232

TRANSACTIONSOF THE ROYAL SOCIETYOF TROPICAL MEDICINE AND HYGIENE, VOL. 71, No. 3, 1977.

Malaria eradication in Portugal

L. J. BRUCE-CHWATT*
Formerly Director, Ross Institute, London School of Hygiene and Tropical Medicine
I?meritus Professor of Tropical Hygiene, University of London
AND
JULIAN DE ZULUETA?
Formerly Regional OJficer for Malaria, World Health Organization,
Regional Ofice for Europe, Copenhagen

Summary was given more attention in the 18th century by Ribeiro

Research on malaria, which was endemic in several
parts of Portugal at the beginning of this century, was
intensified in the 1940s and led to the development of
better control methods, especially in the rice-growing
areas of the country. In the 1950s residual DDT spray-
ing was introduced and followed by extensive detection
of cases of malaria and their treatment. Plans for eradica-
tion of the disease were made, and by 1958 the trans-
mission of the infection was interrupted in nearly all
areas of European Portugal. The country was placed in
the maintenance phase of malaria eradication and the
certification of malaria eradication was confirmed by the
WHO in 1973.
The political and military events of the past five years
greatly increased the number of cases of malaria imported
into Portugal from tropical Africa and indicated the need
for much vigilance to prevent the resumption of trans-
mission by the local vectors. It appears that the measures
put into action have succeeded in this respect. This was
due to the high degree of effective surveillance and also
to the fact that Anopheles atroparvus does not readily
transmit the exotic strains of Plasmodium falciparum and
P. vivax. However, further vigilance must be maintained
and intensified.
Introduction
In November 1973 the World Health Organizations
Expert Committee on Malaria approved the recommen-
dation that Portugal be entered in the official register of
areas where malaria has been eradicated (WHO, 1974).
This was an important step in the history of eradication
of malaria from the European continent, a task that was
completed in 1975, when the two cases of indigenous
malaria, found in one small area of Greece, could be
hopefully considered as the last ones, signalling the end
of an era. A brief account of the progress of malaria
eradication in Portugal may be of interest and value at
the time when the goal of a global conquest of this
disease is still so distant, although its principle is valid in
appropriate socio-economic conditions.
Malaria in Portugal
The occurrence of seasonal fevers (sezonismo) in
Portugal has been known for centuries, but this disease
*Present address: Wellcome Museum of Medical Science,
183 Euston Road, London NW1 2BP.
tPresent address: World Health Organization, P.O. Box
1013, Islamabad, Pakistan.
Sanchez, one of the countrys most distinguished physi-
cians. Malaria assumed an increasing importance in the
19th century when rice cultivation was greatly extended.
In 1903 Ricardo Jorge, the great Portuguese epidemiolo-
gist, collected a series of reliable data on the incidence of
malaria and its seasonal distribution (JORGE,1903). But
the real advance of scientific knowledge started only in
1931 when Dr. Jose Albert0 de Faria created a malaria
research station at Benavente; in 1933, with the assistance
of the Rockefeller Foundation, a nationwide malaria
survey was carried out by HILL, LANDEIRO& CAMBOURNAC
(1938). Subsequently, a malaria research station was
established at Aguas de Moura, where studies were begun
on malaria related to rice cultivation. In 1938 this station
was transformed into a Malaria Institute (Dire@0 dos
Services, 1942).
Studies carried out during the 1930s and 1940s on
the epidemiology, entomology and control of malaria
were published in a series of papers by LANDEIRO &
CAMBOURNAC(1935), HILL (1937a, b), HILL et al. (1938),
CAMBOURNAC (1939, 1942, 1944), CAMBOURNAC &
FONSECA(1948), CAMBOURNAC& HILL (1940), CAM-
BOURNAC& PITTA SIM~ES(1944a, b), CAMBOURNACei al.
(1949, 1952).
The results of surveys showed that out of 18 districts
of Portugal 15 were malarious. The annual number of
cases of malaria was close to 100,000 with 500 deaths.
The general conclusions were as follows:
(i) Malaria occurs chiefly in the alluvial valleys of the
principal rivers and their tributaries, namely the
Sado, the Tagus (Tejo), the Mondego, and to a
lesser extent the Guadiana and the Douro (Fig. 1).
(ii) The Sado river basin was the chief focus of malaria
(in 1938), and in Aguas de Moura-a village on the
edge of rice-fields irrigated from a tributary of the
Sado-over 80 X of all infants were infected.
(iii) Similar conditions were found in most of the other
areas where rice was grown and the degree of endemi-
city was related to the amount of rice grown. In
1937 there were some 20,000 hectares (50,000 acres)
under rice cultivation.
(iv) P. falciparum and P. vivax were found in almost
equal proportion of infected cases; P. malariae was
found in 7 % of cases.
(v) The high incidence of malaria was closely related to
the shortcomings of socio-economic conditions of
the rural populations and to the movement of
seasonal itinerant workers, who spread the disease
to other areas (Fig. 1).
 L. J. BRUCE-CHWATT AND JULIAN DE ZULUETA 233

