Malaria Elimination, is it possible?

MALARIA ELIMINATION
A field manual for low and
moderate endemic countries
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Malaria elimination – the interruption of local mosquito-borne
malaria transmission – is the end goal in the fight against the
disease. In addition to being vital for public health and part of
overall development efforts, malaria elimination has a profound
impact on other sectors, such as business and tourism. In this
increasingly interconnected world, no country can afford to be
complacent about the disease. Whether previously malarious or not,
non-malarious countries must support the efforts of endemic
countries to eliminate the disease. This manual has been developed
to provide guidance to the increasing number of countries that have
decided to eliminate malaria from their territory.
An elimination programme builds on the successful control of
malaria mortality and morbidity. The evolution of the programme,
from control to elimination to preventing re-establishment of
malaria, is described in detail, along with the important programme
reorientations.
Drawing on recent experience from various countries with malarious
areas, the feasibility of malaria elimination is discussed, helping
countries to set realistic targets and timescales. Descriptions are
provided of tools and approaches that are specific or particularly
relevant to elimination: case detection, prevention of onward
transmission, and management of malaria foci and of importation
of malaria parasites.
As monitoring and evaluation are essential components of the
programme, recommended indicators, data sources and metho-
dologies are outlined. Monitoring and evaluation not only allow the
progress of the programme to be assessed and documented, but also
allow a credible information database to be established, which is
needed for ultimate certification of malaria elimination.
Certification of malaria elimination – the recognition of a conside-
rable operational achievement – is granted by the World Health
Organization to countries that have successfully maintained their
malaria-free status for at least three consecutive years. Requirements
and procedures for certification are described, along with details of
the follow-up of certification.
Malaria elimination
A fi eld manual for low and
moderate endemic countries
GLOBAL MALARIA PROGRAMME
© World Health Organization 2007
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Illustrations by Anne Guilloux
Printed in France
WHO Library Cataloguing-in-Publication Data
Malaria elimination: a fi eld manual for low and moderate endemic
countries.
1.Malaria – prevention and control. 2.Endemic diseases. 3.Epidemiologic
surveillance. 4.Insect vectors – prevention and control. I.World Health
Organization. II. Global Malaria Programme.
ISBN 978 92 4 159608 4 (NLM classifi cation: WC 765)
Contents
Acknowledgments ........................................................................................... vi
Foreword ...................................................................................................... vii
Executive summary ......................................................................................... ix
Introduction .................................................................................................. 1
1. Malaria ...................................................................................................... 5
2. Principles and practice of malaria elimination ............................... 9
2.1 Malaria case defi nition in elimination programmes .................... 9
2.2 Malaria foci classifi cation for elimination purposes ..................... 9
2.3 Strategies for malaria elimination ................................................... 11
First programme reorientation: the pre-elimination programme
19
Elimination programme .................................................................. 20
Second programme reorientation: from elimination to
prevention of reintroduction of transmission ................................ 23
Prevention of reintroduction programme ...................................... 24
3. Feasibility of malaria elimination ...................................................... 25
3.1 Contextual prerequisites for achieving malaria elimination ........ 25
3.2 Feasibility assessment ....................................................................... 25
3.3 Setting realistic targets and timescales ........................................... 26
4. Tools and approaches specifi c to elimination programmes........ 28
4.1 Detection of cases ............................................................................. 28
4.2 Prevention of onward transmission ................................................ 29
4.3 Management of malaria foci ............................................................ 29
4.4 Management of importation of malaria parasites ......................... 29
4.5 Selected interventions....................................................................... 29
iii
Vigilance ............................................................................................ 29
Malaria surveys ................................................................................. 30
Geographical reconnaissance .......................................................... 30
5. Monitoring and evaluation of progress towards malaria
elimination ............................................................................................... 32
5.1 Purpose and objectives ..................................................................... 32
5.2 Recording and reporting .................................................................. 32
5.3 Establishment of a malaria elimination database .......................... 33
5.4 Establishment of a national independent malaria elimination
monitoring committee ..................................................................... 34
5.5 Monitoring and evaluation – recommended indicators,
data sources and methodologies...................................................... 34
Evaluation of foci .............................................................................. 38
Evaluation of case detection and management .............................. 38
Evaluation of entomological monitoring and vector control
activities ............................................................................................. 38
6. Prevention of the re-establishment of malaria .............................. 40
6.1 Probability of malaria becoming re-established ............................ 41
6.2 Patterns of vigilance ......................................................................... 42
6.3 Organization of the health service .................................................. 42
6.4 Training ............................................................................................. 44
7. WHO certifi cation of malaria elimination ........................................ 45
7.1 Requirements – burden of proof ..................................................... 45
7.2 Procedures for certifi cation ............................................................. 46
7.3 Follow-up of certifi cation................................................................. 50
References ...................................................................................................... 52
Bibliography .................................................................................................. 53
Annexes
Annex 1 Countries and areas with malarious zones ............................. 56
Annex 2 Key for epidemiological classifi cation of cases ....................... 58
Annex 3 Key for operational classifi cation of malaria foci ................... 59
Annex 4 Laboratory techniques for parasite strain identifi cation ....... 61
iv
MALARIA ELIMINATION: A FIELD MANUAL FOR LOW AND MODERATE ENDEMIC COUNTRIES
Annex 5 Obsolete control methods from the Global Malaria
Eradication Programme ........................................................... 63
A5.1 Mass drug administration ........................................... 63
A5.2 Presumptive treatment ................................................. 63
Annex 6 National malaria case register ................................................. 65
Annex 7 Sample malaria case investigation record form ..................... 67
Annex 8 Sample laboratory register form .............................................. 71
