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Malaria is the most important parasitic disease in the Peruvian Amazon region, where 95% of the country’s total number of cases is concentrated. The Peruvian Government has spent a lot of years and effort trying to control this disease. More than 100 years have gone by since 1916, when the first law to reduce malaria transmission was enacted.

In 2017, the Ministry of Health approved the Plan Malaria Cero (PMC) (Zero Malaria Plan), the first program aimed at eliminating a communicable disease approved in the last 50 years. The plan is aimed at eliminating this disease by 2030. Its implementation was a fresh and forceful boost in the fight against malaria, by creating an important technical-scientific team and providing them with the necessary resources for planning and carrying out different activities, such as the distribution of mosquito nets, medicines and equipment, among others.

The plan has three stages: malaria control, malaria elimination and residual malaria elimination. The first stage–already under implementation–focuses on controlling clinical or symptomatic malaria. Field activities started in May 2018, and there was a 40% reduction in the number of malaria cases in just one year compared to the previous one. The goal at the end of this stage is to eliminate 70%-90% of total malaria cases. However, the most important challenges are found in the second stage of the plan.

Though books define malaria as a febrile disease, up to 80% of malaria cases in the Peruvian Amazon region do not show fever or other typical symptoms (so they are called asymptomatic). Besides, thick blood smears, the standard diagnostic test applied by the Ministry of Health, only detects 1 out of 4 infections, as infected people have very few parasites in their blood. The number of parasites is way below the quantity needed to detect malaria by using a microscope only (which is why these cases are called submicroscopic or subpatent infections). Asymptomatic and submicroscopic infections are the disease reservoir: since they cannot be identified or treated timely, they are responsible for maintaining malaria transmission in the communities.

The best goal is to eliminate the malaria reservoir

During the second stage of the plan, for the first time in Peru, the goal will be to eliminate the malaria reservoir by implementing molecular diagnostic methods that are more sensitive, so they can detect the presence of very few parasites in the blood. This intervention is crucial to prevent malaria resurgence.

If we do not eliminate the malaria reservoir, costs for malaria control/elimination will NOT be reduced. We can reduce treatment costs by reducing the number of symptomatic malaria infections, but the disease burden (which varies among endemic communities) not only would remain the same, but could also increase in the medium and long term. Definitive prevention of a case (that is no disease and no infection) means the Peruvian Government can save around US$ 350 per person (preliminary data; there is an ongoing study on costs and benefits of malaria prevention conducted by the PMC). In 10-15 years, the Government would save hundreds of million dollars.

Finally, during the third stage, malaria residual infections will be searched for and eliminated, particularly among people who travel frequently and may reintroduce the disease.

A mistake could ruin the progress achieved so far

Epidemiological surveillance is very important to prevent malaria resurgence. Peru had an important achievement in the fight against malaria in 2011, when transmission of symptomatic infections was reduced by 70% (there were 81,766 cases in 2004 and 23,060 in 2011); however, all progress achieved was ruined in only two years because the malaria reservoir was not controlled. This story is common in all malaria endemic countries in Latin American and all over the world.

Economic resources and political commitment are essential for controlling and eliminating any disease. This introduces the need to properly raise awareness among authorities who make decisions and allocate budget for controlling and eliminating the disease. Nevertheless, public and private institutions, specially research institutions in the country, have a lot to contribute to malaria control and elimination. Generating new technical-scientific knowledge is urgent to improve the strategies that will be used by the PMC. There is still a lot to learn about malaria, mainly knowledge that can be directly used by health workers in the fight against malaria.

A consortium for malaria research in Peru

In June 2019, the Malaria Laboratory of the Alexander von Humboldt Institute of Tropical Medicine of Universidad Peruana Cayetano Heredia organized a workshop on Next Generation Sequencing for malaria research. National and foreign expert malaria researchers got together for the workshop to discuss the needs and the future of malaria research.

Institutions that participated in the first meeting included the Ministry of Health (Directorate General for Strategic Interventions in Public Health, through the Directorate for Prevention and Control of Metaxenic and Zoonotic Diseases, led by the PMC), Universidad Peruana Cayetano Heredia (UPCH), Universidad Nacional de la Amazonía Peruana (UNAP), Global Health Institute of the University of Antwerp (Belgium), Supranational Reference Malaria Laboratory of the National Institute of Health (INS), U.S. Naval Medical Research Unit No. 6 and U.S. Centers for Disease Prevention and Control. The idea of creating a consortium for malaria research in Peru came up during the first meeting with the aim of standardizing criteria and conducting research works whose results can be used in the Zero Malaria Plan to achieve its goal of controlling and eliminating the disease. It would be an interinstitutional collaboration that will group research institutions, universities and the public health system.

The first consortium meeting was held in June at Universidad Peruana Cayetano Heredia.

This is not the first time these institutions are getting together; however, it is the first time they try to generate a formal collaboration framework, particularly with the aim of translating the results of scientific research into malaria control measures that can be implemented in the public health system. The second meeting was held on August 8, at the main building of the Ministry of Health, where participating groups presented the most important results of their research projects.

Malaria is the most important parasitic disease in the Peruvian Amazon region.

Scientific research on malaria in Peru is so rich and diverse that one meeting is not enough to present and discuss all the results. Besides, some research groups were not able to participate in the meeting, including foreign research groups. Therefore, one of the first activities of the new consortium will be a National Symposium on Malaria, scheduled to be held next year. Finally, it is important to highlight that success in malaria elimination is a shared duty. Without joint efforts, we will not be able to control or eliminate malaria in Peru.

Second coordination meeting of the consortium. Photo: Verónica Soto.

Carlos Fernandez-Miñope, molecular biologist, Universidad Peruana Cayetano Heredia

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