.~.,.,.,.~.,.,.,.,. I.:.:..
...~.~..~..~....~.
.~......~.... 1. Zona do Douro
. . . . . . .

2. Zona do Mondego
3. Zona do Tejo,
parte baixa
4. Zona do Tejo,
parte alta
5. Zona do Sado
6, Zona do Guadiana

a Endemic focus

Fig. 1. Geographical zones of malaria in Portugal and foci of endemic malaria in 1957-1959.
234 MALARIA ERADICATION
The methods of control advocated in the late 1930s
were based mainly on the protection of human populations
by screening of houses, establishment of protection zones
where rice-growing was prohibited, introduction of
larvivorous fish (Gambusia) into streams and canals,
intermittent irrigation of rice-fields and improved agri-
cultural methods. Treatment of cases of malaria was
carried out by anti-malaria stations or anti-malaria posts.
Notification of malaria become compulsory in 1939,
and over the period 1931-40 the malaria services had
recorded and treated over 240,000 cases of whom 90%
had positive blood slides for malaria parasites. An
estimate of the economic damage due to malaria revealed
that 95,450 malaria patients of working age who lost an
average of 18 days per annum would cumulatively lose
8,600,OOOescudos over ten years, if during that period
they had only one attack of malaria. In comparison with
this estimated loss, the cost of all anti-malaria measures
during 1931-40 amounted to 5,500,OOOescudos (some
25 million U.S. dollars).
The masterly review by CAMBOVRNAC (1942) of the
whole problem of malaria in Portugal provided all the
epidemiological and other basic data needed for future
planning of control and eradication of malaria in the
country. Only a few salient points of this study can be
mentioned here:
(i) There are five climatic regions of malaria-Northern
coastal region, Central coastal region, Southern
coastal region, Northern continental region, Southern
continental region. High degree of anophelism was
evident in the coastal regions with greater humidity,
but the main vector, A. maculipennis atroparvus,
was found everywhere up to 1,800 m altitude. The
species is generally zoophilic, indoor-biting and
indoor-resting. A. maculipennis typicus, A. claviger
and A. plumbeus were occasionally found, but of no
importance as vectors of malaria.
(ii) P. vivax was most common in the northern regions,
while P. falciparum was occasionally prevalent in the
south, especially in the Sado area. P. malariae
averaged 5-7% of all infections and was found
mainly in the Northern coastal region.
(iii) The transmission of malaria took place mainly
between the end of April and mid-October; the peak
of anopheline density was in June-July or July-
August, depending on the latitude of the locality.
Generally speaking, the transmission period was of
four months duration in the north and five months
in the south.
(iv) In the Northern coastal and Northern continental
regions (where P. vivax was most common) the
spleen rate in children, two to 12 years of age, varied
between 10 and 25 %; in the Central coastal region
the spleen rate varied between 25-50x; in the
Southern coastal region (where P. falciparum was
periodically prevalent) the spleen rates were over
50 % and could reach 80 % in some areas.
(v) There was close relationship between the rice cultiva-
tion, the high density of A. atroparvus and the high
incidence of malaria. In the Southern coastal region
each hectare of irrigated rice produced about 20,000
Anopheles daily from May to July.
In 1945 the malaria service was reorganised and given
a considerable degree of administrative independence
(LOBO DA COSTA, 1963,1967).
With the arrival of residual insecticides, DDT was used
in 1946-48 as a larvicidal emulsion, applied to rice
irrigation ditches (at 20 ppm every 20 days) with reason-
IN PORTUGAL
ably good results, but since 1949 residual spraying has
been increasingly used. The population protected by
DDT and HCH residual spraying increased from 50,000
in 1949 to 300,000 in 1952 and decreased to 200,000
during the next three years. In addition to imagocidal
methods, other antimalaria measures such as mass drug
administration were carried out in some areas; all
confirmed cases were treated by chloroquine and
pyrimethamine.
Although the coverage by residual insecticides (mainly
DDT at 2 g/m) was far from total (at its peak activity
only some 300,000 persons were protected by DDT
spraying out of more than two million living in malarious
areas), the decrease of mortality and morbidity due to
malaria was spectacular (Fig. 2).
In 1956 endemic malaria disappeared everywhere and
the few remaining foci in the valleys of Sado and Mira
were small. Thus, in 1956 the decision to change the
policy of malaria control to malaria eradication was fully
justified.
By 1958 it became obvious that over the whole hypo-
endemic area of 7,700 kmz, with a population of nearly
1.5 million, malaria had disappeared; however, low
malaria morbidity remained in areas covering 36,000 kmz,
with a sparse population of about 630,000. Consequently,
the residual spraying of DDT was stopped and the
surveillance was based on passive case detection; thus,
only cases notified by the medical personnel were treated
and followed by an epidemiological follow-up. 12 cases
of malaria were found in 1958 and investigated: of these,
eight (three P. vivax, four P. falciparum, one P. malariae)
were classified as imported, and the remaining four
P. vivax infections, although tentatively classified as
indigenous, could not be related to any evidence of
malaria transmission in the territory of continental
Portugal.
The plan of operations for malaria eradication pre-
pared in 1959 was approved in principle by the Govern-
ment and by the World Health Organization, but not
signed by either of them for various reasons. The national
authorities stated that since 1958, when only four cases
of indigenous malaria were reported (and even these
were of doubtful origin), the country entered into the
final phases of malaria eradication.
Progress towards malaria eradication
At the end of 1959 it could be recognized that the whole
country had three main, epidemiologically different
areas :
(i) Area where malaria was unknown or from which it
disappeared without any special action: 45,000 kmz,
with 6.5 million population.
(ii) Area with unstable malaria from which the disease
had disappeared about five years ago, following
malaria control measures: 7,700 km2 with 1.5 million
population.
(iii) Area with moderatelv stable malaria but low mor-
bidity, where improved and extended surveillance
needed to be introduced: 36,000 km2 with 635,000
population (Fig. 2).
In view of the fact that some cases of malaria in
frontier areas with Spain were occurring in south-eastern
zones, an agreement was reached in 1960 with the Spanish
authorities to improve the control of immigrants and
seasonal workers.
It was agreed that in parts of Portugal, where the
population density was high, where malaria was unstable
or hypoendemic, where the indigenous cases were absent