Annex 9 Sample malaria foci investigation record form ...................... 72
Annex 10 Recommendations for the United Arab Emirates malaria
programme, post-certifi cation period .................................... 74
A10.1 Surveillance of malaria cases ....................................... 74
Early detection of malaria cases .................................. 74
Prompt treatment and case management ................... 75
A10.2 Surveillance of vector ................................................... 76
A10.3 Vector control ................................................................ 76
Chemical and biological control with other sectors .. 76
Mobile survey teams ..................................................... 76
International Health Regulations guidelines for
fumigation of aircraft and ships to prevent port malaria 76
A10.4 Health education ........................................................... 76
A10.5 Expanding the Malaria Control Department to
become a vector-borne disease control department .. 77
A10.6 Regional training and demonstration centre for malaria 77
Annex 11 Key documents to be prepared by the national government
for the certifi cation evaluation team ....................................... 78
Annex 12 Outline of the content of the fi nal report by the certifi cation
evaluation team ......................................................................... 79
Annex 13 Information to be included in annual report for follow-up
of WHO certifi cation ................................................................ 80
Glossary ...................................................................................................... 81
v
CONTENTS
Acknowledgements
The World Health Organization (WHO) Global Malaria Programme wishes
to thank Dr Anatoli Kondrachine for his work on the early draft of this man-
ual and to acknowledge the valuable contributions of Dr Hoda Atta, Dr Peter
Bloland, Dr Charles Delacollette, Dr Mikhail Ejov, Dr Georges Ki-Zerbo, Dr
Kamini Mendis and Dr Walther Wernsdorfer, who reviewed and amended the
elimination strategy and manual during a meeting in Geneva, Switzerland, May
2007. The comments received from Dr Mohammad Khalifa, Dr Abderrahmane
Laamrani El Idrissi, Dr Majed Al-Zedjali, Dr Simon Hay, Dr Andrei Beljaev
and Mr Mohamed Laaziri at a fi nal review of the manual during a workshop
for the WHO Eastern Mediterranean Region in Dubai, United Arab Emirates,
June 2007, are gratefully acknowledged.
Technical editor: Dr Aafje Rietveld, WHO Global Malaria Programme
vi
Foreword
Some 35 years after the effort to eradicate malaria worldwide was abandoned,
malaria elimination features again on the global health agenda. In recent years,
an increasing number of countries with low and moderate transmission areas
have decided to eliminate malaria transmission from their entire territory. In
January 2007, the United Arab Emirates was the fi rst formerly endemic coun-
try since the 1980s to be certifi ed by the World Health Organization (WHO) as
malaria-free. Certifi cation of malaria elimination is granted to countries that
have successfully maintained their malaria-free status for a period of at least
three years. It is recognition of a considerable operational achievement.
In order to provide guidance on the implementation of effective malaria elimi-
nation programmes, WHO has produced this manual.
Effective malaria elimination programmes set realistic targets and follow a
comprehensive and funded plan of action, backed up by government commit-
ment at the highest levels. Such programmes:
• detect and cure malaria patients;
• interrupt local mosquito-borne malaria transmission;
• identify and clear up residual foci of malaria transmission;
• develop and implement vigilance systems for maintaining the malaria-free
status;
• prevent re-establishment of transmission despite continuing importation of
parasites;
• collaborate with neighbouring endemic countries to reduce malaria trans-
mission in the region.
Malaria elimination evolves from a successful countrywide malaria control
effort that has been able to eliminate malaria as a public health problem. In its
early phases, the elimination programme temporarily becomes a specialized
vertical programme that focuses on the spatial distribution of malaria, vector
control, case-fi nding and case investigation. When the goal of elimination is
almost reached, the focus shifts back to the general health services, which are
key to a good vigilance system.
vii
Malaria transmission is particularly diffi cult to interrupt in areas with effi -
cient mosquito vectors, a long or year-round transmission season, poor state of
overall development, marginalized populations and weak health systems with
inadequate coverage of health services, as well as in areas with civil unrest,
illegal cross-border movement, or areas that border high-burden neighbouring
countries and experience intense cross-border population movement. Each of
these factors will reduce the feasibility of malaria elimination.
Malaria elimination cannot be detached from overall development efforts,
including the 2015 Millennium Development Goals. Most countries that have
successfully achieved interruption of malaria transmission have also achieved
an improvement in the overall socioeconomic situation, health services cover-
age and living standards of the population. The malaria-free status adds to
these developments by removing barriers to investment and tourism.
viii
MALARIA ELIMINATION: A FIELD MANUAL FOR LOW AND MODERATE ENDEMIC COUNTRIES
Executive summary
The aims of the global fi ght against malaria are not only to (i) reduce the
burden of malaria in endemic areas, but also (ii) reduce and confi ne the geo-
graphical extent of malaria-endemic areas in the world. The latter entails the
elimination of malaria from countries and localities where this is feasible. The
elimination of malaria is indeed the end goal of the fi ght against the disease,
and is a process which starts with good malaria control.
An increasing number of endemic countries have been successful in inter-
rupting local mosquito-borne malaria transmission – seen as vital for public
health, business and tourism. Others have reduced their malaria burden to
levels where elimination is a possibility. Of the 107 malaria-endemic countries
and areas worldwide, 7 are currently reporting no more locally acquired infec-
tions. In January 2007, the United Arab Emirates was offi cially certifi ed by the
World Health Organization (WHO) as malaria-free, a fi rst since Australia and
Singapore in the 1980s.
The aim of an elimination programme is to identify and treat all people who
carry malaria parasites in their blood and reduce the onward transmission
of infection. As part of essential programmatic elimination requirements,
malaria transmission hot spots are identifi ed and mapped by the national pro-
gramme. Targeted, custom-tailored mosquito control interventions are used
to reduce the vectorial capacity and human–vector contact in these areas, and
eventually halt transmission nationwide.
In the continuum from malaria control to elimination, two important pro-
gramme reorientations take place. The fi rst starts once high coverage with
effective malaria control interventions and overall socioeconomic development
are starting to reduce transmission to a marginal level, with a patchy and focal-
ized geographical spread. At that point, coverage of good-quality laboratory
and clinical services, reporting and surveillance must be reinforced, followed
by other programme adjustments aimed at halting transmission nationwide.
The second programme reorientation starts when locally acquired malaria
cases are close to zero, and malaria parasites that are brought into the coun-
ix
try by people who became infected abroad may pose a bigger threat of con-
tinuation or resumption of transmission than the last dwindling local parasite
strains. The prevention of re-establishment of local malaria transmission from
imported cases relies heavily on the watchfulness of the general health serv-
ices, under the guidance of a small group of malaria experts at central level
backed up by national and local authorities, in collaboration with other sec-
tors such as private industry, tourism and foreign affairs. Nationals who plan
to travel abroad are provided with health information, chemoprophylaxis and
measures to protect against mosquito bites, aimed at reducing the importation
of parasites at source. Visitors and migrants from endemic areas are informed
