Human-made ecologic transformations have occurred at an unprecedented rate over the past 50 years. Prominent among them are water resource development projects. An estimated 40,000 large dams and 800,000 small dams have been built, and 272 million hectares of land are currently under irrigation worldwide. The establishment and operation of water projects has had a history of facilitating a change in the frequency and transmission dynamics of malaria, but analyses of these environmental risk factors are sparse. Here, we present a comprehensive review of studies that assessed the impact of irrigation and dam building on malaria prevalence or incidence, stratified by the World Health Organization's (WHO) sub-regions of the world, and link these studies with the latest statistics on disability adjusted life years, irrigated agriculture, and large dams. We also present estimates of the population at risk due to proximity to irrigation schemes and large dam reservoirs. In WHO sub-regions 1 and 2, which have 87.9% of the current global malaria burden, only 9.4 million people are estimated to live near large dams and irrigation schemes. In contrast, the remaining sub-regions concentrate an estimated 15.3 million people near large dams and up to 845 million near irrigation sites, while here only 12.1% of the global malaria burden is concentrated. Whether an individual water project triggers an increase in malaria transmission depends on the contextual determinants of malaria, including the epidemiologic setting, socioeconomic factors, vector management, and health seeking behavior. We conclude that in unstable malaria endemic areas, integrated malaria control measures, coupled with sound water management, are mandatory to mitigate the current burden of malaria in locations near irrigation or dam sites.

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