title: "Malaria in Europe: From Elimination to Reemergence?" date: "2026-04-03" excerpt: "Malaria was endemic in Europe until the 1970s and briefly returned to Greece in 2009-2012. Could climate change bring it back? A comprehensive historical analysis." category: "diseases" author: "Mosticare Editorial"

Malaria in Europe: From Endemic Disease to Elimination and Back?

By Mosticare Editorial | Published 2026-04-03

Most Europeans today think of malaria as a disease of the tropics -- something to worry about when travelling to sub-Saharan Africa or Southeast Asia, but not a domestic concern. This perception is historically very recent. For most of recorded history, malaria was one of the most devastating diseases on the European continent. It shaped settlement patterns, influenced military campaigns, toppled economies, and killed countless millions.

Europe's victory over malaria, achieved through decades of concerted effort culminating in the 1970s, stands as one of the great public health triumphs of the twentieth century. But as climate change reshapes the continent's ecology and Anopheles mosquito vectors remain abundant, the question of whether malaria could return is no longer theoretical. Greece's experience between 2009 and 2012 proved that reintroduction is possible. The question now is whether it is probable.

Malaria's Deep Roots in Europe

Ancient and Medieval Presence

Malaria has been present in Europe since antiquity. Hippocrates described the characteristic intermittent fevers in the 5th century BCE, distinguishing between the quotidian (daily), tertian (every 48 hours), and quartan (every 72 hours) patterns that correspond to different Plasmodium species. As detailed in a comprehensive historical review published in the journal Pathogens, the disease shaped the health and demographics of the ancient Mediterranean world.

The Roman Campagna -- the low-lying plains surrounding Rome -- was notoriously malarial. The disease likely contributed to the decline of the Roman Empire and influenced the siting of medieval settlements on hilltops away from mosquito-breeding marshlands. The association between swamps and fever was well known, even if the mosquito vector was not identified until 1897 by Ronald Ross.

The "Ague" in Northern Europe

Malaria was not confined to the Mediterranean. Plasmodium vivax, the parasite species that can tolerate cooler climates due to its ability to form dormant liver stages (hypnozoites), was endemic across much of northern Europe, including England, the Netherlands, Scandinavia, and the Baltic states. In England, "the ague" (malaria) was common in the marshy Fens of East Anglia and the Thames estuary until the 19th century.

The Little Ice Age (roughly 1300-1850) did not eliminate European malaria, demonstrating the parasite's resilience. Even during cooler periods, P. vivax persisted in human reservoirs and reactivated during warmer months.

Southern European Burden

In southern Europe, both Plasmodium vivax and the more dangerous Plasmodium falciparum were endemic. Italy, Spain, Greece, Portugal, and the Balkans bore enormous malaria burdens well into the 20th century. The Pontine Marshes south of Rome were drained by Mussolini's government partly as an anti-malaria measure. In Greece, malaria was a leading cause of death and disability into the mid-20th century, with the agricultural regions of the Peloponnese, Macedonia, and Thrace particularly affected.

The Path to Elimination: 1940s-1970s

The DDT Revolution

The development of DDT (dichlorodiphenyltrichloroethane) during World War II transformed malaria control. Indoor residual spraying with DDT proved extraordinarily effective at killing Anopheles mosquitoes. Combined with antimalarial drugs (primarily chloroquine) and environmental management (drainage of marshlands, improved water management), DDT-based campaigns drove malaria transmission to zero across most of Europe.

Country-by-Country Elimination

The timeline of malaria elimination across Europe, as documented by the WHO Regional Office for Europe, illustrates the progressive nature of the campaign:

Netherlands: Last indigenous case in 1959
Spain: Declared malaria-free in 1964
Italy: Declared malaria-free in 1970
Portugal: Certified malaria-free in 1973
Greece: Eliminated malaria in 1974, following an intense control programme (1946-1960)
Turkey: Reduced cases dramatically but faced ongoing challenges in the southeast

By the mid-1970s, malaria had been eliminated from all of western and southern Europe. The WHO European Region was effectively malaria-free for the first time in recorded history.

The Role of Socioeconomic Development

While DDT and antimalarial drugs were critical tools, malaria elimination in Europe was also driven by broader socioeconomic changes: urbanisation, improved housing (window screens, closed dwellings), drainage of agricultural wetlands, better sanitation, and access to healthcare. These factors created a "multiplier effect" that sustained elimination even after DDT use declined.

The Anopheles Vectors: Still Present

A crucial and often overlooked fact: the mosquitoes that transmit malaria never left Europe. Multiple Anopheles species capable of serving as malaria vectors remain abundant across the continent:

Anopheles sacharovi: Found in Greece, Turkey, and the eastern Mediterranean -- the primary vector during the Greek malaria era.
Anopheles maculipennis complex: A group of closely related species distributed across all of Europe, from Scandinavia to the Mediterranean.
Anopheles superpictus: Present in southern Europe and the Balkans.
Anopheles atroparvus: Found in western and northern Europe, including the UK, Netherlands, and Scandinavia.

As noted in an IntechOpen review on malaria eradication in Europe, the continued presence of competent Anopheles vectors means that if malaria parasites are reintroduced (through imported cases), local transmission is biologically possible.

Greece 2009-2012: The Warning

The theoretical risk of malaria reintroduction became reality in Greece between 2009 and 2012.