of the risks of malaria and given easy access to free-of-charge diagnostic and
treatment facilities. Vector control is used to contain local outbreaks and pro-
tect areas that are known to be receptive to the resumption of transmission as
well as exposed to frequent importation of malaria parasites.
Once a country is proven to be free from local transmission for at least three
consecutive years, WHO can grant certifi cation of its malaria-free status.
The world is increasingly interconnected. When malaria is eliminated from a
country, it still remains at risk from imported cases. The dedication of both
the government and programme personnel that was necessary to eliminate
malaria must be sustained so that the requisite knowledge and skills are main-
tained and the health service organized in such a way that these attributes
can be used as and when necessary. Continuous active involvement of local
authorities with budget power1 will be required, as well as engagement from
the tourism and construction industries and other private sectors that employ
immigrants from endemic countries or respond to an infl ux of refugees, as well
as agricultural businesses and others designing projects that have an environ-
mental impact. It will be the role of the ministry of foreign affairs to increase
intercountry collaboration on malaria and the role of regional political or socio-
economic powers to boost regional approaches for malaria control.
Non-malarious countries, whether previously malarious or not, must be con-
cerned about malarious countries and support their efforts against the disease.
This manual describes the principles, practice, tools and approaches, as well as
monitoring and evaluation requirements, for the elimination of malaria from
countries in the 21st century.
1
Able to control and allocate fi nancial resources.
x
MALARIA ELIMINATION: A FIELD MANUAL FOR LOW AND MODERATE ENDEMIC COUNTRIES
1
Introduction
This manual is intended to inform national governments from endemic coun-
tries, partner and donor agencies and fi eld managers about the issues related to
malaria elimination. It will serve as a tool in the implementation, monitoring
and evaluation of malaria elimination programmes.
Malaria elimination aims at sustainable interruption of local malaria trans-
mission by mosquitoes despite a continued presence of malaria vector mos-
quitoes and importation of parasites from abroad through international travel
and migration.
In areas with intense transmission and extreme poverty, where overall health
and development are lagging behind, good malaria control using proven tools,
such as case management with effi cacious medicines (artemisinin-based com-
bination therapy in the case of Plasmodium falciparum) and vector control
with indoor residual spraying and insecticide-treated mosquito nets, will con-
siderably contribute to improving public health.
In areas where essential clinical services are available, the basic needs of the
population are covered, and malaria transmission has been reduced to a
level where less than 5% of all febrile patients with suspected malaria actu-
ally carry malaria parasites, and case-loads are becoming manageable, pro-
gramme re
orientation towards elimination becomes a possibility. The aim of
a pre-elimination programme will be to reduce malaria incidence to less than
1 infection per 1000 people at risk per year, and to set up the quality-controlled
systems required for an elimination programme.
The priorities of a malaria elimination programme are: (i) to identify and treat
malaria patients and all people carrying parasites, including those carry ing
gametocytes, ensuring that they become non-infectious as soon as possible;
and (ii) to sustainably reduce human–vector contact and the vectorial capacity
of the local Anopheles mosquito populations to prevent new infections from
occurring.
The efforts required for malaria elimination are fundamentally different
from malaria control. Some tools and approaches are specifi c to elimination;
2
MALARIA ELIMINATION: A FIELD MANUAL FOR LOW AND MODERATE ENDEMIC COUNTRIES
others take on a much more prominent role than in control efforts. The
choice is based on an in-depth knowledge of the local epidemiology of malaria
parasites, vectors and transmission patterns. Their application is targeted
through the identifi cation of transmission foci and geographical reconnais-
sance. While malaria control assesses accomplishments, malaria elimination
assesses what remains to be accomplished (see Table 1).
All countries aiming for elimination will eventually need to create or enhance
legislation supporting the identifi cation and notifi cation of malaria cases and
mosquito breeding sites, and set up a national malaria case register, intra- and
intercountry coordination mechanisms, comprehensive quality control for
clinical and laboratory services in public and private sectors, effective surveil-
lance and vigilance systems, and special measures to cope with the continuing
importation of parasites by international travellers and migrants.
Solid programme management, adequate resources, responsive and compre-
hensive information systems and geographical access are required to manage
and monitor elimination efforts and achieve targets within realistic timescales
that usually stretch over at least 8–10 years. Efforts can be staggered geographi-
cally and by Plasmodium species, with different phases taking place simultane-
ously in different parts of the country. Where elimination on a national scale is
not deemed feasible, it may still be possible and desirable to create malaria-free
zones.
The development of an operational plan for malaria elimination requires a
comprehensive national effort. Full support from the highest levels of govern-
ment to smooth coordination between different government ministries such
as agriculture, defence, fi nance, health and policy and planning is a prerequi-
site for operational success.
Total budget requirements for achieving elimination depend on the local situ-
ation. Stable funding commitment and fl exible funding is needed to deal with
occasional programme setbacks. Countries that have recently achieved inter-
ruption of transmission have done so primarily with national funding or in the
context of a locally funded subregional, multicountry initiative. Public-sector
funding requirements for health will not dramatically decrease once malaria
has been eliminated, due to the increasing requirements of general health serv-
ices, and the need for vigilance and response capacity to prevent re-establish-
ment of transmission.
The World Health Organization (WHO) grants certifi cation of malaria elimi-
nation to countries that have interrupted local transmission for a period of
three or more years and have high-quality surveillance systems and data to
prove it.
3
INTRODUCTION
Table 1. Diff erence between malaria control and elimination programmesa
ITEM CONTROL PROGRAMME ELIMINATION PROGRAMME
Objective Reduction of the malaria burden The total and maintained ending of local
malaria transmission
Area of operations May depend on degree of endemicity, All malaria transmission foci
on accessibility and social, political or
economic importance
Minimum acceptable Good: reduction of transmission to a Perfect: transmission must be
standard of operations level at which it ceases to be a major interrupted in the entire area; should
public health problem new locally acquired infections occur,
the cause must be determined and
removed
Duration of operations Without limit Country can be considered malaria-free
when transmission has been ended for
three years in the entire territory
Economic aspects Expenditure for malaria interventions Expenditure will continue after
constantly recurring elimination, when the focus will shift to
sustaining effi cient general health
services
Integration with other Often convenient and feasible as an Less feasible largely because elimination
health programmes integrated public health programme has a highly specifi c and usually time-
limited objective
Case-fi nding Mainly through passive case detection Of primary importance, including
(people seeking care) through active case detection
Imported cases Of minor interest – mostly academic – Very important, especially when
with the exception of importation of elimination is achieved
P. falciparum in areas where this does
not normally occur
Epidemiological Of little value, with the exception of Of increasing importance and fi nally
investigation of individual P. falciparum cases in areas where essential as elimination is approached
