re-emergence of malaria in India. Indian J Med Res 1996 Jan 103 26-45
  7. WHO. World Malaria Report 2014. WHO, Geneva. 2014. Available at http://apps.who.int/iris/bitstream/10665/144852/2/9789241564830_eng.pdf
  8. Malaria situation. National Vector Borne Disease control Programme. Available at http://nvbdcp.gov.in/Doc/mal_situation_Jan2015.pdf
  9. Dhingra N et al. Adult and child malaria mortality in India: a nationally representative mortality survey. The Lancet. 20 November 2010;376(9754):1768-1774. doi:10.1016/S0140-6736(10)60831-8. Full Text at http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)60831-8/fulltext#
  10. Hay SI, Gething PW, Snow RW. India’s invisible malaria burden. The Lancet. 20 November 2010;376(9754):1716-1717. doi:10.1016/S0140-6736(10)61084-7. Available at http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)61084-7/fulltext
  11. Indian Express. 2 lakh in India die of malaria annually: Lancet. Available at
    http://www.indianexpress.com/news/2-lakh-in-India-die-of-malaria-annually–Lancet/700930
  12. WHO Stands By Its Malaria Death Estimates. Available at http://blogs.wsj.com/indiarealtime/2010/10/21/who-questions-lancet-on-india-malaria-death-numbers/
  13. Murray CJL et al. Global malaria mortality between 1980 and 2010: a systematic analysis. The Lancet. 2012;379(9814):413-431. doi:10.1016/S0140-6736(12)60034-8. Available at http://www.lancet.com/journals/lancet/article/PIIS0140-6736(12)60034-8/fulltext
  14. Kounteya Sinha. India to raise malaria toll figure 40-fold. Times News Network. Feb 4, 2012. Available at http://articles.timesofindia.indiatimes.com/2012-02-04/india/31024354_1_malaria-deaths-malaria-like-high-fever-malaria-infection
  15. Brooks MI, Singh N, Hamer DH. Control measures for malaria in pregnancy in India. Indian Journal of Medical Research. Sep 2008. Available at http://findarticles.com/p/articles/mi_qa3867/is_3_128/ai_n32060546
  16. Malaria Country Profile India (1995-2007). Available at http://www.whoindia.org/LinkFiles/Malaria_Country_Profile-Malaria.pdf
  17. A Profile of National Institute of Malaria Research. Estimation of True Malaria Burden in India. pp 91-99. Available at http://www.mrcindia.org/MRC_profile/profile2/Estimation of true malaria burden in India.pdf
  18. Bhattacharya S, Sharma C, Dhiman RC, Mitra AP. Climate change and malaria in India. Current Science. 10 Feb 2006;90(3):369-375. Full text at http://www.ias.ac.in/currsci/feb102006/369.pdf