\ \
t
10.000 \
?\
\
\,
\ ,,
:\
1.000
Fig. 2. Malaria in Portugal 1938-1972.
and where medical services were adequate, malaria could
be considered as eradicated and the programme placed
in the maintenance phase. Other parts of the country, in
formerly endemic or epidemic areas, where passive case
detection was not adequate for finding the remaining
malarious foci, were considered as being in the consoli-
dation phase of malaria eradication, so that surveillance
should be based on active case detection. For the purpose
of surveillance activities, the country was divided into
ten zones.
Preliminary studies carried out in 1960-62 showed
that one surveillance agent can cover 4,000 to 6,000
inhabitants per month. The total number of medical and
supporting personnel necessary for the operation of
active surveillance was realistically estimated.
The programme of active case detection started in
235
Indigenous
Cases
\
\
:, imported Cases
\ .o
Y p .-.o
\
\ ,p...o.
: 0
\
\\ /
i !
April 1964 and the organization of the programme was
satisfactory, although it seemed desirable to improve the
delimitation of different zones on epidemiological basis
(PULL, 1964).
The main reason for discontinuation of the active case
detection in 1965 was the fact that over the whole period
only 146 new cases were detected and that most of them
had been already reported by the passive case detection
which functioned as before. Moreover, the cost of the
active case detection was very high.
Since then the malaria eradication programme of
Portugal was virtually in the maintenance phase, con-
sidered by the national health authorities as stage of
vigilance, during which the main attention was given to
the detection and treatment of imported malaria.
The whole history of antimalaria activities in Portugal
236 MALARIA ERADICATION IN PORTUGAL