What Happened

According to Greece's National Public Health Organisation (EODY) and a detailed analysis published in the Travel Medicine and Infectious Disease journal, the events unfolded as follows:

2009-2010: Three locally acquired Plasmodium vivax malaria cases were reported in the agricultural area of Evrotas, Lakonia (Peloponnese).
2011: The situation escalated sharply with 40 locally acquired cases, concentrated in the Evrotas area but also appearing sporadically in five other regions.
2012: Twenty locally acquired cases were reported, still centred on Lakonia.
2013: Aggressive intervention reduced local cases to single digits.

In total, between 2009 and 2013, 62 locally acquired P. vivax cases were confirmed across Greece.

How It Happened

The reintroduction was driven by a convergence of factors:

Imported parasites: Migrant agricultural workers from malaria-endemic countries (primarily Pakistan and Afghanistan) brought P. vivax parasites into the Lakonia region.
Competent vectors: Anopheles sacharovi and other local Anopheles species were present and abundant in the irrigated agricultural areas of Evrotas.
Environmental conditions: Rice paddies, citrus orchards with flood irrigation, and stagnant water bodies provided ideal Anopheles breeding habitat.
Economic crisis: The Greek economic downturn reduced funding for vector control and public health surveillance.

The Response

Greek authorities, supported by the ECDC and WHO, mounted an aggressive response: enhanced surveillance, active case detection, mosquito control (larviciding and adulticiding), screening of at-risk populations, and distribution of insecticide-treated bed nets. By 2013-2014, local transmission had been interrupted.

The Lesson

The Greek experience demonstrated that malaria reintroduction in Europe is not hypothetical. Wherever competent Anopheles vectors exist and infected individuals are present, transmission can occur. The episode also showed that rapid response can contain outbreaks -- but only if surveillance systems are in place.

Climate Change: The Reemergence Risk

Climate change is the factor most likely to alter Europe's malaria equation in the coming decades.

Temperature and the Malaria Parasite

The Plasmodium parasite requires a minimum temperature for development within the mosquito (the extrinsic incubation period). For P. vivax, this threshold is approximately 15 degrees Celsius; for P. falciparum, approximately 18 degrees Celsius. As European temperatures rise, the geographic area and duration of the year during which these thresholds are met is expanding.

Mosquito Range and Season Length

Warmer temperatures and milder winters extend Anopheles activity periods and potentially expand their range. While Anopheles species are already present across Europe, increased temperatures could enhance their population density and extend the transmission season.

Modelling Studies

A Nature Communications Earth & Environment study on climate-dependent mosquito spread and a ScienceDirect analysis of malaria as an emerging threat both indicate that parts of southern Europe could become increasingly suitable for malaria transmission under projected climate scenarios, particularly the RCP4.5 and RCP8.5 warming pathways.

The Caveat

Most experts agree that Europe's socioeconomic conditions -- quality housing, functional healthcare systems, mosquito control infrastructure, and low population density in rural areas where Anopheles breed -- make a return to endemic malaria unlikely in the near to medium term. However, localised outbreaks similar to the Greek episode are considered plausible and potentially more frequent as conditions warm.

Current Surveillance and Imported Cases

Malaria remains a notifiable disease in all EU member states. According to ECDC data, EU countries report between 5,000 and 8,000 imported malaria cases annually, predominantly among travellers returning from sub-Saharan Africa. These cases represent the permanent "seeding" risk: every imported case is a potential source of local transmission if the patient is bitten by a competent Anopheles mosquito before their infection is treated.

Countries most at risk of localised transmission events include:

Greece: With documented precedent and suitable ecology
Italy: Particularly the Po Valley and southern agricultural regions
Spain: Irrigated areas in Andalusia and the Ebro Valley
Turkey: The southeastern provinces
France: The Camargue wetlands and Corsica

What This Means for Europeans

For Travellers

Malaria prophylaxis remains essential for travel to endemic regions. Consult your physician or travel medicine clinic before visiting sub-Saharan Africa, South Asia, or other high-risk areas.

For Residents in At-Risk Areas

While the risk of local malaria transmission in Europe remains low, residents of agricultural areas in Greece, southern Italy, and other hotspots should maintain awareness and support mosquito control efforts. Physical barriers -- window screens, door screens, and bed nets -- provide protection against both Anopheles (nighttime biters) and Aedes (daytime biters).

For Public Health Systems

The Greek experience underscores the need for sustained surveillance capacity, including:

Monitoring imported malaria cases
Anopheles population surveillance in high-risk areas
Rapid response protocols for potential local transmission events
Collaboration with agricultural authorities on water management practices

Frequently Asked Questions

Was malaria really common in Europe?

Yes. Malaria was endemic across Europe for thousands of years, from Scandinavia to the Mediterranean. It was not eliminated until the mid-20th century through DDT spraying, antimalarial drugs, and environmental management.

Could malaria become endemic in Europe again?

Full-scale endemic malaria in Europe is considered unlikely given current socioeconomic conditions. However, localised outbreaks -- as occurred in Greece from 2009 to 2012 -- are possible and may become more frequent with climate change.

Are there malaria mosquitoes in Europe?

Yes. Multiple Anopheles species capable of transmitting malaria remain abundant across Europe. The mosquitoes were never eliminated; only the parasite was removed from the transmission cycle.

Should Europeans take malaria prophylaxis for domestic travel?

No. There is currently no domestic malaria risk in Europe that warrants prophylaxis. However, travellers to malaria-endemic regions outside Europe should always consult with a travel medicine specialist.

About Mosticare: Mosticare develops chemical-free mosquito protection solutions for homes, businesses, and communities across Europe. Our mission: a green, mosquito-free life for every European. Learn more

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