cases they do not normally occur
Epidemiological evaluation Reduction of parasite indices; Proven disappearance of indigenous
reported malaria incidence malaria cases
Administrative standard Measurement of accomplishments Measurement of what remains to be
of progress accomplished
Unit of intervention Population, patient Focus (locality)
Administration of the May not be the best but is suffi cient Must be fully effi cient and speedy;
programme if not, there will be a danger of failure
a
Adapted from WHO Expert Committee on Malaria. Sixth report (1).
4
MALARIA ELIMINATION: A FIELD MANUAL FOR LOW AND MODERATE ENDEMIC COUNTRIES
The initiative for development of this manual was taken at the WHO
Global Malaria Programme consultation on malaria elimination, held in
Tunis, Tunisia, 25–26 February 2006. The fi rst draft was produced by Dr
Anatoli Kondrachine in July 2006, to which parts of the document developed
by Dr Andrei Beljaev, Guidelines on the elimination of residual foci of malaria
transmission, were added (2). The elimination strategy and the manual were
subsequently reviewed and adapted during a WHO Global Malaria Programme
meeting to fi nalize the manual, held in Geneva, Switzerland, 14–16 May 2007. A
fi nal review took place during a workshop for the WHO Eastern Mediterranean
Region on malaria elimination and malaria-free initiatives, in Dubai, United
Arab Emirates, 13–14 June 2007. The fi nal manuscript was produced by the
WHO Global Malaria Programme.
This manual requires fi eld-testing in a number of different situations.
Comments on the document are welcome and should be sent to:
Global Malaria Programme
World Health Organization
CH-1211 Geneva 27
Switzerland
Fax: +41 (0) 22 791 4824
E-mail: InfoGMP@who.int
1. Malaria1
Malaria remains one of the main global health problems of our time, causing
more than 1 million deaths per year, with about 90% of deaths and 60% of
cases occurring in Africa south of the Sahara. It is caused by the protozoan
parasite Plasmodium and transmitted by Anopheles mosquitoes, which bite
mainly between sunset and sunrise.
There are four species of malaria parasites that infect people – P. falciparum,
P. vivax, P. malariae and P. ovale. Of these, P. falciparum and P. vivax are the
most common. Falciparum malaria can be fatal. Severe falciparum malaria
has a case-fatality rate of around 10% in reasonably well-equipped hospitals.
Vivax malaria is an acute but not life-threatening illness and is associated with
anaemia and splenomegaly. Like P. falciparum, it causes low birth weight in
neonates. Unlike P. falciparum, P. vivax and P. ovale can stay dormant in the
liver as hypnozoites for up to several months or even years after inoculation
by the mosquito. Forms of malaria caused by P. malariae and P. ovale are less
severe and rarely life-threatening; the former can lead to chronic immuno-
pathological sequelae.
The four human malaria species are not evenly spread across the malaria-
affected areas of the world, and their relative importance varies between and
within different areas, by zoogeographical region. P. falciparum is the most
common species and predominates across Africa south of the Sahara. P. vivax
predominates in the subtropics and coexists with P. falciparum in tropical
Asia, the tropical Americas and the Horn of Africa. P. ovale is found in Africa
and sporadically in South-East Asia and the western Pacifi c. P. malariae has a
similar geographical distribution to P. falciparum but its incidence is patchy.
Unlike the other malaria parasites, blood infection with P. malariae can con-
tinue undetected for decades. The risk of contracting malaria is highly variable
from country to country and even between areas in a country.
1
This chapter is adapted from Malaria control in complex emergencies: an inter-agency
fi eld handbook (3).
5
6
MALARIA ELIMINATION: A FIELD MANUAL FOR LOW AND MODERATE ENDEMIC COUNTRIES
The female Anopheles mosquito is the vector of malaria parasites. There are
more than 400 different species of Anopheles mosquitoes throughout the
world, but only some 60 of these are vectors of malaria under natural condi-
tions, of which 30 are vectors of major importance. Each species has a different
behaviour pattern. Most areas have multiple species of Anopheles, and differ-
ent ones occur in different parts of the world. Highly effi cient species such as
A. gambiae sensu stricto, A. arabiensis and A. funestus predominate in Africa
south of the Sahara. Less effi cient vectors such as A. stephensi in urban settings,
and A. minimus and A. dirus in hilly or mountainous zones predominate in
Asian countries.
The transmission cycle of malaria is represented in Figure 1. After a human
is infected, the parasites pass through the human liver phase and blood cycle
onto the next phase, in the mosquito.
P. falciparum takes 8–11 days to complete the mosquito phase (sporogony) at
an optimal ambient temperature of 28 °C and 22 days at 20 °C. The tempera-
ture of the mosquito gut equals the ambient temperature: a low environmental
temperature therefore results in a longer development time for the parasite in
the mosquito. Below 20 °C, P. falciparum is unable to develop. Thus, in moun-
tainous areas of East Africa above 2000 metres, there is little malaria trans-
mission because it is too cold. P. vivax can develop in the mosquito at lower
ambient temperatures, so P. vivax transmission is found in some areas where
the average temperature is too low to allow P. falciparum transmission (for
example, in the Russian Federation). The human liver phase and blood cycle
combined take P. falciparum 15.5–17 days.
In total, the incubation interval of P. falciparum is 23.5–39 days depending
on ambient temperatures. The same interval takes P. vivax about 20 days,
making the control of P. vivax more complex than that of P. falciparum. The
liver-stage hypnozoites of P. vivax are responsible for late relapses, which are
strain-dependent.
The global distribution of malaria risk areas in 2006 is shown in Figure 2. A
total of 107 countries and areas were considered to have malarious zones (see
Annex 1). Of these, 15 have never had or no longer have local P. falciparum
transmission. Seven countries reported no indigenous cases; two of these
countries have reported no such cases since 1998. The United Arab Emirates
fi nalized the requirements for certifi cation of malaria elimination in 2006. In
January 2007, it was the fi rst formerly endemic country to be certifi ed by WHO
as malaria-free since Australia and Singapore in the 1980s.
7
1. MALARIA
Figure 1. Transmission cycle of malariaa
a
Adapted, by permission of the publishers, from Life cycle of Plasmodium spp. (4) and Sullivan (5)
8
MALARIA ELIMINATION: A FIELD MANUAL FOR LOW AND MODERATE ENDEMIC COUNTRIES
Figure 2. Distribution of malaria risk areas in the worlda
a
Adapted from International travel and health: situation as on 1 January 2007 (6).
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2. Principles and practice of malaria
elimination
Malaria elimination is the interruption of local mosquito-borne malaria trans-
mission. It does not require the elimination of disease vectors or a complete
absence of reported malaria cases in the country: imported malaria cases will
continue to be detected due to international travel, and may on occasion lead
to the occurrence of introduced cases in which the infection is a fi rst genera-
tion of local transmission subsequent to an imported case.
Elimination of malaria is an option, not an obligation. It can be envisaged when
a successful malaria control programme is succeeding in reducing the burden
of mortality and morbidity to a marginal level. Not all countries will be able
to fully interrupt malaria transmission with currently available tools. Box 1
provides an overview of the continuum from control to elimination, indicat-
ing the required programme types by current level of malaria transmission.
2.1 Malaria case defi nition in elimination programmes
For elimination purposes, a malaria case is a person in whom, regardless of the
presence or absence of clinical symptoms, malaria parasites have been con-
fi rmed by quality-controlled laboratory diagnosis. Figure 3 gives an overview
of the classifi cation of malaria cases by origin of infection, as used in malaria
pre-elimination and elimination programmes. A key for the epidemiological
classifi cation of cases is included in Annex 2.
2.2 Malaria foci classifi cation for elimination purposes1