©malariasite.com ©BS Kakkilaya | Last Updated: Oct 2, 2016

Global Malaria Risk

Malaria in Africa: Risk, Resistance and Prophylaxis

CountryMalaria RiskSpeciesDrug ResistanceProphylaxis
AlgeriaSmall focus in Ihrir (Illizi Department); Sporadic P. vivax and imported P. falciparumSporadic P. vivax and imported P. falciparumSporadic casesAvoid mosquitoes
AngolaAll areasMainly P. falciparum (92%); P. ovale and P. malariae also occurResistance to chloroquine and Sulfa-PyrimethAtovaquone/proguanil or doxycycline or mefloquine
BeninAll areasMainly P. falciparum; P.n malariae alsoMulti-drug resistant P. falciparumAtovaquone/proguanil or doxycycline or mefloquine
BotswanaNorthern districts of Central, Chobe, Ngamiland, North East, and OkavangoMainly P. falciparumChloroquine resistance Atovaquone/proguanil or doxycycline or mefloquine
Burkina FassoAll areasP. falciparum in >95%; P. malariae, P. ovale knownResistance not commonAtovaquone/proguanil or doxycycline or mefloquine
BurundiAll areasMostly P. falciparum; P.n malariae in Rusizi valleyChloroquine resistance knownAtovaquone/proguanil or doxycycline or mefloquine
CameroonAll areasMainly P. falciparum; P. malariae and P. ovale alsoMulti drug resistanceAtovaquone/proguanil or doxycycline or mefloquine
Canary IslandsNo malariaNo malariaNo malariaNone
Cape VerdeAll areas; seasonalOnly P. falciparum; imported P. malariae and P. ovaleNo resistanceAvoid mosquitoes
Central African RepublicAll areasP. falciparum; imported P. malariae?Multi drug resistanceAtovaquone/proguanil or doxycycline or mefloquine
ChadMainly southern parts and bordering SudanP. falciparumChloroquine resistanceAtovaquone/proguanil or doxycycline or mefloquine
Comoros IslandAll areasP. falciparum?Multi drug resistanceAtovaquone/proguanil or doxycycline or mefloquine
CongoAll areasP. falciparum?Multi drug resistanceAtovaquone/proguanil or doxycycline or mefloquine
Cote d'IvoireAll areasP. falciparumChloroquine resistanceAtovaquone/proguanil or doxycycline or mefloquine
Democratic Republic of Congo (Zaire)All areasP. falciparumChloroquine resistanceAtovaquone/proguanil or doxycycline or mefloquine
DjiboutiAll areasAlmost all due to P. falciparum; P. vivax in Balbala areaChloroquine resistanceAtovaquone/proguanil or doxycycline or mefloquine
EgyptFree from malaria except in El Fayoum Oasis areaP. vivaxNot knownNone
Equatorial GuineaAll areasMostly P. falciparum; a few cases of P. malariae and P. vivaxChloroquine resistanceAtovaquone/proguanil or doxycycline or mefloquine
EritreaAll areasP. falciparum (90%) and P. vivax (10%)Chloroquine resistanceAtovaquone/proguanil or doxycycline or mefloquine
EthiopiaAll areas except border areas with Somalia and Djibouti and the city of Addis AbabaMostly P. falciparum; a few cases of P. malariae and P. vivaxChloroquine resistanceAtovaquone/proguanil or doxycycline or mefloquine
GabonAll areasMostly P. falciparum; a few cases of P. malariae and P. ovaleMulti drug resistanceAtovaquone/proguanil or doxycycline or mefloquine
GambiaAll areasP. falciparum?Multi drug resistanceAtovaquone/proguanil or doxycycline or mefloquine
GhanaAll areasP. falciparum?Multi drug resistanceAtovaquone/proguanil or doxycycline or mefloquine
GuineaAll areasP. falciparumChloroquine resistanceAtovaquone/proguanil or doxycycline or mefloquine
Guinea BissauAll areasP. falciparum (90%); a few cases of P. malariae and P. ovale (10%)Chloroquine resistanceAtovaquone/proguanil or doxycycline or mefloquine
KenyaAll areas at altitudes lower than 2,500 meters; no risk in NairobiP. falciparum?Multi drug resistanceAtovaquone/proguanil or doxycycline or mefloquine
LesothoNo malariaNo malariaNo malariaNone
LiberiaAll areasP. falciparum (82%), P. malariae (39%) and P. ovale (9%)Resistance to chloroquine and Sulfa-PyrimethAtovaquone/proguanil or doxycycline or mefloquine
LibyaNo malariaNo malariaNone
MadagascarAll areasP. falciparum?Multi drug resistanceAtovaquone/proguanil or doxycycline or mefloquine
MalawiAll areasP. falciparum?Multi drug resistanceAtovaquone/proguanil or doxycycline or mefloquine
MaliAll areasP. falciparum (95%); P. ovale and P. malariae (5%)?Multi drug resistanceAtovaquone/proguanil or doxycycline or mefloquine
MauritaniaAll areasMostly P. falciparum; a few cases of P. malariae and P. vivaxChloroquine resistanceAtovaquone/proguanil or doxycycline or mefloquine
MauritiusRural areas only; no risk on Rodrigues IslandMostly P. falciparumResistance to chloroquine and Sulfa-PyrimethAtovaquone/proguanil or doxycycline or mefloquine
MayotteAll areasOnly P. falciparum?Multi drug resistanceAtovaquone/proguanil or doxycycline or mefloquine
MoroccoLimited risk in rural areas of Khouribga ProvinceP. vivaxNo resistanceNone
MozambiqueAll areasP. falciparum?Multi drug resistanceAtovaquone/proguanil or doxycycline or mefloquine
NamibiaOnly northern parts- provinces of Kunene, Ohangwena, Okavango, Caprivi, Omaheke, Omusati, Oshana, Oshikoto, and Otjozondjupa.P. falciparumChloroquine resistanceAtovaquone/proguanil or doxycycline or mefloquine
NigerAll areasP. falciparumChloroquine resistanceAtovaquone/proguanil or doxycycline or mefloquine
NigeriaAll areasP. falciparum?Multi drug resistanceAtovaquone/proguanil or doxycycline or mefloquine
ReunionNo malariaNo malariaNo malariaNone
RwandaAll areasP. falciparumMulti drug resistanceAtovaquone/proguanil or doxycycline or mefloquine
Sao Tome and PrincipeAll areasMostly P. falciparum; P. malariae, P. ovale and P. vivax also reportedMulti drug resistanceAtovaquone/proguanil or doxycycline or mefloquine
SenegalAll areasMostly P. falciparum; a few cases due to P. malariae and P. ovaleMulti drug resistanceAtovaquone/proguanil or doxycycline or mefloquine
SeychellesNo malariaNo malariaNo malariaNone
Sierra LeoneAll areasMostly P. falciparumMulti drug resistanceAtovaquone/proguanil or doxycycline orn mefloquine
SomaliaAll areasMostly P. falciparum (90%); also P. malariae and P. vivaxChloroquine resistanceAtovaquone/proguanil or doxycycline or mefloquine
South AfricaAreas with risk: Low altitude areas of the Mpumalanga Province, Northern Province, and northeastern KwaZulu-Natal as far south as the Tugela River, Kruger National Park.Mostly P. falciparum (96%); P. ovale (4%)Resistance to chloroquine and Sulfa-PyrimethAtovaquone/proguanil or doxycycline or mefloquine
St. HelenaNo malariaNo malariaNo malariaNone
SudanAll areasP. falciparum (>85%);
P. vivax, P. ovale and P. malariae cause the rest
Multi drug resistanceAtovaquone/proguanil or doxycycline or mefloquine
SwazilandRisk in all lowlandsP. falciparumChloroquine resistanceAtovaquone/proguanil or doxycycline or mefloquine
TanzaniaAll areas at altitudes lower than 1,800 metersMostly P. falciparum?Multi drug resistanceAtovaquone/proguanil or doxycycline or mefloquine
TogoAll areasMostly P. falciparum (90%); also P. malariae and P. ovaleMulti drug resistanceAtovaquone/proguanil or doxycycline or mefloquine
TunisiaOnly imported casesMostly P. falciparumNo resistanceNone
UgandaAll areasMostly P. falciparumMulti drug resistanceAtovaquone/proguanil or doxycycline or mefloquine
ZambiaAll areasMostly P. falciparumMulti drug resistanceAtovaquone/proguanil or doxycycline or mefloquine
ZimbabweAll areas except the cities of Harare and BulawayoMostly P. falciparumMulti drug resistanceAtovaquone/proguanil or doxycycline or mefloquine

