Evaluating Sri Lanka’s malaria re-establishment prevention using IHR and JEE frameworks

(2025) 24:211 Wickremasinghe et al. Malaria Journal https://doi.org/10.1186/s12936-025-05456-w Malaria Journal Open Access RESEARCH Evaluating Sri Lanka’s malaria re‑establishment prevention using IHR and JEE frameworks Rajitha Wickremasinghe1*†, Deepika Fernando2†, Gretchen Newby3, Ruwanthi Perera1, Amandhi Caldera1 and Kamini Mendis2† Abstract Background The International Health Regulations (IHR) developed and approved by the World Health Organization (WHO) in 2005 provide an overarching legal framework that stipulates countries’ rights and obligations in handling and managing public health events and emergencies that may cross local and international borders. Sri Lanka established an IHR Steering Committee in 2016 providing an opportunity to significantly enhance intersectoral collaboration and information sharing, thereby improving the health and health security of humans and animals. A Joint External Evaluation (JEE) of IHR core capacities was conducted in Sri Lanka in 2018 to assess the country’s preparedness to meet IHR. The aim of this study was to investigate the preparedness of the country for maintaining prevention of re-establishment of malaria in terms of IHR criteria based on indicators considered in the JEE conducted in 2018. Methods The criteria (prevent, detect, respond and IHR related activities) in the JEE which were relevant for the prevention of re-establishment of malaria in Sri Lanka were reviewed. The assessment was done by the authors. The Delphi technique was used to provide the relevant evidence and to assign a score by consensus following the scoring system that was originally used by the JEE. Results In the prevent domain, all subdomains obtained a score of 5 except for IHR coordination due to the unavailability of a functional mechanism for coordination between relevant sectors. In detect domain, many of the subdomains demonstrated sustainable capacity. However, further improvement was required in workforce development. In the response domain, emergency preparedness subdomain demonstrated the greatest need for further improvement especially in emergency operation centre capacities, procedures and plans which obtained a score of two, reflecting limited capacity. In the fourth subdomain, IHR-related activity, securing the ports of entry demonstrated capacity even though the systems were not sustainable. Other subdomains achieved the highest score. Conclusions This study demonstrates that the IHR framework provides an useful tool to assess the capacity of a country during PoR to sustain malaria-free status. This novel approach used for the first time, has demonstrated that Sri Lanka has the sustainable capacity for the prevention of re-establishment of malaria 12 years after elimination. It is proposed that a malaria-specific tool using an IHR lens be developed and an evaluation be conducted once in 5 years in countries with high receptivity and importation risk certified as malaria-free. Keywords IHR, International Health Regulations, Malaria, Prevention of re-establishment, Joint External Evaluation † Rajitha Wickremasinghe, Deepika Fernando and Kamini Mendis have contributed equally and are Joint first authors. *Correspondence: Rajitha Wickremasinghe Full list of author information is available at the end of the article © The Author(s) 2025. Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/. Wickremasinghe et al. Malaria Journal (2025) 24:211 Background The International Health Regulations (IHR) were developed and approved by the World Health Organization (WHO) in 2005, providing an overarching legal framework that stipulates countries’ rights and obligations in managing and reporting public health events and emergencies that may cross local and international borders. The IHR are part of international law that has been espoused by 196 countries, including the 194 WHO Member States. Some of the rights and obligations for countries include the requirement to report public health events. Sri Lanka established an IHR Steering Committee in 2016, providing an opportunity to significantly increase collaboration and information exchange between ministries, sectors and disciplines and thereby improve the health and health security of humans and animals. Sri Lanka has evidenced high levels of expertise and operational capacity for dealing with public health threats and emergencies [1]. The country also benefits from teams of experienced public health professionals who are trusted by the public [2]. A Joint External Evaluation (JEE) of IHR core capacities was conducted in Sri Lanka in 2018 to assess the country’s preparedness to meet IHR [3]. The team comprised 10 international experts representing WHO, Centres for Disease Control and Prevention and Public Health Agency, Sweden and representatives from many institutions from Sri Lanka. A format was proposed to assess the capacity of the country to meet IHR in four domains; prevent, detect, respond, and IHR-related hazards at and points of entry. Under each of these four domains, a set of items were identified for review; based on the evidence available for each item a score was assigned from 1 to 5 after consultation with representatives of different institutions (see Supplementary Table 1 and footnote in Supplementary Table 1). As Sri Lanka has eliminated malaria, prevention of reestablishment (PoR) of malaria in the country should be considered as part of IHR [4]. PoR of malaria is the sole responsibility of the Anti-Malaria Campaign (AMC) under the Ministry of Health; the campaign is headquartered in Colombo under the central government with regional offices under the provincial health authorities located in the periphery. The AMC headquarters is responsible for developing policy and providing technical assistance to the regions. This study was carried out in Sri Lanka, a tropical country with high receptivity and importation risk, as the country has been free of indigenous transmission of malaria for over 12 years. This is the first (...truncated)