Interventions during pre-elimination and elimination programmes are based
on the concept of a malaria focus, assuming that transmission is focalized and
no longer homogeneous across the country. A focus is a defi ned and circum-
scribed locality situated in a currently or formerly malarious area and con-
taining the continuous or intermittent epidemiological factors necessary for
malaria transmission. Examples are a town, village or other defi ned geographi-
9
1
Adapted from Guidelines on the elimination of residual foci of malaria transmission
(2).
10
MALARIA ELIMINATION: A FIELD MANUAL FOR LOW AND MODERATE ENDEMIC COUNTRIES
cal area in which there are Anopheles breeding sites, feeding and resting places,
and people exposed to biting by the vectors.1
Figure 4 gives an overview of the transition of the functional status of a malaria
focus depending on the local situation. A key for the operational classifi cation
of malaria foci is included in Annex 3.
BOX 1
Transitions from malaria control to elimination
High transmission areas
In areas where the geographical distribution of malaria cases is country- or area-wide,
the prime objective is to reduce malaria mortality, morbidity and transmission inten-
sity. In these areas, the malaria control programme should make all possible eff orts to
achieve universal coverage of cost-eff ective preventive and treatment interventions.
In addition, monitoring, health information systems, and intercountry and cross-
border collaboration are critical to reduce the burden of malaria to consistently less
than 5% of all patients with febrile disease.
Low transmission areas
In some areas, natural conditions and/or control eff orts have limited the transmis-
sion intensity to a marginal point where risk is low and localized in well-defi ned
geographical areas. An almost universal access to antimalarial measures and their
documented impact on the malaria burden make it possible to envision programme
reorientation towards elimination. The fi rst aim at this pre-elimination stage is to
reduce the malaria burden to manageable levels at an annual malaria incidence of
less than 1 case per 1000 people at risk. This is achievable by perfecting the qual-
ity and targeting of case management and vector control operations, and introduc-
ing/maintaining activities aimed at consistently reducing the onward transmission
from existing cases in residual and new active foci. A strong surveillance system, with
the cooperation of all health-care providers, must be established at this stage. These
areas can subsequently aim to halt local malaria transmission through incremental
stages.
Areas where transmission has been interrupted
In areas where interruption of malaria transmission has been achieved, the goal will
be to prevent re-establishment of local transmission through prevention of onward
transmission from imported cases. Once the entire country has been free from local
malaria transmission for three consecutive years, the process for certifi cation of the
malaria-free status can be started.
1
In contrast, evaluation of the progress of pre-elimination and elimination pro-
grammes is usually measured by entire districts or other administrative divisions.
When defi ning populations at risk or the percentage of the national territory affect-
ed by malaria, it is appropriate to determine, for example, the number of districts
with active foci.
11
2. PRINCIPLES AND PRACTICE OF MALARIA ELIMINATION
2.3 Strategies for malaria elimination
Malaria elimination builds on the foundation laid by intensive malaria con-
trol, with universal coverage of intensifi ed, effi cacious interventions for vector
control and case management. As the malaria programme evolves, the qual-
ity and targeting of operations increase, and the area of intervention narrows
from the wider population to transmission foci, to individual malaria cases.
Malaria elimination requires:
• evidence-based data on the achievement of successful malaria control;
• suffi cient evidence that transmission can be interrupted by scaling up
planned interventions;
• clearly defi ned responsibilities for management, including decentralized
authority and enforcement of regulatory and disciplinary measures;
Figure 3. Classifi cation of malaria cases by origin of infection
malaria infection
due to
mosquito-borne
transmission
acquired
locally
induced
e.g. due to blood transfusion,
congenital malaria
indigenous
all cases without evidence
of a direct link to
an imported case
introduced
first-generation local
transmission;
epidemiologically linked
to proven imported case
imported
relapsing
history of P. vivax or P. ovale
infection within past 3 years;
no epidemiologically
linked cases in vicinity
acquired
abroad or
outside area
not due to
mosquito-borne
transmission
12
MALARIA ELIMINATION: A FIELD MANUAL FOR LOW AND MODERATE ENDEMIC COUNTRIES
• effective systems to ensure coordination between public, private and community-
based agencies and services, and to implement cross-border programmes;
• intensive joint intersectoral efforts;
• adequate pre- and in-service training of service providers and high-quality
supervision/mentoring;
• sustained advocacy, social mobilization, health education and behaviour
change communication to support the preparation and implementation of
the elimination programme;
• the existence of a monitoring, evaluation and surveillance plan able to timely
measure progress, including assessments by independent team(s);
• long-term predictable and sustainable funding available to support planned
and unexpected expenses;
• eventually, systems in place for effective vigilance to prevent reintroduction.
Figure 5 gives an outline of the major phases and milestones in malaria pro-
gramme evolution.1
Figure 4. Transition of functional status of a malaria focus depending on the situationa
a
Adapted from Guidelines on the elimination of residual foci of malaria transmission (2).
1
The methodology developed in the 1950s for the Global Malaria Eradication Pro-
gramme was designed to cover malaria control operations from start (fully endemic)
to fi nish (zero cases), passing from the preparatory phase to the attack, consolida-
residual
non-active
residual
active
endemic
cleared up
absent
CA
S
ES
TR
AN
SM
IS
S
IO
N
CO
N
TR
O
L
transmission possible
transmission impossible
present
absent
present
effective
ineffective
new
potential
pseudo
focus
new
active
13
2. PRINCIPLES AND PRACTICE OF MALARIA ELIMINATION
The type of organization and the specifi c measures to be applied in order to
achieve malaria elimination will always be governed by local conditions.
The stage of elimination dictates the specifi c programme interventions for:
• case management,
• vector control and prevention,
• monitoring and evaluation,
• health systems issues.
Based on the fi ndings of an annual assessment by an independent national
malaria elimination monitoring committee, the plans of action for the fol-
lowing year are modifi ed. The participation of general health services and the
community at large, particularly in case detection, is essential for the success
of the programme, as is close interaction with relevant non-health sectors.
The following sections describe the major programme reorientations and
approaches from malaria control to elimination to prevention of reintroduc-
tion. Tables 2A–2C provide more detail of the interventions, milestones, indi-
cators and programmatic issues for each of these phases.
Figure 5. Malaria programme phases and milestones on the path to malaria eliminationa
SPR: slide or rapid diagnostic test positivity rate.
a
These milestones are indicative only: in practice, the transitions will depend on the malaria burden that a programme can
realistically handle (including case notifi cation, case investigation, etc.).
SPR < 5%
in fever cases
1st programme
reorientation 2
nd programme
reorientation
< 1 case/1000
population at risk/year 0 locally
acquired cases
3 years
WHO
certification
control pre-elimination elimination prevention of
reintroduction
tion and maintenance phases. Present-day elimination programmes are launched in
countries and areas where there is already very good malaria control. This places the
milestones for programme reorientation comparatively forward towards the inter-
ruption of transmission. For example, the attack phase in eradication corresponds
roughly to the period covered by the late stage of intensifi ed control and the pre-
elimination programme.
14
MALARIA ELIMINATION: A FIELD MANUAL FOR LOW AND MODERATE ENDEMIC COUNTRIES
Ta
b
le
2
A
.
P
rof
i