Malaria in Asia: Risk, Resistance and Prophylaxis

CountryMalaria RiskSpeciesDrug ResistanceProphylaxis
AfghanistanRisk in all areas at altitudes lower than 2000 meters from April to DecemberP. vivax and P. falciparumChloroquine-resistant P. falciparumChloroquine +proguanil; atovaquone/proguanil, doxycycline, mefloquine
BahrainNo malariaNo malariaNo Risk
BangladeshAll areas except city of DhakaP. vivax and P. falciparumP. falciparum resistant to chloroquine and Pyrimethamine/SulfaAtovaquone/proguanil or doxycycline or mefloquine
BhutanRisk in the southern belt of five districts: Chirang, Samchi, Samdrupjongkhar, Sarpang, and Shemgang. P. vivax and P. falciparumP. falciparum resistant ton chloroquine and Pyrimethamine/SulfaAtovaquone/proguanil, doxycycline, mefloquine
Brunei Darussalam No riskNo malariaNo risk
Burma (Myanmar) Rural only. No risk in cities of Yangon and Mandalay (Throughout the year in Karen State; March to December in Chin, Kachin, Kayah, Mon, Rakhine and Shan states, Pegu Division, and Hlegu, Hmawbi, and Taikkyi townships of Yangon Division; April to December in the rural areas of Tenasserim Division; May to December in Irrawaddy Division and the rural areas of Mandalay Division; June to November in the rural areas of Magwe Division, and in Sagaing Division)Predominantly due to P. falciparum; alson P. vivaxP. falciparum resistant ton chloroquine and Pyrimethamine/Sulfa; Mefloquine resistance reported in the eastern part ofn Shan StateAtovaquone/proguanil, doxycycline, mefloquine (not in eastern part of Shan State)
Cambodia All areas including Angkor Wat temple complex; no risk in Phnom Penh and around Lake Tonle SapPredominantly due to P. falciparum; alson P. vivaxMulti drug resistance P. falciparum: Resistance to chloroquine and pyrimeth/sulfadoxine; resistance to mefloquine reported in western provinces near the Thai borderAtovaquone/proguanil, doxycycline, mefloquine (not in western provinces)
ChinaRisk in rural areas of Hainan, Yunnan, Fuijan, Guangdong, Guangxi, Guizhou, Sichuan, Tibet (in the Zangbo River Valley only), Anhui, Hubei, Hunan, Jiangsu, Jiangxi, Shandong, Shanghai and Zhejiang provinces. Transmission during warm weather (North of 33 N: July to November; between 33 N to 25 N: May to December; south of 25u00b0 N: year-round); No malaria risk in urban areas nor in the densely populated plain areas.P. falciparum as well as P.n vivaxMultidrug-resistant P. falciparum in Hainan and Yunnan provincesNo need unless planning to stay in remote rural areas; Travelers to rural areas of the Hainan and Yunnan provinces should take atovaquone/proguanil or doxycycline or mefloquine; chloroquine would suffice for other areas
China - Hong KongNo risk in urban areas; limited risk in extremely rural areasP. falciparum as well as P. vivaxNo resistanceChloroquine in remote rural areas
China - MacaoNo riskNo malariaNo risk
CyprusNo riskNo malariaNo risk
East TimorAll areasPredominantly P. falciparumP. falciparum resistant ton chloroquine and Pyrimetha/SulfaAtovaquone/proguanil, doxycycline, mefloquine
IndiaAll areas lower than 2,000 meters (thatn excludes some parts of the states of Himachal Pradesh, Jammu, Kashmir, and Sikkim)P. vivax (80%); P. falciparum (20%)P. falciparum, resistant to chloroquine all over, resistant to Sulfa/pyrimethamione in north eastern statesAtovaquone/proguanil, doxycycline, mefloquine
IndonesiaAll areas including Irian Jaya, temple complex of Borobudur on Java and rural areas of remainder of the islands. No risk in Jakarta Municipality, big cities and resorts in Java, Sumatra and BaliP. falciparum and P. vivaxP. falciparum resistant ton chloroquine and Pyrimetha/Sulfa; P. vivax resistant to chloroquineAtovaquone/proguanil or doxycycline or mefloquine
IranP. vivax in some areas north of the Zagros mountains and in western and south-western regions during the summer months; P. falciparum in rural areas of Sistan-Baluchestan, Kerman (southern tropical part) and Hormozgan Provinces during March to NovemberP. falciparum and P. vivaxP. falciparum resistant to chloroquine and Sulfa-PyrimethChloroquine in P. vivax risk areas; chloroquine + proguanil in P. falciparum risk areas
IraqAreas in the north below 1500 m - Provinces of Duhok, Erbil, Ninawa, Sulaimaniya, Tamim, and BasrahOnly P. vivaxNo chloroquine resistanceChloroquine only
IsraelFree from malariaNo malariaNo malaria
JapanNo riskNo malariaNo risk
JordanNo riskNo malariaNo risk
Korea, DPR (North)Limited risk in some southern areasOnly P. vivaxNo resistanceLimited risk
Korea, Republic (South)Risk limited to Demilitarized Zone and to rural areas in the northern parts of Kyonggi Do and Gangwon Do ProvincesOnly P. vivaxNo resistanceLimited risk
KuwaitNo riskNo malariaNo risk
Lao People's Democratic Republicn (Laos)All areas exceptu00a0the city of VientianeMostly P. falciparumChloroquine resistanceAtovaquone/proguanil or doxycycline or mefloquine
LebanonNo riskNo malariaNo risk
MalaysiaRisk limited to rural areas; no risk in urban and coastal areasP. falciparum; some cases of P. knowlesiResistance to chloroquine and Sulfa-PyrimethAtovaquone/proguanil or doxycycline or mefloquine
MaldivesNo riskNo malariaNo risk
MongoliaNo riskNo malariaNo risk
NepalRural areas in the Terai and Hill Districts of Bara, Dhanukha, Kapilvastu, Mahotari, Parsa, Rautahat, Rupendehi and Sarlahi, and especially along the Indian border; at altitudes lower than 1,200 meters; no risk in Kathmandu and typical Himalayan treksPredominantly due to P. vivax, also P. falciparumP. falciparum resistant to chloroquine and Sulfa-PyrimethAtovaquone/proguanil or doxycycline or mefloquine
OmanLimited risk in remote areas of Musandam Province; no cases since 2001P. falciparumChloroquine resistanceLimited risk; no need
PakistanAll areas, including the cities, at altitudes lower than 2,000 metersP. falciparum (~60%), P. vivax (~40%)Resistance to chloroquine and Sulfa-PyrimethAtovaquone/proguanil or doxycycline or mefloquine
PhilippinesThroughout the year in areas below 600 m, rural areas and Subic Bay; no risk in the provinces of Aklan, Bilaran, Bohol, Capiz Catanduanes, Cebu, Guimaras, Iloilo, Leyte, Masbate, northern Samar, Sequijor and metropolitan Manila as well as urban areas or in the plainsPredominantly P. falciparum; Also P. vivaxP. falciparum resistant to chloroquine and Sulfa-PyrimethAtovaquone/proguanil or doxycycline or mefloquine
QatarNo riskNoneNo malariaNo risk
Saudi ArabiaThroughout the year in most of the Southern Region - Jizan province (except in the high-altitude areas of Asir Province) and in certain rural areas of the Western Region; no risk in cities of Jeddah, Mecca, Medina and Taif.Predominantly P. falciparumChloroquine resistanceChloroquine+Proguanil or Atovaquone/proguanil or doxycycline or mefloquine
SingaporeNo riskNoneNo malariaNo risk
Sri LankaRisk in all areas except the districts of Colombo, Galle Kalutara, and Nuwara EliyaP. vivax (87%), P. falciparum (13%)Resistance to chloroquine and Sulfa-PyrimethChloroquine+Proguanil or Atovaquone/proguanil or doxycycline or mefloquine
Syrian Arab RepublicLimited risk from May to October in foci along the northern border, especially in the north-eastern part of the country (in El Hassaka province)Only P. vivaxNo resistanceOnly Chloroquine for areas with risk
TaiwanNo riskNoneNo malariaNo risk
ThailandLimited risk throughout the year in rural, especially forested and hilly areas of the whole country, mainly towards the international borders with Cambodia, Laos, and Burma. No risk in cities and major tourist resorts like Bangkok, Chiangmai, Pattaya, Phuket, SamuiP. vivax and P. falciparum; some cases of P. knowlesiP. falciparum resistant to chloroquine and Sulfa-Pyrimeth; resistance to mefloquine and to quinine near the borders with Cambodia and Myanmar.Atovaquone/proguanil or doxycycline or mefloquine; doxycycline for areas near Cambodia and Myanmar borders
TurkeyRisk from May to October in the south-eastern parts and in Amikova and Cukurova Plain. No risk in the main tourist areas in the west and south-west of the countryOnly P. vivaxNo resistanceOnly Chloroquine
United Arab EmiratesNo riskNoneNo malariaNo risk
VietnamAll areas except urban centres, the Red River delta, and the coastal plain areas of central Viet Nam. High-risk areas are the provinces of Dak Lak, Gia Lai and Kon Tum, Ca Mau, Bac Lieu, and Tay Ninh; no risk in Hanoi, Ho Chi Minh City, Da Nang, Nha Trang, Qui Nhon and HaiphongPredominantly P. falciparum; some cases of P. knowlesiResistance to chloroquine and Sulfa-PyrimethAtovaquone/proguanil or doxycycline or mefloquine
YemenAll areas at altitudes lower than 2,000 meters; no risk in Sana'aPredominantly P. falciparumChloroquine resistanceChloroquine+Proguanil