could be divided into seven stages (Table I):
Table I - Stages of malaria eradication in Portugal
(i) Initial stage before Study of the problem of
1938 malaria and its definition.
(ii) Malaria control by Organization of malaria
traditional methods, control by antilarval
1938-49 methods, diagnosis and
treatment of cases, health
education.
(iii) Improved and Antilarval methods.
extended methods Imagocidal spraying.
of malaria control, Extension of control of
1949-56 immigrants.
Preparation of plans for
malaria eradication.
Co-ordination on antimalaria
measures between Spain and
Portugal.
- had an effect on the vector as well as on its predators.
(iv) Intermediate stage, Extension of passive case
1958-62 detection methods.
(v) Surveillance stage, Legal provisions for malaria
196465 control.
Period of active case
detection.
(vi) Stage of vigilance, Intensive control of
1966-73 immigrants.
Co-ordination of surveillance
with overseas services.
(vii).Maintenance phase Certification of malaria
of malaria eradication eradication in 1973.
Continuation of measures to
prevent malaria transmission
from imported cases.
The Portuguese authorities regard the Stages (ii) and
(iii) as the attack phase of the malaria eradication
programme. Stages (iv) and (v) are considered to be the
phase of consolidation, and from Stage (vi) onwards the
country is regarded as being in the maintenance phase of
malaria eradication (Fig. 2).
frequently found then in rural areas. In ordinary unpro-
tected peasant dwellings, the densities of A. atroparvus
could also be very high. This explains how a species not
particularly attracted by man, with a sporozoite rate of
only 0.12%, could produce the spleen and parasite rates
seen in early days in Portugal.
In his investigations on A. atroparvus, CAMBOURNAC
(1942) found that mosquito counts in specially built rabbit
hutches were the most effective method for assessment of
densities of the vector all the year around, including the
period of hibernation during the winter months. Counts
of resting A. atroparvus during the period 1967-73 gave
a monthly average during the months of June, July,
August, when the highest densities were recorded, of
approximately 4,000. The corresponding figure during
1939 was 20,000. Although the recent densities were still
remarkably high, they were only one-fifth of what they
were in the days of high malaria prevalence (DALMEIDA
ROQUE,1959). This reduction may have been due to a
decreasing cultivation of rice in the immediate vicinity
of Aguas de Moura; other factors, such as the use of
herbicides, are more difficult to assess,as they may have
The Gambusia larvivorous fish introduced in the rice-fields
of Portugal, as a measure against malaria in early days,
appears to have been reduced by the use of herbicides.
Whatever the explanation may be, it seems that a
diminution of vector densities, even in rice-field areas, has
taken place in recent years in Portugal.
Susceptibility tests carried out on A. atropurvus since
1960 have given results showing a development of insecti-
cide resistance to both the DDT and dieldrin groups of
insecticides. The degree of resistance to the latter (13 %
mortality after one hours contact to 4 y0 dieldrin papers
in recent tests) precluded the use of this insecticide as an
attack measure; the situation regarding DDT is similar.
In some recenf tests (Aguas de Moura, June-July 1973)
the mortality to one and two hours exposure to 4%
DDT was 19% and 65% respectively. This clearly indi-
cates a development of resistance, but the insecticide may
still retain some of its residual effect against A. atvoparvus,
since the resistance pattern of mosquito population varies
in different areas. In practice, however, it would be
unsafe to rely on DDT should a renewal of transmission
require the application of remedial measures. Suscepti-
bility to malathion, on the other hand, remains, until now,
at a normal level.

