**Author details**

**5. Concluding remarks**

330 Towards Malaria Elimination - A Leap Forward

Increasing concern about emerging infectious diseases has rekindled scientific and public interest in malaria. Reminders of widespread malaria endemicity across Europe in the past, the continuing presence of known and emerging vectors and the reality of a substantial population influx—including potential parasite carriers—from endemic areas combined with projections of climate change have raised the question of a possible re-emergence of malaria foci in the continent. Taking geomorphological, climatic and entomological factors into account, the risk of malaria resurgence appears to differ in various parts of Europe. In the northwest, manmade environmental changes in housing and livestock farming has led to continuing loss of breeding sites for *An. atroparvus*, the major vector in the area. In the event of a temperature rise in the region, mosquito survival would increase and *Plasmodium* sporogony would be facilitated, but the scarcity of mosquito vectors and the tendency of relevant species to preferentially feed on animals create an epidemiological setting where there is practically no considerable threat of renewed autochthonous transmission. *An. plumbeus*, with its reported adaptability to urban habitats and increased anthropophily could assume a more epidemiologically significant role as a vector in the future. Even so, however, provided that healthcare retains its current high standards, timely treatment of patients would prevent the buildup of an infectious human reservoir, thus preventing establishment of the parasite in the local mosquito populations. An influx of human gametocyte carriers could result in limited local transmission around untreated patients, which would be spatially and temporally restricted, provided of course that local healthcare services are aware of the risk and effective in early case detection and treatment. Regarding Southern Europe, there can be no doubt that current climatic conditions are favorable for malaria transmission in selected areas, where competent mosquito vectors like *An. labranchiae* and *An. sacharovi* are also present in epidemiologically significant densities. The recent occurrence of sporadic autochthonous cases and minor outbreaks has demonstrated that previously endemic malaria parasite species, principally *P. vivax,* are still theoretically transmissible in the area. A future temperature rise might expand vector distribution and abundance, increasing the risk for malaria transmission in the long run, but such a change is unlikely to develop overnight. However, two variables that could unpredictably influence vulnerability south of Europe are changing rapidly, that is, population movement and economic hardship. It was only 20 years ago that Turkey and central Asia experienced epidemic malaria resurgence from small residual reservoirs, demonstrating the catalytic impact mass population displacement and socioeconomic upheaval could have on malaria epidemiology in vulnerable areas. Europe is currently witnessing an unprecedented influx of immigrants from malaria endemic areas, many of which are asymptomatic carriers of dormant *Plasmodium* forms. It is believed that the highly organized and efficient European healthcare services can avert malaria re-establishment through prompt diagnosis and treatment, provided that they maintain their current high operational standards. However, nowadays malaria is being imported into Europe through areas severely affected by economic recession, which is putting an increasing strain on available health resources for natives and migrants alike. Therefore, although the resurgence of malaria in Europe is currently unlikely, it is crucially important to improve, maintain and financially support disease awareness, diagnostic expertise, clinical competence, sustained surveillance and vector control to ensure that malaria is not allowed a foothold in the European continent.

Evangelia-Theophano Piperaki

Address all correspondence to: epiper@med.uoa.gr

Department of Microbiology, Medical School, National and Kapodistrian University of Athens, Athens, Greece
