Despite progress over the years, malaria remains a formidable challenge. According to the latest global report published by the World Health Organization (WHO), in 2023, the number of malaria cases was estimated at 263 million, with an incidence of 60.4 cases per 1000 population at risk. This represents an increase of 11 million cases from the previous year and a rise in incidence from 58.6 cases per 1000 population at risk in 2022. Africa continues to carry the heaviest burden of the disease, accounting for an estimated 94 percent of malaria cases worldwide in 2023, with the top five countries carrying the heaviest estimated burden of malaria cases in 2023 being Nigeria (26 percent), the Democratic Republic of the Congo (13 percent), Uganda (5 percent), Ethiopia (4 percent), and Mozambique (4 percent). Globally, in 2023, the number of deaths was estimated at 597 000, with Africa carrying the heaviest burden of mortality accounting for approximately 95 percent of estimated malaria deaths worldwide.
Following the COVID-19 pandemic, a large number of countries have been confronted by significant challenges to malaria control, ranging from fragile health systems, weak surveillance, and chronic funding shortfalls to the rising spread of antimalarial drug resistance and the invasion different mosquito species. These challenges have been exacerbated by a challenging global context, various conflicts or crises, and climate change, among other issues.
In Eritrea, malaria has been a longstanding national public health challenge and the risk of malaria remains moderate to high within large swathes of the country. Of the country’s 58 sub-zobas, 41 are categorized as malaria endemic localities. According to local reports and estimates, Gash Barka, Debub, and Semenawi Keih Bahri account for the vast majority – amounting to greater than 90 percent – of the national burden. As with many other countries, malaria has historically been a formidable threat to several vulnerable population groups in the country, such as pregnant women and children. For instance, young children tend to be extremely vulnerable since they have not developed immunity to malaria. Meanwhile, pregnancy reduces a woman’s immunity to malaria, making her more susceptible to infection and increasing her risk of severe disease and death.
Since independence, and particularly following the establishment of the National Malaria Control Program in 1995, Eritrea has made large, important inroads against the disease. Through the combination of an array of control and prevention interventions, which has included the mass distribution of longlasting insecticide-treated nets, indoor residual spraying, drainage and larval source management, effective case management and surveillance, and strong community mobilization, awareness, and reception, progress has been registered in addressing the national malaria burden.
Insecticide-treated nets have been one of the cornerstones of Eritrea’s malaria control efforts. Over the years, millions have been distributed to households nationwide (particularly those in high transmission areas). This intervention has contributed significantly to reducing malaria cases and deaths, especially among children under five and pregnant women. Regular monitoring and re-treatment of these nets have ensured their continued effectiveness in preventing mosquito bites. Additionally, indoor residual spraying has been important in reducing malaria transmission in areas with intense seasonal surges. Historically, campaigns have been conducted in high-risk areas during peak malaria transmission seasons, especially in the lowland regions.
Alongside the above, Eritrea has invested in improving its healthcare infrastructure, with an emphasis on ensuring that diagnostic services for malaria are available at health centers and remote outposts. Furthermore, the country has made significant progress in improving the availability and accessibility of drugs and treatment, which are critical to reducing the severity of malaria and preventing deaths. What is more, in addition to vector control measures, Eritrea has also implemented environmental management strategies aimed at reducing mosquito breeding sites, while also working to raise awareness about malaria prevention and treatment through public health campaigns, including radio programs, community meetings, and outreach by healthcare workers. By involving local communities, Eritrea has fostered a greater sense of ownership over malaria control measures.
Eritrea’s efforts have translated into some positive results. In terms of cases, between 1998 and 2016, malaria incidence in Eritrea dropped significantly, declining from 157 to 34 cases per 1,000 people. Following further reductions to 18 cases per 1,000 in 2018, there has been a slight increase in cases in recent years (although steps are being taken to address this). Shifting to reported malaria deaths, they have been low and continue to fall, dropping from 405 in 1998 to 21 in 2016 and 4 in 2023 (an overall reduction of approximately 99 percent). Notably, in recent years, only a small percentage of all malaria cases in the country were in highly vulnerable populations, such as children under five years of age or pregnant women.
Of note, the country’s progress over the years made it one of a small number of countries to achieve the United Nations Millennium Development Goals target related to malaria (Goal 6, which it met ahead of the 2015 target date). In 2016, during the 26th Summit of the African Union (AU), it even received an award from the African Leaders Malaria Alliance in recognition of its, “commitment, innovation, and progress in the fight against malaria.” (The African Leaders Malaria Alliance is a coalition of AU Heads of State and Government established to drive accountability and action for results against malaria and neglected tropical diseases, and to promote reproductive, maternal and child health.)
Looking ahead, some challenges remain. Alongside a recent rise in cases in some areas of the country, resistance to insecticides and antimalarial drugs – a looming global challenge – poses a threat to longterm malaria control efforts.
However, local health authorities remain committed to ensuring that Eritrea transitions from pre-elimination toward elimination of malaria, with the long-term goal of ultimately eliminating and preventing the reintroduction of malaria by 2030. (The path to malaria free status is characterized by four distinct programmatic phases: control, pre-elimination, elimination, and prevention of reintroduction. Subsequently, once a country has proven, beyond a reasonable doubt, that the chain of local malaria transmission by Anopheles mosquitoes has been interrupted nationwide for at least three consecutive years, it is then granted a certification of malaria free status from the WHO.)
Encouragingly, in recent years Eritrea has sustained efforts to achieve the vision of a malaria free future. Steps have been taken to address factors that increase malaria risk and the country has worked to promote malaria control interventions. As well, entomology laboratories for research have been established in parts of Gash Barka, such as Elabered and Tesseney, helping in identification of species and parasites, while efforts continue to ensure early diagnosis and treatment, as it prevents deaths and contributes to reducing transmission. Additionally, progress is being made on the development of a refined subnational stratification map based on epidemiological data triangulated with appropriate metrics, namely entomological, ecological/demography, and interventions coverage data, to better disaggregate the malaria situation and inform targeting of interventions.