Entomological aspects Organization and functions of Portuguese antimalaria

The entomological factors involved in the transmission
of malaria in Portugal have been particularly well studied.
Since the early investigations on the distribution of
Anopheles in the country, it became clear that A. claviger,
A. plumbeus and A. macul@ennis typicus were not involved
in the transmission of malaria and that the only vector
in the country was A. maculipennis atroparvus. The
publications of CAMBO~RNAC& HILL (1938, 1940) and
the monograph of CAMBOURNAC(1942) give an excellent
account of the habits of this mosquito and its role in the
transmission of malaria in Portugal.
This investigation indicated the enormous densities
reached by this species in the endemic areas, particularly
in the rice-growing zones which were associated with high
spleen and parasite rates in the 1930s. CAMBOIJRNAC
(1939) demonstrated that as many as 400 larvae of
A. atroparvus were produced daily per square meter of
water surface. This resulted in densities of several thou-
sand adult Anopheles in stables and rabbit hutches
services
Once a country has reached the maintenance phase of
eradication, the re-establishment of transmission depends
on the receptivity, viz., the extent to which anopheline
vectors and environmental conditions are favourable to
malaria transmission, and on its vulnerability, viz., the
number of imported cases of malaria. Since the anti-
malaria services are responsible for eradication of
malaria from Portugal and for prevention of its resurgence,
the planning and function of these services deserve some
attention (WHO, 1967).
The Anti-Malaria Services (Services Anti-Sezonaticos
or Anti-Paludicos) were established in 1938, but fully
reorganized in 1945 under the title Services de Higiene
Rural e Defesa Anti-Sezonatica (SHRDAS), with a
degree of technical and administrative autonomy. The
anti-malaria campaign carried out by this organization
was the foundation for the future malaria eradication in
Portugal.
 L..J.BRlJCE-CHWATTAND
The SHRDAS has a central Directorate in Lisbon and
ten peripheral units. These units provide a network
covering the whole country and their anti-malaria
functions consist of blood examinations of persons
reporting with febrile symptoms or of carrying out such
examinations at the request of medical practitioners. In
addition to that, they institute epidemiological inquiries
relevant to each confirmed case, treat and follow-up the
patients, supervise groups of seasonal workers and
immigrants from overseas. Moreover, they carry out
residual insecticidal spraying, wherever a focus of malaria
transmission occurs.
The relevant information comes from the Directorate
General of Health which receives from the military
authorities and civilian official organizations the list of
persons that returned from overseas, together with their
addresses. Each of those persons receives from the
appropriate zone a letter pointing out that they may have
been infected with malaria, and inviting them to report
directly or through their doctor to the nearest SHRDAS
post for examination. Most people thus contacted respond
to the invitation and records of imported malaria are
based on the results of blood examination. Any positive
cases are treated accordingly.
The second source of information on imported malaria
are the medical practitioners, since malaria has been a
notifiable disease since 1938. The notification is forwarded
to the Director General of Health Services who informs
the SHRDAS. The surveillance activity of this organiza-
tion can be judged by the fact that during the period
1970-72 over 110,000 persons were examined for the
presence of malaria infection, and 1,536 casesof imported
malaria were diagnosed and treated. Since 1972 the ad-
ministrative organization of SHRDAS underwent some
changes, related to the replanning of all medical and
social services, based on a network of Health Centres
(Centros de Satide) which, in turn, will be related to the
network of all existing hospitals. Integration of SHRDAS
and other similar units into the Health Centres is pro-
ceeding, though its pace depends on the setting up of these
centres.
In 1972, at the request of the Government, the World
Health Organization dispatched a group of experts to
assessthe progress of malaria eradication in Portugal and
to appraise the claim that the elimination of malaria from
the country can be substantiated.
This came at the time when Portugals links with its
overseas territories were still strong and when the
military operations in Angola and Mozambique were near
their peak. Naturally, the WHO team felt that the problem
of the influx into the country of malaria infections
contracted overseas was of primary importance (BRUCE-
CHWATT &ZULUETA,~~~~).
The size of movements of Portuguese nationals between
European Portugal and its overseas territories was con-
siderable during the past decade. Thus, during the period
1967-72 the average annual number of civilians departing
to or arriving from the former Portuguese Colonial
territories was between 15,000 and 20,000.
The problem of military personnel returning home
after two to three years service overseas was of primary
importance, because of the numbers involved and also
on account of a high incidence of tropical diseases seen
in these men. During the military operations of 1961 to
1972 there were approximately 100,000 military personnel
serving in Africa and some 10,QOOto 20,000 were return-
ing to their home country every year. The importance of
prevention of tropical diseases brought into Portugal by
JULIANDEZULUETA 237
demobilized military was fully realized by the Government
and in 1966 an Inter-Ministerial Committee was set up
for this purpose. This committee approved a series of
methods for the detection of infectious and parasitic
diseases in returning military contingents.
All civilian immigrants arriving in the country had to
report to the passport control offices who noted their
future address. All airlines and shipping companies also
provided the SHRDAS with the names and addresses of
travellers and immigrants. Each medical officer of
peripheral units of antimalaria services received regularly
the list of persons who would reside in the area under his
jurisdiction. He then prepared an itinerary to visit the
persons concerned and investigated the possibility of any
febrile attack being due to malaria.
The immigrants are divided into three groups:
(a) unlikely carriers of malaria, (b) possible carriers,
(c) very probable carriers. Most of the immigrants belong
to the second group and they are seen by the antimalaria
officer every one to two months during the first year and
then in March or April of the next year. The third group
which comprises people who recently had febrile attacks
and/or show an enlargement of the spleen have a blood
examination, are given full treatment and are followed
up until their successive blood slides are consistently
negative.
A special procedure was established for members of the
Armed Forces returning from overseas. Each of them
underwent a medical examination before his return home,
on his release from the Forces.
The military authorities report to the Ministry of
Health the names and, as far as possible, the address of
all individuals who completed their military service
overseas. All peripheral units of SHRDAS are notified
of the names and addresses of nationals arriving within
their relevant zones.
The general practitioner who sees the immigrant may
demand the assistance of the nearest antimalaria specialist
if he suspects that any febrile symptoms of his patients
are due to malaria. These diagnostic and curative
services are free.
All immigrants and military coming from overseas are
given on their arrival a leaflet, explaining the importance
of malaria and stressing the need to report to relevant
authorities any case of febrile disease.
Portuguese medical authorities with considerable
experience of malaria base the correct treatment of the
infection on reliable parasitological diagnosis. All cases
of P. fulcipamm malaria are treated by a standard course
of 4 aminoquinolines (1,500 mg base in three days);
should gametocytes be present on blood examination
then primaquine is given for three days at 15 mg base
daily. All P. vivax and other infections with possibilities
of relapse are given standard schizontocidal treatment
followed by radical cure (primaquine 15 mg base for
14 days) (CAMBO~RNAC et al., 1952; CAMBOURNAC,
1969).
Some measure of the impact on the health services of
Portugal of the returning military contingents can be
judged from study by COUTINHO (1971). According to
this investigation carried out on 3,206 individuals on
their return from Angola, GuinB- and Mozambique
malaria parasites were found in 69 (2.2%); of these, 50
had P. vivax, 11 P. falcipavum, eight P. malariae.
Military authorities adhere to the principle of chemo-
therapeutic suppression of malaria, and personnel leaving
African territories receive chloroquine (300mg/base/week)
to be taken for four weeks after their return to Portugal.
238 MALARIA ERADICATION IN PORTUGAL

