Egypt has been declared ‘malaria-free’ by the World Health Organization (WHO), in what it has called a “truly historic” milestone after nearly a century of work to eradicate the disease.
Malaria in Egypt can be traced back to ancient times. Scientists believe that King Tutankhamen, the boy pharaoh who died aged 19, was likely toppled by a severe bout of the mosquito-borne disease in 1324 BC.
Dr Tedros Adhanom Ghebreyesus, WHO Director-General, said that malaria in Egypt “now belongs to its history and not its future.”
“This certification of Egypt as malaria-free is truly historic, and a testament to the commitment of the people and government of Egypt to rid themselves of this ancient scourge,” he said in a statement on Sunday.
Certification is granted when a country proves that the transmission chain, carried by the Anopheles mosquito, is interrupted for at least the previous three consecutive years.
Egypt is the 44th country to be declared malaria-free and the third within the WHO Eastern Mediterranean Region (EMRO) – following Morocco in 2010 and the United Arab Emirates in 2007.
But the WHO said the certification was “not the end of the journey but the beginning of a new phase.”
‘Vision, dedication and unity’
Across the globe, the mosquito-borne disease remains rampant: in 2022, it killed 608,000 people and infected close to 250 million, with the largest burden concentrated in sub-Saharan Africa.
Prof Bob Snow, an expert in Malaria epidemiology at the University of Oxford, said that it is “rapid economic development and urbanisation” that has “transformed the landscape of malaria across the Middle East and North Africa.”
“If you look at an aerial view of Cairo today, compared to 10 years ago, you’ll see that it’s going to be pretty hard for the sort of malaria mosquitoes to proliferate in that area. They don’t like urban landscapes,” he told The Telegraph.
The WHO praised the Egyptian government for their “vision, dedication and unity” to stamp out the disease.
Malaria cases in Cairo were long concentrated in its communities located along the sweeping banks of the Nile river, as it provided an optimum breeding ground for mosquitoes.
Early efforts to wipe out transmission can be traced back to the 1920s, when the country introduced environmental engineering, prohibiting the cultivation of rice and agricultural crops near urban settlements.
The Second World War caused a surge in infections, with more than three million cases recorded in 1942, driven by population displacement, disruption of the health service.
That same year, Egypt suffered from an invasion of Anopheles arabiensis, a highly efficient mosquito endemic to Africa, when it was transported by boat up the Nile and caused thousands of deaths. Egypt effectively contained the outbreak, but it served as a wakeup call.
Dr Hanan Balkhy, WHO Regional Director for the Eastern Mediterranean, commended Egypt’s “sustained, robust surveillance investments in a strong, integrated health system.”
‘Malaria could almost certainly come back’
The 1950s and 60s were distinguished by a very effective campaign of environmental management, powered by larval control and mosquito surveillance. But the 1969 construction of the Aswan Dam, one of the world’s largest, threw this into disarray, creating a fresh breeding ground for mosquitoes.
To mitigate the risk, Egypt and neighbouring Sudan – where malaria is endemic – launched a joint collaboration in 1970, implementing strict vector control and public health surveillance around the dam. No indigenous cases have been reported since 1998.
By 2001, malaria was considered firmly under control and Egypt’s ministry of Health launched a vigorous effort to stamp out remaining cases.
A brief outbreak in Aswan in 2014 was quickly contained through early detection and vector control. By the end of June 2014, the last malaria case was cured and no more were detected in two years.
Prof Snow said that while malaria has largely “disappeared” in large parts of North Africa and the Middle East, it is important not to neglect the disease, as the ‘malaria-free’ certification can always be “reversed.”
“Malaria could almost certainly come back,” he said. “The mosquitoes don’t go away. The disease goes away, the infection goes away, but the vectors are still there, and you can bring infection back in from somewhere else.”
In 2016, Egypt established a High Committee for Integrated Vector Management to enhance coordination in fighting vector borne disease.
Prof Snow added that vector borne disease surveillance requires more investment, but that it is infections such as dengue, chikungunya and Zika – carried by the Aedes Albopictus species, or Asian Tiger mosquito – that pose the “biggest threat.”
“You might get a mosquito that is adapted to urban areas, like the Indian Anopheles stephensi [the main vector of urban malaria],” he warned. “If that arrives, then you’ve got a problem.”
He added that climate charge and large population movement could also pose threats.
“It’s a complex picture, but it’s like any other infectious disease,” said Prof Snow. “Even if it’s not a problem now, it could become a problem again in the future.”
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