Dr Roma Chilengi, head of clinical trials at the KEMRI/Wellcome Trust Research Programme in Kilifi, Kenya discusses the way forward for malaria elimination

Elimination means reducing to zero the incidence of a specified disease in a defined geographical area as a result of deliberate efforts. For malaria, this means a situation where incidence of the disease is reduced to zero in a given area, and this should be demonstrable by sensitive diagnostic tests.

The accepted definition of elimination is however a sobering reality for the bulk of sub-Saharan Africa. The depth from which certain places have to be lifted is daunting, as they are still way behind in malaria “control” benchmarks. Unfortunately, the health systems infrastructure, which is critical to achievement of malaria elimination, is very poor or non-existent in most places.

Since the problem of malaria also does not follow political borders, variation in the burden and transmission intensity cuts across national boundaries. For example, the malaria burden within Kenya varies, such that the problem is declining on the coast while it is still a substantial problem in the western parts. Therefore, to attain elimination, health systems need to be sufficiently capable of establishing the correct burden, identifying proper interventions, deploying them, and monitoring and evaluating the process.

This is why many may be pessimistic about malaria elimination as a target, believing it to be way beyond the reach of some places. Some countries will realise elimination, while others may not be able to do so within the foreseeable future, given the currently available tools.

There is therefore a great need to sharpen and develop new tools altogether to help in the fight against malaria. A malaria vaccine offers a great hope of achieving significantly improved malaria control, particularly in Africa, where the ecological habitat is such that effective mosquito control has proved difficult or impossible to maintain.

The success of other vaccination campaigns within Africa demonstrate that the control of major infectious diseases is achievable on a global scale: smallpox has been eradicated as a result of vaccination, polio seems close to being eliminated, and measles is virtually under control in many African countries.