Table II - Cases of malaria in returning Portuguese nationals as reported from overseas and cases confirmed by SHRDAS
units

Results by species of plasmodia

Number of positive Number of cases of
Year cases reported from imported malaria P. ovale and
overseas recorded by SHRDAS P. vivax P. falciparum P. malaviae mixed infections

1969 2,063 353 227 79 10 37

1970 2,562 480 335 75 3 67
1971 3,934 473 328 85 8 52
1972 4,400 584 421 103 13 47

Table III - Cases of malaria recorded in Portugal or notified during the period 1959-74

Autochthonous cases Imported cases

Species
Induced by Introduced Deaths due
Year Relapses blood or Total Other or Other Total to Grand
transfusion unknown V F M mixed V F M malaria Total

1959 3 6 97 11 4 6 2 12 21
1960 5 5 4 1 7 10 4 21 26
1961 3 2 1 63 3 11 6 17 23
1962 3 3 1 2 16 6 1 23 26
1963 29 5 1 35 35
1964 1 3 62 62
1965 2: 1; 3 3 82 1 82
1966 149 22 3 5 179 179
1967 1 1 196 32 4 4 236 2 237
1968 4 4 224 60 9 8 311 315
1969 227 79 10 37 353 1 353
1970 1 1 335 75 3 67 479 2 480
1971 328 85 a 52 473 473
1972 421 103 13 47 584 2 584
1973 365 173 9 47 594 3 594
1974 463 362 29 49 903 2 903
-
Notes: (1) Letters V, F and M refer to infections with P. vivax, P. falcipavum and P. malariae.
(2) Figures given under the last column do not include cases of malaria recorded in Portuguese nationals intending
to return from overseas, mainly from Angola and Mozambique. These were as follows: 1969-2,063 cases,
1970-2,568 cases, 1971-3,934 cases, 1972-4,400 cases. Figures for subsequent years are not available.