Malaria in South East Asia Region: South and South eastern Asia (SEA region) harbours most cases of malaria in the Asian continent. An estimated 1,216 million people or 70% of the total population of SEA Region are at risk of malaria. Out of which around 29% population at moderate to high risk of malaria, 71% are at low risk of malaria where as remaining 30% of population free from malaria (See Table). About 96% of the population of moderate to high risk of malaria in SEA Region are living in Bangladesh, India, Indonesia, Myanmar and Thailand and contributing more than 95% of confirmed malaria cases and deaths. During 2000-2009, in SEA Region, malaria confirmed cases of malaria ranged between 2.16 -2.83 millions and malaria deaths between 3188 – 6978. The proportion of P. falciparum was between 44 – 60%.

During 2009 total 2.7 million confirmed  malaria cases (Microscopically and RDT) and 3188  malaria deaths were reported in the Region where as estimated malaria cases were around 26 -36 million  and malaria deaths between 42300 – 77300. The P. faciparum proportion remained around 60.5% (including RDT positives). The highest number laboratory confirmed cases were reported from India (1,563,344)  followed by Indonesia (544,470) and Myanmar (414,008) where as the lowest number of cases was reported from Sri Lanka (558) followed by Bhutan(972) and Nepal(3,335). Among the population living in malarious areas, infants, young children and pregnant women have been identified as higher malaria risk group. Other group of people which constitute higher malaria risk are mobile population particularly those engaged in forest-related economy, gem-mining, fishing, industrial and road construction work. In some countries, ethnic minorities, refugees, displaced persons tourists and pilgrims also constitute high risk group.[4]

Malaria situation in forest and forest related areas remains serious problem due to highly efficient vectors, multiple-vector transmission, prolonged transmission season, and drug-resistant P. falciparum malaria combined with large scale and uncontrolled population movement. Forest related malaria constitutes about 40% of total malaria cases of total malaria cases and about 60% of the total P. falciparum cases in the Region. As forests are becoming increasingly accessible due to the exploitation of their natural resources, very often such population movements result in epidemics of malaria in such areas.[4]

Several cases of P. knowlesi, acquired from macaque monkeys, have been reported from countries such as Malaysia, Thailand, Viet Nam, Myanmar, and Phillippines.[5-9]

