Some countries have eliminated malaria, but cases are increasing elsewhere

The world has made progress towards eliminating malaria, with 44 countries and one territory (La Réunion) certified as malaria-free. Egypt, where malaria has existed since at least the time of the pharaohs, joined the malaria-free list in October.

Between 2000 and 2023, an estimated 2.2 billion cases of malaria and 12.7 million deaths from the mosquito-borne disease were averted, according to a report by the World Health Organization released on December 11.

But challenges including climate change, conflict and biological threats have eroded some recent gains, with 11 million more cases of malaria in 2023 than in 2022. Most of these cases occurred in Africa. Globally 597,000 people died of malaria in 2023, most of them young children in Africa. That’s down slightly from 600,000 worldwide in 2022.

The WHO has called for a 75 percent reduction in malaria deaths by 2025 compared to 2015 levels. That would be 5.5 deaths among 100,000 people at risk for the parasitic disease. But by 2023, the death rate was more than double the target at 13.7 deaths per 100,000 people at risk. And the incidence of malaria cases worldwide is nearly three times higher than the target.

Malaria is an ancient disease, says Jane Carlton, a geneticist and director of the Johns Hopkins Malaria Research Institute. “It’s been around for a very long time and that’s because it’s so challenging to try and get rid of.”

Here’s a closer look at the challenges and successes in the fight to eradicate malaria.

What are the biggest challenges to eliminating malaria?

Evolution is one of the biggest threats to malaria control efforts, says Carlton.

“The malaria parasite is a very cunning biological species. It can evolve very quickly,” says Carlton. He has become resistant to almost every drug used against him.

Now, this includes partial resistance to artemisinin, a drug used to treat the disease. Partial drug resistance has been confirmed in Eritrea, Rwanda, Uganda and Tanzania, while WHO suspects that partial resistance may be present in Ethiopia, Namibia, Sudan and Zambia.

“This is very concerning,” says William Moss, a pediatric infectious disease expert at the Johns Hopkins Malaria Research Institute. “If we lose those drugs, that will be a huge setback.”

Malaria parasites have also lost part of a gene that is the basis of a rapid test used to diagnose the disease (SN: 25.4.24). Parasites with the missing part of the gene were reported in 41 countries where malaria is endemic, the WHO report said.

In Southeast Asia, a malaria parasite is called Plasmodium knowlesi that primarily infected monkeys are increasingly infecting humans (SN: 11/4/18). In 2023, 3,290 cases were reported, up from 2,768 cases reported in 2022.

Mosquitoes are also evolving resistance to insecticides and spreading to places they have never been seen before. Between 2018 and 2023, 55 countries recorded mosquitoes resistant to pyrethroid insecticides used in bed nets. And five countries have reported mosquitoes resistant to neonicotinoid insecticides.

In addition, a species of mosquito that carries malaria called Anopheles stephensi conquered Africa (SN: 11/2/22). This species is native to South Asia, but has now been found in eight African countries. It’s a concern because it lives and breeds easily in urban areas, Moss says. This could mean greater transmission in cities.

Climate change and severe weather are also threats. For example, floods in Pakistan in 2022 skyrocketed malaria cases from 506,000 in 2021 to 4.3 million in 2022. One analysis predicts that climate change could cause 550,000 more malaria deaths globally between 2030 and 2049.

Human factors also threaten progress. Political unrest, armed conflict, economic turmoil and unstable health care systems make malaria prevention and treatment difficult. “In those countries where the health system has improved over the years, which are stable economies, they have the potential, the opportunity to be able to eliminate malaria,” says Carlton. “In other countries where health systems are not very developed, where they can be destroyed by war [or] countries where there is political strife, [those are] countries where malaria will unfortunately continue.”

What are the most promising strategies to get rid of malaria?

New malaria vaccines could reduce the number of young children who get malaria (SN: 6/30/21), say Moss and Carlton. Vaccines are just starting to be deployed, so they haven’t yet made a big dent in malaria deaths, Moss says.

But from 2019 to 2023, about 2 million children in Ghana, Kenya and Malawi received the first approved malaria vaccine known as RTS,S/AS01. The vaccine was associated with a 13 percent reduction in deaths from all causes except injury, and a 22 percent reduction in hospitalizations for severe malaria. As of December 2024, 17 countries have introduced malaria vaccines as part of routine childhood vaccinations.

Carlton is also excited about genetically modified mosquitoes that could reduce or even crash mosquito populations or render mosquitoes unable to carry malaria parasites (SN: 6/3/22). Such mosquitoes carrying the “gene” have not been released into the wild and are probably years away from deciding whether they will ever be approved by the countries where they could be used. Genetic manipulation causes a particular gene – such as one that causes sterility or immunity against the malaria parasite – to be inherited by most offspring. Some people worry that it could drive mosquito species to extinction or have unknown ecological consequences. Several African countries are considering releasing such genetically modified mosquitoes, Carlton says. “It’s still an uphill road, I’d say, but I can see light at the end of the tunnel.”

According to the WHO report, improved bed nets using combinations of insecticides are increasingly being used. Such combinations can combat insect resistance.

More young children are being given seasonal treatments to prevent malaria. In 2023, an average of 53 million children were treated per cycle, up from 170,000 in 2012. Nigeria alone treated 28.6 million children last year. Ivory Coast and Madagascar are the latest countries to introduce the treatments, bringing the number to 19 African countries.

People in 34 African countries are given treatment to prevent malaria during pregnancy. In 2023, 44 percent of eligible pregnant women and girls received the full three-dose treatment—still well below the target of 80 percent.