Information published by the Portuguese medical
military authorities overseas (LEITXO, 1972) indicated
that some units overseas had a monthly malaria incidence
of 30 per 1,000 corresponding to about 360 per 1,000 per
annum. This high figure could contribute to a continuing
and considerable influx of imported malaria into Portugal.
According to COUTINHO(1971), about 11,000 cases of
malaria could have been imported into Portugal during
the past years of military operations in Africa. However,
the fact remains that in spite of considerable numbers of
such cases in Portugal there is no evidence of renewed
transmission.
Tables II and III show the comparative numbers of
cases of malaria reported from overseas units and the
actual numbers of cases recorded by the health services
over the period 1969-72.
More recent figures give the following numbers of
cases of malaria imported into Portugal: 1973-594;
1974-903; 1975-971. It appears that in spite of an
increasing number of such cases there is no evidence of
malaria due to local transmission. In this respect, the
present malaria situation in Portugal is not different
from that reported from other European countries
(BRUCE-CHWATTet al., 1974), such as France or Italy.
Conclusions
Three years ago the World Health Organization (1974)
approved the recommendation that European Portugal
be entered in the WHO Official Register of areas where
malaria has been eradicated.
Since the very concept of eradication of malaria from
a country is related to the presence of local transmission
of the infection, as evidenced by the detection of indi-
genous cases of malaria, the presence of such cases was
the touchstone of the reality of the maintenance phase of
malaria eradication in Portugal.
 L. J. BRUCE-CHWATT
Since 1973, in spite of a large number of cases of
imported malaria entering the country, in the wake of
independence of former Portuguese overseas territories,
there has been no evidence of local transmission, although
one case found in 1975 at Beja might have been of this
origin. All reported and investigated cases of malaria
were genuinely of imported origin or constituted relapses
of previous infections. Fortunately, about 80% of those
returning settle down in urban areas, and especially in
Lisbon and Oporto where conditions for local trans-
mission of malaria do not exist.
The number of potential malaria carriers in former
military personnel returning to civilian life and settling
down in rural areas is relatively small and probably does
not exceed 200 to 300 per year. This alone decreases
greatly the possibility of introduction of malaria into
areas where the mosquito vector is abundant. The degree
of coverage of the country by health units and especially
by the peripheral units of the antimalaria services is
satisfactory and the health education system, as well as
easy availability of treatment of recurrent or relapsing
malaria, made any major degree of transmission most
unlikely.
Obviously, the success of malaria eradication in
Portugal was due to the early pioneering studies of the
epidemiology of this disease and to the application of this
knowledge in strategically selected areas of the country.
Moreover, the early organization of a semi-autonomous
antimalaria service with an effective system of detection
and treatment of cases played an important part in the
elimination of remaining foci of malaria.
However, other favourable factors have also played a
significant part in this successful venture. Among these,
one should stress the changed entomological aspects.
There is a wealth of evidence that the transmission of
malaria in Portugal by the proven vector (4. atroparvus)
depends to a large extent on high vector densities related
to the presence of rice-fields. The vector is generally
zoophilic and, as a rule, only in special conditions of high
mosquito density, combined with poor housing and low
standards of living, can malaria transmission occur.
Recent observations have confirmed a striking decrease
in vector density. This combined with a possible lack of
receptivity of the local A. atropnrvus to transmit strains of
P. falcipnrum of tropical origin may explain the absence
of transmission in Portugal in recent years, despite the
large number of imported cases (SHUTE, 1940; ZULUETA
et al., 1975).
The amount of malaria in Portugal reached its low ebb
in 1958-62; since then there have been no indigenous
cases and very few imported cases, each of which has
been rapidly traced and efficiently dealt with. However,
beginning with and especially since 1975 a new situation
has arisen. Due to the repatriation of large numbers of
both civilians and military from the former Portuguese