Malaria in Australia and Oceania: Risk, Resistance, Prophylaxis

CountryMalaria RiskSpeciesDrug ResistanceProphylaxis
AustraliaNo malariaNo malariaNo malariaNo risk
Cook IslandNo malariaNo malariaNo malariaNo risk
FijiNo malariaNo malariaNo malariaNo risk
French Polynesia (Society Islands [Tahiti, Moorea, Bora-Bora], Marquesas Islands [Nuku Hiva, Hiva Oa, Ua Huka], and Austral Islands [Tubuai, Rurutu, Rimatara, Rapa])No malariaNo malariaNo malariaNo risk
Kiribati (Tarawa, Tabuaeran [Fanning Island], Kiritimati [Christmas Island], and Banaba [Ocean Island])No malariaNo malariaNo malariaNo risk
Marshall IslandsNo malariaNo malariaNo malariaNo risk
Micronesia (Yap Islands, Pohnpei, Chuuk, Kosrae)No malariaNo malariaNo malariaNo risk
NauruNo malariaNo malariaNo malariaNo risk
New CaledoniaNo malariaNo malariaNo malariaNo risk
New ZealandNo malariaNo malariaNo malariaNo risk
NiueNo malariaNo malariaNo malariaNo risk
Northern Mariana Islands (Saipan, Tinian, Rota Island)No malariaNo malariaNo malariaNo risk
PalauNo malariaNo malariaNo malariaNo risk
Papua New GuineaRisk in all areas lower than 1800 metersPredominantly P. falciparum; also P. vivaxP. falciparum resistant to chloroquine and Sulfa-Pyrimeth; P. vivax resistant to chloroquineAtovaquone/proguanil or doxycycline or mefloquine
PitcairnNo malariaNo malariaNo malariaNo risk
SamoaNo malariaNo malariaNo malariaNo risk
Solomon IslandsRisk in all areas except for the southern province of Rennell and Bellona, the eastern province of Temotu, and the outer islands of Tikopia, Anuta, and FatutakaPredominantly P. falciparumP. falciparum resistant to chloroquine and pyrimeth/sulfadoxineAtovaquone/proguanil or doxycycline or mefloquine
TokelauNo malariaNo malariaNo malariaNo risk
TongaNo malariaNo malariaNo malariaNo risk
TuvaluNo malariaNo malariaNo malariaNo risk
U.S. Trust Territory of the Pacific Islands (Guam, American Samoa, Johnston Atoll, Wake Island, Midway Islands)No malariaNo malariaNo malariaNo risk
VanuatuRisk in all areas.Predominantly P. falciparum; also P. vivaxP. falciparum resistant to chloroquine and Sulfa-Pyrimeth; P. vivax resistant to chloroquineAtovaquone/proguanil or doxycycline or mefloquine
Wallis and FutunaNo malariaNo malariaNo malariaNo risk

Malaria in North America: Risk, Resistance, Prophylaxis

CountryMalaria RiskSpeciesDrug ResistanceProphylaxis
AnguillaNo malariaNo malariaNo malariaNo risk
Antigua & BarbudaNo malariaNo malariaNo malariaNo risk
BahamasNo malariaNo malariaNo malariaNo risk
BarbadosNo malariaNo malariaNo malariaNo risk
BelizeAll districts, but risk is highest in the southern region.Almost exclusively P. vivaxNo resistanceChloroquine
BermudaNo malariaNo malariaNo malariaNo risk
CanadaNo malariaNo malariaNo malariaNo risk
Cayman IslandsNo malariaNo malariaNo malariaNo risk
Costa RicaModerate risk throughout the year in the cantons of Los Chiles (Alajuela Province) and Matina and Talamanca (Limon Province); lower risk in cantons in the provinces of Alajuela, Guanacaste and Heredia, and in other cantons in Limon Province; negligible or no risk in the other cantons.Almost exclusively P. vivaxNo resistanceChloroquine
CubaNo malariaNo malariaNo malariaNo malaria
DominicaNo malariaNo malariaNo malariaNo malaria
Dominican RepublicLow risk throughout the year in rural areas of the western provinces (Castanuelas, Hondo Valle and Pepillo Salcedo)Only P. falciparumNo resistanceChloroquine
El SalvadorVery low risk throughout the year in Santa Ana, Ahuachapan and La Union Provinces, in rural areas of migratory influence from Guatemala.Only P. vivaxNo resistanceChloroquine
GrenadaNo malariaNo malariaNo malariaNo malaria
Guadeloupe and St. Martin Island No malariaNo malariaNo malariaNo malaria
GuatemalaRisk throughout the year below 1500 m; high risk in Alta Verapaz, Baja Verapaz, Peten and San Marcos, and moderate risk in Escuintla, Huehuetenango, Izabal, Quiche, Retalhuleu, Suchitepequez and Zacapa.Predominantly P. vivaxNo resistanceChloroquine
HaitiThroughout the year in forest areas in Chantal, Gros Morne, Hinche, Jacmel and Maissade.Only P. falciparumNo resistanceChloroquine
HondurasHigh risk throughout the year; low risk inn San Pedro Sula and the city of Tegucigalpa. P. falciparum risk is the highest in Sanitary Region VI, including Islas de la Bahia.Predominantly due to P. vivax; also P. falciparumNo resistanceNo resistance
JamaicaNo malariaNo malariaNo malariaNo malaria
MartiniqueNo malariaNo malariaNo malariaNo malaria
MexicoThroughout the year in some rural areas - high risk in the states of Chiapas, Quintana Roo, Sinaloa and Tabasco; moderate risk in the states of Chihuahua, Durango, Nayarit, Oaxaca and Sonora; and low risk in Campeche, Guerrero, Michoacan and Jalisco.Almost exclusively P. vivaxNo resistanceChloroquine
MontserratNo malariaNo malariaNo malariaNo malaria
Netherlands Antilles (including Aruba, Bonaire, Curacao, and Sint Maarten islands)No malariaNo malariaNo malariaNo malaria
NicaraguaHigh risk throughout the year in Chinandega, Jinotega, Nueva Segovia, RAAN, RAAS and Rio San Juan; low or negligible risk in Carazo, Madriz and MasayaPredominantly P. vivaxNo resistanceChloroquine
PanamaLow risk throughout the year in Bocas del Toro in the west and Darien and San Blas in the east; no or negligible risk in other areas. Predominantly P. vivaxChloroquine-resistant P. falciparum in Darien and San Blas provinces.Chloroquine for Bocas Del Toro Province; atovaquone/proguanil or doxycycline or mefloquine for Dariu00e9n Province and San Blas Province (including the San Blas Islands)
Puerto RicoNo malariaNo malariaNo malariaNo malaria
St. LuciaNo malariaNo malariaNo malariaNo malaria
St. Vincent & GrenadinesNo malariaNo malariaNo malariaNo malaria
St. Kitts & NevisNo malariaNo malariaNo malariaNo malaria
Trinidad & TobagoNo malariaNo malariaNo malariaNo malaria
Turks and CaicosNo malariaNo malariaNo malariaNo malaria
United StatesNo malariaNo malariaNo malariaNo malaria
Virgin Islands (U.S.)No malariaNo malariaNo malariaNo malaria
Virgin Islands (U.K.)No malariaNo malariaNo malariaNo risk