le
b
y
p
ro
g
ra
m
m
e
t
yp
e

IT
EM

CO
N
TR
O
L
P
RO
G
R
AM
M
E

PR
E
-E
L
IM
IN
A
T
IO
N
P
RO
G
R
AM
M
E

E
L
IM
IN
A
T
IO
N
P
RO
G
R
AM
M
E

PR
EV
EN
T
IO
N
O
F
R
E
IN
TR
O
DU
C
T
IO
N
P
RO
G
R
AM
M
E
M
a
in
p
ro
g
ram
m
e
g
o
a
l

R
ed
u
ce
m
o
rb
id
it
y
a
n
d

H
a
lt
lo
ca
l
t
ra
n
sm
is
s
io
n

H
a
lt
lo
ca
l
t
ra
n
sm
is
s
io
n

P
re
ve
n
t
r
e
-e
s
ta
b
l
is
hm
en
t
o
f
lo
ca
l



m
o
r
ta
l
it
y

n
a
t
io
nw
id
e

n
a
t
io
nw
id
e

t
ra
n
sm
is
s
io
n
Ep
id
em
io
lo
g
ic
a
l
o
b
je
c
t
iv
e

R
ed
u
ce
b
u
rd
en
o
f
m
a
la
r
ia

R
ed
u
ce
n
um
b
e
r
o
f
a
c
t
iv
e
f
o
c
i
t
o
z
e
ro

R
ed
u
ce
n
um
b
e
r
o
f
a
c
t
iv
e
f
o
c
i
t
o
z
e
ro

P
re
ve
n
t
in
t
ro
d
u
ce
d
c
a
se
s
a
n
d
in
d
ig
en
ou
s


R
ed
u
ce
n
um
b
e
r
o
f
lo
ca
ll
y
a
cq
u
ir
ed

R
ed
u
ce
n
um
b
e
r
o
f
lo
ca
ll
y
a
cq
u
ir
ed

ca
se
s
s
e
co
n
d
a
ry
t
o
in
t
ro
d
u
ce
d
c
a
se
s


ca
se
s
t
o
z
e
ro

ca
se
s
t
o
z
e
ro
T
ra
n
sm
is
s
io
n
o
b
je
c
t
iv
e

R
ed
u
ce
t
ra
n
sm
is
s
io
n

R
ed
u
ce
o
nw
a
rd
t
ra
n
sm
is
s
io
n


R
ed
u
ce
o
nw
a
rd
t
ra
n
sm
is
s
io
n

R
ed
u
ce
o
nw
a
rd
t
ra
n
sm
is
s
io
n


in
te
n
s
it
y

fr
om
e
x
is
t
in
g
c
a
se
s

fr
om
e
x
is
t
in
g
c
a
se
s

fr
om
im
p
o
r
te
d
c
a
se
s
U
n
it
o
f
in
te
rv
en
t
io
n

Co
un
t
ry
-
o
r
a
re
a
-w
id
e

Fo
c
i

Fo
c
i,
in
d
iv
id
u
a
l
c
a
se
s

In
d
iv
id
u
a
l
c
a
se
s



(
lo
ca
ll
y
a
cq
u
ir
ed
a
n
d
im
p
o
r
te
d
)

(
im
p
o
r
te
d
c
a
se
s
o
n
ly
)
M
il
e
s
to
n
e
f
o
r
t
ra
n
s
it
io
n

SP
R
<
5%
in
s
u
sp
e
c
te
d

<
1
c
a
se
p
e
r
1
0
0
0
p
op
u
la
t
io
n

Ze
ro
lo
ca
ll
y
a
cq
u
ir
ed
c
a
se
s

—
to
n
e
x
t
p
ro
g
ram
m
e
t
yp
e
a

m
a
la
r
ia
c
a
se
s

a
t
r
is
k
p
e
r
y
ea
r

D
a
ta
s
ou
rc
e
f
o
r
m
ea
su
r
in
g

P
ro
x
y
d
a
ta
:
h
ea
lt
h
f
a
c
il
it
y

P
ro
x
y
d
a
ta
:
h
ea
lt
h
f
a
c
il
it
y
d
a
ta
,

N
o
t
ifi
c
a
t
io
n
r
ep
o
r
ts
,

—
p
ro
g
re
s
s
t
ow
a
rd
s
r
ea
ch
in
g

d
a
ta

n
o
t
ifi
c
a
t
io
n
r
ep
o
r
ts

in
d
iv
id
u
a
l
c
a
se
in
ve
s
t
ig
a
t
io
n
s
,

m
il
e
s
to
n
e
s

Co
nfi
rm
a
to
ry
d
a
ta
:

Co
nfi
rm
a
to
ry
d
a
ta
:

g
en
o
ty
p
in
g

p
op
u
la
t
io
n
-b
a
se
d
s
u
rv
e
y
s

p
op
u
la
t
io
n
-b
a
se
d
s
u
rv
e
y
s

SP
R
:
s
l
id
e
o
r
r
ap
id
d
ia
g
n
o
s
t
ic
t
e
s
t
p
o
s
it
iv
it
y
r
a
te
.
a

Th
e
se
m
il
e
s
to
n
e
s
a
re
in
d
ic
a
t
iv
e
o
n
ly
:
in
p
ra
c
t
ic
e
,
t
h
e
t
ra
n
s
it
io
n
s
w
il
l
d
ep
en
d
o
n
t
h
e
m
a
la
r
ia
b
u
rd
en
t
h
a
t
a
p
ro
g
ra
m
m
e
c
an
r
e
a
l
is
t
ic
a
l
ly
h
an
d
le
(
in
c
lu
d
in
g
c
a
se
n
o
t
ifi
c
a
t
io
n
,
c
a
se
in
ve
s
t
ig
a
t
io
n
,
e
tc
.)
.
15
2. PRINCIPLES AND PRACTICE OF MALARIA ELIMINATION
Ta
b
le
2
B
.

In
te
rv
en
t
io
n
s
b
y
p
ro
g
ra
m
m
e
t
yp
e
IN
T
ER
V
EN
T
IO
N

CO
N
TR
O
L
P
RO
G
R
AM
M
E

PR
E
-E
L
IM
IN
A
T
IO
N
P
RO
G
R
AM
M
E
a

E
L
IM
IN
A
T
IO
N
P
RO
G
R
AM
M
E

PR
EV
EN
T
IO
N
O
F
R
E
IN
TR
O
DU
C
T
IO
N
P
RO
G
R
AM
M
E
Ca
se

•
U
p
d
a
te
d
ru
g
p
o
l
ic
y
,
u
se
o
f
A
C
T

•
D
ru
g
p
o
l
ic
y
c
h
an
g
e
t
o
:

•

Im
p
lem
en
ta
t
io
n
o
f
n
ew
d
ru
g
p
o
l
ic
y

•
C
a
se
m
an
ag
em
en
t
o
f
im
p
o
r
te
d
m
a
la
r
ia
m
an
ag
em
en
t

•
Q
A
/Q
C
o
f
la
b
o
ra
to
ry
d
ia
gn
o
s
is


–

ra
d
ic
a
l
t
re
a
tm
en
t
f
o
r
P
.
v
iv
a
x

•
R
ou
t
in
e
Q
A
/Q
C
e
xp
e
r
t
m
ic
ro
sc
op
y

•
A
w
a
re
n
e
s
s
o
f
d
ru
g
r
e
s
is
ta
n
ce
p
a
t
te
rn
s


(m
ic
ro
sc
op
y
/R
D
T
)


