Imported malaria cases: a source of moving backward from elimination to the preelimination phase in malaria control.

TO THE EDITOR—The World Health Organization (WHO) Eastern Mediterranean Region has a total population of 513 million, nearly half of which resides in areas at risk for malaria. Among the countries with low malaria burden limited to certain areas and with effective malaria programs, Iran has experienced a gradual decline in malaria over the past decade, now approaching the ultimate goal of disease elimination. The first WHO report from Iran on the disease status in 1924 indicated malaria as the most prevalent disease with high morbidity and mortality [1]. Almost a decade later, the first malaria study unit was established in Iran providing free quinine for malaria patients. Throughout the next 20 years, numerous measures were taken to tackle the malaria burden including drug prophylaxis and treatment, antimosquito spraying with DDT, and a few antilarval control measures such as Gambusia fish release. However, it was not until 1956 that the Malaria Eradication Program (MEP) was launched in Iran with the collaboration of WHO and UNICEF, a turning point in the fight against malaria. The preparatory, attack, and consolidation phases of MEP continued for more than a decade in northern Iran, while the southern provinces suffered fromuncontrollable outbreaks of the disease. The year 1973 was a milestone in the history of antimalaria campaigns in Iran; the northern parts of the country entered the elimination phase of MEP, a hitherto unsurpassed achievement [1]. Since the commencement of the present century, global and regional antimalaria programs have been revitalized by the introduction of the Roll Back Malaria program (http://www.rbm.who. int/index.html), WHO regional malaria strategies, and United Nations Millennium Development Goals. According to the WHO World Malaria Reports 2009– 2011, there was evidence of steady decrease in the number of malaria cases in Iran, which was accompanied by extensive realization of malaria control objectives (ie, elimination phase in 2010) [2]. Nevertheless, according to the WHO World Malaria Report 2012, Iran moved a category backward, from elimination to the preelimination phase, in 2011. The percentage of people living in the malaria-free areas decreased, from 97% (in 2010) to 84% (in 2011), whereas the number of active foci increased from 564 (in 2010) to 694 (in 2011). Interestingly, the geographical distribution of the confirmed malaria cases was limited from southern and central Iran in 2010 to only the southeastern part of the country in 2011. Furthermore, an increase could be observed in the number of confirmed malaria cases despite an unchanged trend in the number of indigenous malaria cases [3]. These observations might indicate the necessity of cooperation with malaria-endemic countries bordering Iran to control the imported malaria cases. Moreover, successfully implemented strategies by organizations pioneering the global campaigns against other diseases could enhance the current and future antimalaria programs [4, 5].