Malaria in South America: Risk, Resistance, Prophylaxis

CountryMalaria RiskSpeciesDrug ResistanceProphylaxis
ArgentinaLimited risk in rural areas along the borders with Bolivia (lowlands of Jujuy and Salta provinces) and with Paraguay (lowlands of Corrientes and Misiones provinces).Only P. vivaxNo resistanceChloroquine for risk areas
BoliviaThroughout the year below 2500 m in the departments of Beni, Pando, Santa Cruz and Tarija, and in the provinces of Lacareja, Rurenabaque, and North and South Yungas in La Paz Department. Lower risk exists in Cocha-bamba and Chuquisaca. Falciparum malaria occurs in Beni and Pando, especially in the localities of Guayaramerin, Puerto Rico and Riberalta.Predominantly due to P. vivaxP. falciparum resistant to chloroquine and pyrimeth/sulfadoxineChloroquine; mefloquine for northern departments
BrazilMost forested areas below 900 m within the nine states of the "Legal Amazonia" region (Acre, Amapa, Amazonas, Maranhao (western part), Mato Grosso (northern part), Para (except Belem City), Rondonia, Roraima and Tocantins; risk is negligible or non-existent in other areasP. vivax (77%), P. falciparum (23%)Multidrug-resistant P. falciparumAtovaquone/proguanil or doxycycline or mefloquine
ChileNo malariaNo malariaNo malariaNo malaria
ColombiaHigh risk throughout the year in rural/jungle areas below 800 m, especially in the Amazonia, Orinoquia, Pacifico and Uraba-Bajo Cauca regions; highest risk in Amazonas, Choco, Cordoba, Guainia, Guaviare, Putumayo and Vichada. Chloroquine-resistant P. falciparum exists in Amazonia, Pacifico and Uraba-Bajo Cauca. P. vivax (54%), P. falciparum (46%) P. falciparum resistant to chloroquine and pyrimeth/sulfadoxineAtovaquone/proguanil or doxycycline or mefloquine
EcuadorRisk throughout the year below 1500 m; some risk in Cotopaxi, Loja and Los Rios, higher risk in El Oro, Esmeraldas and Manabi, no risk in Guayaquil or Quito.P. vivax (77%)P. falciparum (23%)Chloroquine resistant P. falciparum in Esmeraldas ProvinceChloroquine for most; mefloquine for Esmeraldas province
Falkland IslandsNo malariaNo malariaNo malariaNo malaria
French GuianaHigh risk throughout the year in nine municipalities bordering Brazil (Oiapoque river valley) and Suriname (Maroni river valley); risk is low or negligible in the other 13 municipalities.P. falciparum (70%), P. vivax (30%)Multidrug-resistant P. falciparumAtovaquone/proguanil or doxycycline or mefloquine
GuyanaHigh risk throughout the year in all parts of the interior; sporadic cases in the densely populated coastal belt.P. vivax (52%), P. falciparum (48%)Chloroquine-resistant P. falciparumAtovaquone/proguanil or doxycycline or mefloquine
ParaguayModerate risk in the Alto Paraa, Caaguazu and Canendiyu areas; no or negligible risk in other aeras.Only P. vivaxNo resistanceChloroquine
PeruHigh risk in Ayacucho, Cajamarca, Cerro de Pasco, Chachapoyas, Chanca-Andahuaylas, Cutervo, Cusco, Huancavelica, Jaen, Junin, La Libertad, Lambayeque, Loreto, Madre de Dios, Piura, San Martin, Tumbes and Ucayali araes. P. falciparum in Jaen, Lambayeque, Loreto, Luciano Castillo, Piura, San Martin, Tumbes and Ucayali araes.P. vivax (78%), P. falciparum (22%)P. falciparum resistant to chloroquine and pyrimeth/ sulfadoxineAtovaquone/proguanil or doxycycline or mefloquine
SurinameHigh risk throughout the year in the three southern districts; risk is low or negligible in Paramaribo city and the other seven coastal districtsP. falciparum (76%) and P. vivaxP. falciparum resistant to chloroquine and pyrimeth/ sulfadoxineAtovaquone/proguanil or doxycycline or mefloquine
UruguayNo malariaNo malariaNo malariaNo malaria
VenezuelaThroughout the year in some rural areas of Apure, Amazonas, Barinas, Bolivar, Sucre and Tachira states; P. falciparum restricted to jungle areas of Amazonas (Atabapo), Bolivar (Cedeno, Gran Sabana, Raul Leoni, Sifontes and Sucre) and Delta Amacuro (Antonia Diaz, Casacoima and Pedernales). P. vivax and P. falciparumP. falciparum resistant to chloroquineAtovaquone/proguanil or doxycycline or mefloquine

