Really malaria-free Europe?

Concerning the past World Malaria Day¹ on 25^th April 2017, with the message “Malaria prevention works: let's close the gap” and its special focus on prevention gaps in access to proven malaria control tools, we consider this moment opportune to comment upon the current status of autochthonous (indigenous) malaria in Greece² and the recent consideration³ by WHO of malaria-free area of the WHO European Region. This WHO European region includes all European countries (“Europe”), but also others like Turkey, Russian Federation, Israel or Tajikistan.

On 2015, WHO declared the European region to become the first malaria-free region globally, and this situation has been included on the World Malaria Report 2016.³ The numbers of malaria (indigenous) cases in the European region decreased from 90,712 in 1995 to zero cases in 2015, according to this report. This amazing goal was achieved joining different pillars such as vector control, malaria surveillance, cross-border cooperation or research and development. Staying malaria-free will not be an easy task and should involve political commitment, sustained vigilance and different resources as explained in the report.

In this report,³ WHO has considered that countries with 3 consecutive years of zero autochthonous (indigenous) cases of malaria are considered to have eliminated malaria. One of the key targets is Preventing re-establishment of malaria in all countries that are malaria-free, being one near-term milestone along the way to track for 2020, as part of the WHO Global Technical Strategy¹ for malaria 2016–2030, adopted in 2015.

Four¹ surrounding “Mediterranean” countries such are Morocco, Egypt, Turkey and Syria were endemic for malaria in 2000 and are no longer endemic in 2016. The same situation occurred for some countries of the WHO European region: Turkey, Georgia, Azerbaijan, Armenia, Kirgizstan, Tajikistan, Turkmenistan and Uzbekistan.

Within the WHO European region, only one country, Tajikistan,¹ has not yet 3 consecutive years of zero indigenous cases (its last case being reported in July 2014).

Nevertheless, we have not found any reference to the local⁴ outbreak of autochthonous Plasmodium vivax malaria in Laconia on 2009 and 2010 and the existing situation^2,5 of “autochthonous malaria cases in Greece”.

Table 1 shows the number of autochthonous cases on period 2009–2015 and the last 4 years separately 2014, 2015, 2016 and 2017 (up to 18^th May), and the percentage of autochthonous malaria cases against total malaria cases in Greece during each study period included.

Table 1.

Reported total malaria cases and autochthonous malaria cases in Greece, 2009–2017.

Total reported cases	Year
	2009–2015^2	2014^5	2015^5	2016^4	2017^4^,^b
Autochthonous malaria cases	82^a	0	6	5	2
Total reported cases	3504	38	79	83	8
Autochthonous cases/total (%)	23.43%	0%	7.5%	6%	25%

a

None cases reported on 2014.

b

Data up to 18 May 2017.

During the period 2009–2015, the percentage between autochthonous cases/total cases was above 20%. The tendency showed from 2013 was going relatively well (decreasing), although far from zero cases in last 3 consecutives years, with zero cases only in 2014, 6 cases and 5 cases in 2015 and 2016 respectively. Percentage remained below 8%.

However, this 2017 shows higher percentage of autochthonous cases (>20%) compared with last 2 years and, similar to the period 2009–2015. Overall, only 2 autochthonous cases out of 8 total malaria cases is a good achievement in terms of quantity, yet, strictly speaking, the “quality” measured on percentage has around turned and has quadrupled in the last year.

This percentage points out again autochthonous malaria to be unresolved. In any case, since the local⁴ outbreak of autochthonous P. vivax malaria started on 2009, there was only one year with zero cases (2014) and the situation seems to be continuous along the way.

In conclusion, it can be said that autochthonous malaria remains active in Greece and, we have doubts on whether these cases neither have been included into the Malaria Report 2016 nor had been considered on the declaration of malaria-free area of the European region. We consider that the situation in Greece needs further monitoring and measures against malaria being upfront of priorities.

Authors contributions

Conceived the idea of the report: AO. Extracted and analyzed data: AO, MFLB, TF, JA. Wrote the paper: AO. All authors have seen and approved the final manuscript.