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A Big 'Woo-Hoo' For Europe On #WorldMalariaDay: No New Cases In 2015

In the 1940s, planes demonstrate DDT spraying at Congressional Airport, outside of Washington, D.C. They were part of a fleet headed to Greece to target mosquito breeding areas.

Wouldn't it be great if the world could get rid of malaria altogether?

We've got a long way to go. Last year, there were about 214 million cases and 438,000 deaths from the mosquito-borne disease.

But just in time for World Malaria Day, there is some good news on the malaria front.

Europe has reported no new cases of the disease transmitted on the continent in 2015. It's an accomplishment worthy of celebration, says Dr. Joel Breman, an expert in infectious diseases, tropical medicine and epidemiology at the National Institutes of Health.

"We can start with the big woo-hoo, hip-hip hooray," Breman says. "This is a marvelous and noteworthy accomplishment."

Of course, there is a "but" or two. There remains much work to be done, for one thing, even in Europe, where it will take three consecutive years without internal transmission before the continent can be officially certified as malaria-free.

And in this case, "malaria-free" doesn't actually mean free of malaria. Thousands of new cases continue to arrive in Europe every year with travelers, immigrants and refugees.

Wiping out the disease in places like Africa and Southeast Asia will be far more difficult due to lack of infrastructure, political stability and reliable health care.

Still, Europe's achievement holds lessons for the developing world, where malaria could be eliminated with the right combination of money, commitment, collaboration, mosquito-control — and constant vigilance.

Breman says, "I think we can do it [everywhere], but it will take a longer time frame."

Malaria was once widespread in Europe. Before 1955, when the World Health Organization began its first global malaria-eradication campaign, the disease was rampant and mortality rates were high, particularly in southern European countries like Italy, Greece, Portugal and in the former Soviet Union. Around the turn of the 19th century, according to one study, Italy alone had 2 million cases (out of a population of 30 million), and as many as 20,000 Italians died from malaria each year.

The insecticide DDT made a huge difference, as did targeted efforts to detect and treat the disease, says Elkhan Gasimov, technical officer of vector-borne and parasitic diseases at WHO in Copenhagen. By 1975, cases had become so sporadic that Europe was considered malaria-free.

That didn't last long, in part because the medical community stopped worrying about it.

"Everyone considered that Europe was free, and the vigilance of the system went down," Gasimov says. "People stopped expecting malaria cases."

In the 1990s, malaria came roaring back. Resistance to insecticides and drugs played a role. In the Soviet Union, political, economic and social unrest also made drugs and other supplies scarce. Funding for insecticides dried up. And communication between countries broke down. Many countries lost their ability to treat new cases.

Across all of the southern European region, including the ex-Soviet countries, more than 90,000 cases were reported in 1995. And without an established tracking program in the region at the time, Breman suspects, many more cases were likely undiagnosed or unreported.

Yet again, European countries committed resources to control the disease. And yet again, their efforts started to work. By 2005, there were just 5,000 cases left in about 10 European countries.

That's when the really intensive work began. Case by case, health officials swooped in to identify sources of infection, obliterate mosquito breeding grounds and treat illnesses immediately. "You can't miss one case," Gasimov says, "and eliminate malaria."

In 2013, Europe recorded just 37 internally transmitted cases of malaria — in Greece, Tajikistan and Turkey. In 2015, the WHO announced the European Region was entirely free of internally spread cases of the disease.

Other countries that have wrestled the upper hand from malaria include Morocco, the United Arab Emirates, Mauritius and the United States, which officially eliminated the disease in 1951 (though here, too, new cases arrive every year with people traveling from elsewhere).

Europe's roller-coaster history emphasizes that relentless nature of the global war against malaria.

"Eternal vigilance is the price of liberty," Breman says. "You can't let up."

Community involvement is another important lesson that the developing world could learn from what Europe went through, Gasimov says. In Kyrgyzstan, plays in schools and theaters helped people understand what malaria is and how it spreads, so they were more accepting of elimination efforts and more motivated to take steps to protect themselves.

Cooperation across borders will also be necessary. Because people frequently travel back and forth between Georgia and Azerbaijan, Gasimov says, both countries had to work together and at the same time to keep outbreaks from taking turns cropping up on either side of the border. A viable vaccine would help, too.

Above all, it's going to take money to get rid of malaria everywhere — money for surveillance, money for treatment, money for education, money for research, and money for mosquito control. It's also going to take money to keep up the hard work, even as efforts seem to be taking hold. By some estimates, the cost for worldwide eradication could be in the hundreds of billions of dollars.

"The key issue is for us to maintain this malaria-free status," Gasimov says. "What we need for that is vigilance. The system should always be ready. We cannot say, 'Oh it's clear, let's forget about it.' We cannot forget malaria."

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