Malaria in Europe: Risk, Resistance, Prophylaxis

CountryMalaria RiskSpeciesDrug ResistanceProphylaxis
AlbaniaNo malariaNo malariaNo malariaNo malaria
AndorraNo malariaNo malariaNo malariaNo malaria
ArmeniaFrom June to October in some of the villages in Ararat Valley, (Masis, Ararat, and Artashat regions); no risk in tourist areas.Only P. vivaxNo resistanceChloroquine (limited risk)
AustriaNo malariaNo malariaNo malariaNo malaria
AzerbaijanLimited risk from June to September in lowland areas, (between the Kura and the Arax rivers, Lenkeran, Mugan-Salyan, Priaraks and Sirvan provinces)Only P. vivaxNo resistanceChloroquine (limited risk)
AzoresNo malariaNo malariaNo malariaNo malaria
BelarusNo malariaNo malariaNo malariaNo malaria
BelgiumNo malariaNo malariaNo malariaNo malaria
Bosnia/ HerzegovinaNo malariaNo malariaNo malariaNo malaria
BulgariaNo malariaNo malariaNo malariaNo malaria
CroatiaNo malariaNo malariaNo malariaNo malaria
Czech RepublicNo malariaNo malariaNo malariaNo malaria
DenmarkNo malariaNo malariaNo malariaNo malaria
EstoniaNo malariaNo malariaNo malariaNo malaria
Faroe IslandNo malariaNo malariaNo malariaNo malaria
FinlandNo malariaNo malariaNo malariaNo malaria
FranceNo malariaNo malariaNo malariaNo malaria
GeorgiaFrom July to October in some villages in the south-eastern part of the country (districts of Lagodekhi, Sighnaghi, Dedophilistskaro, Saraejo, Gardabani, and Marneuli in the Kakheti and Kveno Kartli regions). No risk in Tbilisi Only P. vivaxNo resistanceChloroquine (limited risk)
GermanyNo malariaNo malariaNo malariaNo malaria
GibraltarNo malariaNo malariaNo malariaNo malaria
GreeceNo malariaNo malariaNo malariaNo malaria
GreenlandNo malariaNo malariaNo malariaNo malaria
HungaryNo malariaNo malariaNo malariaNo malaria
IcelandNo malariaNo malariaNo malariaNo malaria
IrelandNo malariaNo malariaNo malariaNo malaria
ItalyNo malariaNo malariaNo malariaNo malaria
KazakhstanNo malariaNo malariaNo malariaNo malaria
KyrgyzstanFrom June to September in some southern and western parts of the country, (Batken, Osh and Zhele-Abadskaya provinces in areas bordering Tajikistan and Uzbekistan).Only P. vivaxNo resistanceChloroquine (limited risk)
LatviaNo malariaNo malariaNo malariaNo malaria
LiechtensteinNo malariaNo malariaNo malariaNo malaria
LithuaniaNo malariaNo malariaNo malariaNo malaria
LuxembourgNo malariaNo malariaNo malariaNo malaria
MadeiraNo malariaNo malariaNo malariaNo malaria
MacedoniaNo malariaNo malariaNo malariaNo malaria
Malta No malariaNo malariaNo malariaNo malaria
MoldovaNo malariaNo malariaNo malariaNo malaria
MonacoNo malariaNo malariaNo malariaNo malaria
NetherlandsNo malariaNo malariaNo malariaNo malaria
NorwayNo malariaNo malariaNo malariaNo malaria
PolandNo malariaNo malariaNo malariaNo malaria
PortugalNo malariaNo malariaNo malariaNo malaria
RomaniaNo malariaNo malariaNo malariaNo malaria
RussiaNo malariaNo malariaNo malariaNo malaria
San MarinoNo malariaNo malariaNo malariaNo malaria
Serbia/ MontenegroNo malariaNo malariaNo malariaNo malaria
Slovak RepublicNo malariaNo malariaNo malariaNo malaria
SloveniaNo malariaNo malariaNo malariaNo malaria
SpainNo malariaNo malariaNo malariaNo malaria
SwedenNo malariaNo malariaNo malariaNo malaria
SwitzerlandNo malariaNo malariaNo malariaNo malaria
TajikistanFrom June to October, in Khatlon Region, Dushanbe, Gorno-Badakhshan and Leninabad Region.Predominantly P. vivax; P. falciparum in the southern part of the country.Chloroquine resistanceChloroquine plus proguanil in the southern part of the country
TurkmenistanFrom June to October in some villages in the south-eastern part of the country, mainly in Mary district.Only P. vivaxNo resistanceChloroquine (limited risk)
UkraineNo malariaNo malariaNo malariaNo malaria
United KingdomNo malariaNo malariaNo malariaNo malaria
UzbekistanSporadic cases in Surkhanda-rinskaya Region (Uzunskiy, Sariassiskiy and Shurchinskiy districts).P. vivaxNo resistanceChloroquine (limited risk)

Further Reading:

  1. http://wwwnc.cdc.gov/travel/yellowbook/2010/chapter-2/malaria-risk-information-and-prophylaxis.aspx
  2. WHO. International Travel and Health. 2010. Available at http://www.who.int/ith/ITH2010.pdf
  3. Kidson C, Indaratna K. Ecology, economics and political will: The vicissitudes of malaria strategies in Asia.  Parasitologia
    Jun 1998;40(1-2):39-46.
  4. WHO: Regional office for SEA. Malaria: Disease burden in SEA region. Available at http://www.searo.who.int/en/Section10/Section21/Section340_4018.htm
  5. Chaturong Putaporntip, Thongchai Hongsrimuang, Sunee Seethamchai et al. Differential Prevalence of Plasmodium Infections and Cryptic Plasmodium knowlesi Malaria in Humans in Thailand. The Journal of Infectious Diseases 2009;199:1143–1150
  6. Balbir Singh, Lee Kim Sung, Anand Radhakrishnan et al. A large focus of naturally acquired Plasmodium knowlesi infections in human beings. The Lancet 2004;363(9414):1017-1024
  7. Janet Cox-Singh, Balbir Singh. Knowlesi malaria: newly emergent and of public health importance? Trends in Parasitology. 2008;24(9):406-410
  8. Peter Van den Eede, Hong Nguyen Van, Chantal Van Overmeir et al. Human Plasmodium knowlesi infections in young children in central Vietnam. Malaria Journal 2009;8:249. Full Text at http://www.malariajournal.com/content/8/1/249
  9. Cyrus Daneshvar, Timothy ME Davis, Janet Cox-Singh, Mohammad Zakri Rafa’ee, Siti Khatijah Zakaria, Paul CS Divis, Balbir Singh. Clinical and Laboratory Features of Human Plasmodium knowlesi Infection. Clinical Infectious Diseases 2009;49:852–860
  10. World Malaria Report 2010. Available at http://whqlibdoc.who.int/publications/2010/9789241564106_eng.pdf
  11. Global Malaria Action Plan. Available at http://www.rollbackmalaria.org/gmap
  12. Roll Back Malaria. Progress & Impact Series. Number 2. April 2010. World Malaria Day 2010: Africa Update. Available at http://www.unicef.org/media/files/rbm-reportII-en.pdf
  13. Roberts DR, Tren R. International advocacy against DDT and other public health insecticides for malaria control. Research and Reports in Tropical Medicine January 2011;2011(2):23-30. DOI 10.2147/RRTM.S16419. Available at http://www.dovepress.com/getfile.php?fileID=8597
  14. Rowe AK et al. Caution is required when using health facility-based data to evaluate the health impact of malaria control efforts in Africa. Malaria Journal 2009;8:209 doi:10.1186/1475-2875-8-209. Available at http://www.malariajournal.com/content/pdf/1475-2875-8-209.pdf