–

A
C
T
a
n
d
g
am
e
to
cy
te
t
re
a
tm
en
t

•
A
c
t
iv
e
c
a
se
d
e
te
c
t
io
n


ab
ro
ad
,
t
o
f
o
rm
u
la
te
p
re
ve
n
t
io
n

•

C
l
in
ic
a
l
d
ia
gn
o
s
is
s
om
e
t
im
e
s



fo
r
P
.
fa
lc
ip
a
ru
m

•
M
on
it
o
r
in
g
a
n
t
im
a
la
r
ia
l
d
ru
g


g
u
id
e
l
in
e
s


a
c
ce
p
ta
b
le

•
1
0
0%
c
a
se
c
onf
i
rm
a
t
io
n
b
y


re
s
is
ta
n
ce

•
M
on
it
o
r
in
g
a
n
t
im
a
la
r
ia
l
d
ru
g


m
ic
ro
sc
op
y


re
s
is
ta
n
ce

•
M
ic
ro
sc
op
y
Q
A
/Q
C



•
M
on
it
o
r
in
g
a
n
t
im
a
la
r
ia
l
d
ru
g





re
s
is
ta
n
ce
V
e
c
to
r
c
on
t
ro
l

•

T
ra
n
sm
is
s
io
n
r
ed
u
c
t
io
n
t
h
ro
u
gh
h
ig
h

•
G
eo
g
ra
ph
ic
a
l
r
e
co
n
n
a
is
sa
n
ce

•
G
eo
g
ra
ph
ic
a
l
r
e
co
n
n
a
is
sa
n
ce

•
P
e
r
fe
c
t
m
a
la
r
ia
c
a
se
d
e
te
c
t
io
n
m
e
ch
an
ism
an
d
m
a
la
r
ia


p
op
u
la
t
io
n
c
o
ve
ra
g
e
o
f
IT
N
/L
L
IN

•

To
ta
l
IR
S
c
o
ve
ra
g
e
in
f
o
c
i

•
V
e
c
to
r
c
on
t
ro
l
t
o
r
ed
u
ce
t
ra
n
sm
is
s
io
n

•
C
lu
s
te
r
r
e
sp
on
se
a
n
d
p
re
ve
n
t
io
n
p
re
ve
n
t
io
n


an
d
IR
S

•

IV
M
a
n
d
IT
N
/L
L
IN
a
s
c
om
p
lem
en
ta
ry


in
r
e
s
id
u
a
l
a
c
t
iv
e
a
n
d
n
ew
a
c
t
iv
e
f
o
c
i

•
P
re
ve
n
t
io
n
o
f
m
a
la
r
ia
in
t
ra
ve
ll
e
rs
,
in
c
lu
d
in
g

•

En
to
m
o
lo
g
ic
a
l
s
u
rv
e
il
la
n
ce


m
ea
su
re
s
in
s
p
e
c
ifi
c
s
it
u
a
t
io
n
s

•
V
e
c
to
r
c
on
t
ro
l
t
o
r
ed
u
ce
r
e
ce
p
t
iv
it
y
in


h
ea
lt
h
e
d
u
ca
t
io
n
a
n
d
e
n
g
ag
em
en
t
o
f

•

Ep
id
em
ic
p
re
p
a
re
dn
e
s
s
a
n
d
r
e
sp
on
se

•

Ep
id
em
ic
p
re
p
a
re
dn
e
s
s
a
n
d
r
e
sp
on
se


re
ce
n
t
f
o
c
i


t
ra
ve
l
a
g
en
c
ie
s

•

IP
Tp
in
h
yp
e
re
n
d
em
ic
a
re
a
s

•

En
to
m
o
lo
g
ic
a
l
s
u
rv
e
il
la
n
ce

•
O
u
tb
re
a
k
p
re
p
a
re
dn
e
s
s
a
n
d
r
e
sp
on
se





•

En
to
m
o
lo
g
ic
a
l
s
u
rv
e
il
la
n
ce





•
P
re
ve
n
t
io
n
o
f
m
a
la
r
ia
in
t
ra
ve
ll
e
rs

M
on
it
o
r
in
g
a
n
d

•

Im
p
ro
ve
s
u
rv
e
il
la
n
ce
a
n
d
n
a
t
io
n
a
l

•
G
IS
-b
a
se
d
d
a
ta
b
a
se
o
n
c
a
se
s
a
n
d

•

C
a
se
in
ve
s
t
ig
a
t
io
n
a
n
d
c
la
s
s
ifi
c
a
t
io
n

•
V
ig
il
an
ce
e
va
lu
a
t
io
n


co
ve
ra
g
e


ve
c
to
rs

•

Fo
c
i
in
ve
s
t
ig
a
t
io
n
a
n
d
c
la
s
s
ifi
c
a
t
io
n

•
C
a
se
in
ve
s
t
ig
a
t
io
n

•

Co
un
t
ry
p
rof
i

le
s

•

E
l
im
in
a
t
io
n
d
a
ta
b
a
se

•
R
ou
t
in
e
g
en
o
ty
p
in
g

•
P
.
fa
lc
ip
a
ru
m
o
u
tb
re
a
k
n
o
t
ifi
c
a
t
io
n
in

•
M
a
la
r
ia
in
d
ic
a
to
r
s
u
rv
e
y
s
(M
IS
,
M
IC
S
,

•

C
en
t
ra
l
r
e
co
rd
s
b
an
k

•
M
a
la
r
ia
s
u
rv
e
y
s


a
cc
o
rd
an
ce
w
it
h
IH
R
(
20
05
)


DH
S
)

•
G
en
o
ty
p
in
g
,
i
so
la
te
b
an
k

•

Im
m
ed
ia
te
n
o
t
ifi
c
a
t
io
n
o
f
c
a
se
s

•
A
n
n
u
a
l
r
ep
o
r
t
in
g
t
o
W
H
O
o
n
m
a
in
te
n
an
ce



•
M
a
la
r
ia
s
u
rv
e
y
s

•
M
e
te
o
ro
lo
g
ic
a
l
m
on
it
o
r
in
g


o
f
m
a
la
r
ia
-
fr
e
e
s
ta
tu
s



•

Im
m
ed
ia
te
n
o
t
ifi
c
a
t
io
n
o
f
c
a
se
s
Co
n
t
in
u
ed
o
n
p
ag
e
1
6
16
MALARIA ELIMINATION: A FIELD MANUAL FOR LOW AND MODERATE ENDEMIC COUNTRIES
Ta
b
le
2
B
.

Co
n
t
in
u
ed
IN
T
ER
V
EN
T
IO
N

CO
N
TR
O
L
P
RO
G
R
AM
M
E

PR
E
-E
L
IM
IN
A
T
IO
N
P
RO
G
R
AM
M
E
a

E
L
IM
IN
A
T
IO
N
P
RO
G
R
AM
M
E

PR
EV
EN
T
IO
N
O
F
R
E
IN
TR
O
DU
C
T
IO
N
P
RO
G
R
AM
M
E
H
e
a
lt
h
s
y
s
te
m
s

•
A
cc
e
s
s
t
o
t
re
a
tm
en
t

•

En
g
ag
in
g
p
r
iv
a
te
s
e
c
to
r

•

Fu
ll
c
o
op
e
ra
t
io
n
o
f
p
r
iv
a
te
s
e
c
to
r

•

In
te
g
ra
t
io
n
o
f
m
a
la
r
ia
p
ro
g
ram
m
e
s
taf
f

in
to
is
su
e
s

•
A
cc
e
s
s
t
o
d
ia
gn
o
s
t
ic
s

•

Co
n
t
ro
l
o
f
O
TC
s
a
le
o
f
a
n
t
im
a
la
r
ia
l

•
N
o
O
TC
s
a
le
o
f
a
n
t
im
a
la
r
ia
l
m
ed
ic
in
e
s


o
th
e
r
h
ea
lt
h
a
n
d
v
e
c
to
r
c
on
t
ro
l

•
H
e
a
lt
h
s
y
s
tem
s
t
re
n
g
th
en
in
g


m
ed
ic
in
e
s

•

F
re
e
-o
f-
ch
a
rg
e
d
ia
gn
o
s
is
a
n
d


p
ro
g
ram
m
e
s


(c
o
ve
ra
g
e
,
p
r
iv
a
te
a
n
d
p
u
b
l
ic

•
A
va
il
ab
il
it
y
o
f
q
u
a
l
ifi
e
d
s
taf
f



t
re
a
tm
en
t
f
o
r
a
ll
m
a
la
r
ia
c
a
se
s


se
c
to
rs
,
Q
A
)