overseas territories (and some estimates quote the total
number of returnees as high as one million and more)
the possibility of renewed transmission cannot be
ignored.
With the diminished size of the vector population,
with its known refractoriness to certain tropical strains
of malaria parasites, with the ecological changes resulting
from the industrialization of the country, it seemsdifficult
to see how the disease could re-establish its old hold in
the rural areas of Portugal. Only in the case of a marked
lowering of the standards of living, of a migration from
the towns to the villages, of a diminution of medical and
health facilities, including those provided by the Anti-
AND JULIAN DE ZULUETA 239
Malaria Services, could the re-establishment of malaria
in the country be envisaged. These considerations apply
not only to Portugal but to other countries in Europe
where malaria has been recently eradicated. Fortunately
for Portugal, the political and social upheaval which
could threaten the health conditions and more specifically
the malaria situation, has been averted in the past and
will, in all probability, be averted in the future.
_Acknowledgements
We wish to acknowledge with sincere gratitude the
guidance and assistance received from Professor F. J. C.
Cambournac, to whom the successof malaria eradication
in Portugal owes so much. We also wish to thank
Professor A. Salazar Leite, Dr. A. Sampaio, Dr. A. Lobo
da Costa, Dr. J. Santana Queiroz, Dr. A. Ramos,
Dr. A. Faria, Dr. R. dAlmeida Roque, Dr. F. Coutinho,
Dr. Julio Cesar Valente dAlmeida and Senhora Maria
Utilia de Lacerda for their co-operation and help.
We are grateful to the Portuguese authorities and to
Dr. Leo Kaprio, Director of the World Health Organiza-
tions Regional Office for Europe, for permission to
publish this paper.
Our thanks go also to Mrs. Jaqui Carter and Mr. W.
Norman of the Wellcome Museum of Medical Science,
for the preparation of the typescript, the map and the
graph.
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Book Review
Insects and the life of man. Wigglesworth, V. B. (1976).
Collected essays on pure science and applied biology.
London: Chaaman & Hall. 217 vv. ISBN 0 412 14730 0.
Paperback price 53.25. Hardback edition g6.00.
This collection of sixteen essays comprises, for the
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Wigglesworth to learned societies and international
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matter is most varied, and includes, for example, malaria
in time of war, insects of the orchard, and Sir John
Lubbocks contribution to entomology, but the content
is uniformly enjoyable and informative. Several of the
essays reflect the authors close links with medical
entomology. The account of the climatic and ecological
circumstances which led up to the 1935 malaria epidemic
in Sri Lanka is still pertinent today for an understanding
of the current malaria problems in that country. The
comments and thoughts on pesticides written 25 to 30
years ago are particularly interesting, and the essay on
DDT and the balance of nature reflects the disquiet
felt even then by entomologists at the possible misuse of
pesticides, and at the absence of adequate studies on
their long-term effects on insect and vertebrate popula-
tions.
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Accepted for publication 26th January, 1977.
Throughout the essays the reader is given illuminating
snippets of entomological history. In the essay on Sir
John Lubbock (1834-1913), best known as a banker and
statesman, Sir Vincent deals in some detail with one of the
outstanding entomologists of the last century and
describes the achievements of this notable experimenta-
list, who was a pioneer in the study of insect behaviour.
In the short essay on Wordsworth, on the other hand, the
poet is taken vigorously to task for the anti-science
sentiments which appeared in his writings.
Sir Vincent Wigglesworth is known to several genera-
tions of biologists as the foremost insect physiologist
and, not unexpectedly, the essays on his favoured subject
are among the most enjoyable. Although they were
written with great objectivity, one cannot help but be
conscious of the great contribution which the author
himself made to his subject. The essay on the epidermal
cell illustrates well the clear thinking and elegant tech-
nique which characterize all Sir Vincents scientific work.
All in all, this collection of essays portrays not only
relationships between insects and man, as the title
suggests, but also the philosophy and biological wisdom
of the most distinguished entomologist of our time.
W.W. MACDONALD