©malariasite.com ©BS Kakkilaya | Last Updated: Mar 9, 2015

The Challenge of Malaria

Malaria, the disease as old as humanity itself, and often called as the ‘King of Diseases’, continues to haunt and taunt mankind. Known since millennia, malaria has played a major role in the history of mankind and it is often said that but for malaria, the history and geographical demarcations of our planet would have been different from what we have today. More than a century after identification of the causative parasites, and more than half a century after finding effective drugs and insecticides, it continues to wreak havoc on millions, particularly in the poorest parts of our world. Malaria is the fifth cause of death from infectious diseases worldwide (after respiratory infections, HIV/AIDS, diarrhoeal diseases, and tuberculosis) and the second in Africa, after HIV/AIDS. The dreaded disease is difficult to eradicate and its control is possible ONLY with coordinated efforts of the general public, healthcare personnel and government agencies. With global warming threatening to increase the mosquito density and the spread of other mosquito borne infections like Dengue and Chikungunya, time has come for all of us to wake up.

Malaria is an infectious disease caused by the parasites called Plasmodia. There are five identified species of this parasite causing human malaria, namely, Plasmodium vivax, P. falciparum, P. ovale, P. malariae and P. knowlesi. The infection is transmitted between humans by the female anopheles mosquito. It is a disease that can be treated in just 48 hours, yet it can cause fatal complications if the diagnosis and treatment are delayed. Despite centuries of efforts, malaria continues to infect millions and kill thousands.

According to the latest World Malaria Report 2015 [WMR 2015], malaria transmission occurs in five of the six WHO regions, with Europe remaining free. Globally, an estimated 3.2 billion people continue to be at risk of being infected with malaria and developing disease, and 1.2 billion are at high risk (>1 in 1000 chance of getting malaria in a year). There were 214 million cases globally in 2015, of which 88% were from the African region, 10% from SE Asia region and 2% from Eastern Mediterranean region. There were an estimated 438000 deaths, 90% from Africa, 7% from SE Asia region and 2% from Eastern Mediterranean region. Of these, 306000 deaths have occurred in children aged under 5 years.[WMR 2015] [In comparison, 198 million infections and 584 000 deaths were estimated in 2013.(WMR 2014)] More than 30000 cases of malaria are reported annually among travelers from developed world visiting malarious areas.[Leder K et al] With the shrinking globe, perennially prevalent malaria, therefore, remains an ever existing danger for humanity, in every part of the globe. In most areas, malaria and poverty co-exist, with the average GDP and average growth of per capita GDP in malarious countries being about one fifth of those in non-malarious countries.

Efforts to control malaria are being strengthened, with gradual increase in funding, better diagnosis and treatment, and increased coverage of mosquito control measures and provision of insecticide treated bednets. According to WMR 2015, 57 of 106 countries that had ongoing transmission in 2000 have reduced malaria incidence by >75% and another 18 countries are estimated to have reduced malaria incidence by 50–75%. In endemic areas of Africa, infection prevalence among children aged 2–10 years is estimated to have declined from 33% in 2000 to 16% in 2015, with three quarters of this change occurring after 2005. The malaria mortality rate, which takes into account
population growth, is estimated to have decreased by 60% globally between 2000 and 2015. It is estimated that a cumulative 1.2 billion fewer malaria cases and 6.2 million fewer malaria deaths occurred globally between 2001 and 2015 than would have been the case had incidence and mortality rates remained unchanged since 2000. In sub-Saharan Africa, it is estimated that malaria control interventions accounted for 70% of the 943 million fewer malaria cases occurring between 2001 and 2015, averting 663 million malaria cases. Of the 663 million cases
averted due to malaria control interventions, it is estimated that 69% were averted due to use of insecticide-treated mosquito nets (ITNs), 21% due to artemisinin based combination therapy (ACT) and 10% due to indoor residual spraying (IRS).[WMR 2015]

Yet a lot more remains to be done and challenges are also increasing. Global financing for malaria control increased
from an estimated US$ 960 million in 2005 to US$ 2.5 billion in 2014. International funding for malaria control, which accounted for 78% of malaria programme funding in 2014, decreased from US$ 2.1 billion in 2013 to US$ 1.9 billion in 2014 (i.e. by 8%), primarily due to changes in the funding arrangements of the Global Fund to Fight AIDS, Tuberculosis and Malaria. Most (82%) international funding was directed to the WHO African Region. Domestic funding for national malaria control programmes (NMCPs) was estimated to have increased by 1% between 2013 and 2014, from US$ 544 million to US$ 550 million. Spending on malaria control commodities (ACTs, ITNs, insecticides and spraying equipment for IRS, and RDTs) is estimated to have increased 40-fold over the past 11 years, from US$ 40 million in 2004 to US$ 1.6 billion in 2014, and accounted for 82% of international malaria spending in 2014. In that year, ITNs were responsible for 63% of total commodity spending, followed by ACT (25%), RDTs (9%) and IRS (3%).[WMR 2015]

Availability and accessibility of treatment for malaria need to be increased. Although, the proportion of children aged under 5 years, with P. falciparum malaria and who received an ACT, is estimated to have increased from less than 1% through 2005 to 16% in 2014, this proportion falls substantially short of the target of universal access for malaria case management, as envisaged in the GMAP. The number of ACT treatment courses procured from manufacturers increased from 11 million in 2005 to 337 million in 2014; the WHO African Region accounted for 98% of all manufacturer deliveries of ACT in 2014, with more than half of the total being doses for children. The number of ACT treatments delivered by manufacturers to the public sector in 2014 (223 million) was lower than the number delivered in 2013; likewise, NMCPs distributed 169 million treatments in 2014 through public sector facilities, approximately 20 million fewer than in 2013. [WMR 2015]

Of the 78 countries reporting any monitoring data since 2010, 60 reported resistance to at least one insecticide in one malaria vector from one collection site, and 49 countries reported resistance to insecticides from two or more insecticide classes. Pyrethroid resistance was the most commonly reported; in 2014, three quarters of the countries monitoring this insecticide class reported resistance.

©malariasite.com ©BS Kakkilaya | Last Updated: Jan 12, 2016