P
ro
g
ra
m
m
a
t
ic

•
P
ro
cu
rem
en
t
,
s
u
p
p
ly
m
an
ag
em
en
t

•

E
l
im
in
a
t
io
n
p
ro
g
ra
m
m
e

•

Im
p
lem
en
ta
t
io
n
o
f
e
l
im
in
a
t
io
n

•
W
H
O
c
e
r
t
ifi
c
a
t
io
n
p
ro
ce
s
s
is
su
e
s

•
R
e
so
u
rc
e
m
ob
il
iz
a
t
io
n


d
e
ve
lo
pm
en
t


p
ro
g
ram
m
e

•
R
eg
io
n
a
l
in
it
ia
t
iv
e

•

Le
g
is
la
t
io
n

•

Im
p
lem
en
ta
t
io
n
o
f
u
p
d
a
te
d
d
ru
g

•
P
h
a
rm
a
co
v
ig
il
an
ce

•
R
eg
io
n
a
l
in
it
ia
t
iv
e


p
o
l
ic
y
,
v
e
c
to
r
c
on
t
ro
l,
a
c
t
iv
e

•
A
dh
e
re
n
ce
t
o
t
h
e
“
Th
re
e
O
n
e
s”

•
M
ob
il
iz
a
t
io
n
o
f
d
om
e
s
t
ic
fu
n
d
in
g


d
e
te
c
t
io
n
o
f
c
a
se
s


p
r
in
c
ip
le
s

•

E
s
ta
b
l
is
h
m
a
la
r
ia
e
l
im
in
a
t
io
n

•
M
a
la
r
ia
e
l
im
in
a
t
io
n
c
om
m
it
te
e
:

•

In
te
g
ra
t
io
n
w
it
h
o
th
e
r
h
ea
lt
h


co
m
m
it
te
e


–
m
an
ag
e
m
a
la
r
ia
e
l
im
in
a
t
io
n



p
ro
g
ram
m
e
s
f
o
r
d
e
l
iv
e
ry
o
f
in
te
r-

•
R
eo
r
ie
n
ta
t
io
n
o
f
h
e
a
lt
h
f
a
c
il
it
y
s
taf
f




d
a
ta
b
a
se


ve
n
t
io
n
s
,
e
.g
.
IT
N
/L
L
IN
,
IP
Tp




–

re
p
o
s
it
o
ry
o
f
in
fo
rm
a
t
io
n

•
D
om
e
s
t
ic
/e
x
te
rn
a
l
fu
n
d
in
g




–

p
e
r
io
d
ic
r
e
v
iew






–

o
ve
rs
ig
h
t





•
R
eo
r
ie
n
ta
t
io
n
o
f
h
e
a
lt
h
f
a
c
il
it
y
s
taf
f

17
2. PRINCIPLES AND PRACTICE OF MALARIA ELIMINATION
Ta
b
le
2
B
.

Co
n
t
in
u
ed
IN
T
ER
V
EN
T
IO
N

CO
N
TR
O
L
P
RO
G
R
AM
M
E

PR
E
-E
L
IM
IN
A
T
IO
N
P
RO
G
R
AM
M
E
a

E
L
IM
IN
A
T
IO
N
P
RO
G
R
AM
M
E

PR
EV
EN
T
IO
N
O
F
R
E
IN
TR
O
DU
C
T
IO
N
P
RO
G
R
AM
M
E
In
te
rv
en
t
io
n
s

•

C
a
se
m
an
ag
em
en
t
th
ro
u
gh
ou
t
a
l
l

•

In
te
g
ra
te
d
v
e
c
to
r
m
an
ag
em
en
t
,
in
c
lu
d
in
g
m
on
it
o
r
in
g
o
f
in
se
c
t
ic
id
e
r
e
s
is
ta
n
ce
p
ro
g
ra
m
m
e
s

•
G
eo
g
ra
ph
ic
a
l
in
fo
rm
a
t
io
n
c
o
ll
e
c
t
io
n

•
H
um
an
r
e
so
u
rc
e
s
d
e
ve
lo
pm
en
t

•
H
e
a
lt
h
e
d
u
ca
t
io
n
,
p
u
b
l
ic
r
e
la
t
io
n
s
,
a
d
vo
ca
cy


•
O
p
e
ra
t
io
n
a
l
r
e
se
a
rc
h

•

Te
ch
n
ic
a
l
a
n
d
o
p
e
ra
t
io
n
a
l
c
o
o
rd
in
a
t
io
n
,
in
c
lu
d
in
g
in
t
ra
-
a
n
d
in
te
rs
e
c
to
ra
l
c
o
ll
ab
o
ra
t
io
n
,
b
o
th
w
it
h
in
t
h
e
c
ou
n
t
ry
a
n
d
w
it
h
n
e
ig
h
b
ou
r
in
g
c
ou
n
t
r
ie
s


•
M
on
it
o
r
in
g
a
n
d
e
va
lu
a
t
io
n

•

In
d
ep
en
d
en
t
a
s
se
s
sm
en
t
o
f
r
ea
ch
in
g
m
il
e
s
to
n
e
s

•
R
e
so
u
rc
e
m
ob
il
iz
a
t
io
n

•
H
ea
lt
h
s
y
s
tem
s
s
t
re
n
g
th
en
in
g
A
C
T
:
a
r
te
m
is
in
in
-b
a
se
d
c
om
b
in
a
t
io
n
t
h
e
ra
p
y
;
D
H
S
:
D
em
og
ra
p
h
ic
a
n
d
H
e
a
lt
h
S
u
rv
e
y
s
;
G
IS
:
g
eo
g
ra
p
h
ic
in
fo
rm
a
t
io
n
s
y
s
te
m
;
IH
R
(
20
0
5
)
:
In
te
rn
a
t
io
n
a
l
H
e
a
lt
h
R
eg
u
la
t
io
n
s
(
20
0
5
)
;
IP
Tp
:
in
te
rm
it
te
n
t
p
re
ve
n
t
iv
e

t
re
a
tm
en
t
in
p
re
g
n
an
cy
;
IR
S
:
in
d
o
o
r
r
e
s
id
u
a
l
s
p
ra
y
in
g
;
I
TN
:
in
se
c
t
ic
id
e
-
t
re
a
te
d
m
o
sq
u
it
o
n
e
t
;
IV
M
:
in
te
g
ra
te
d
v
e
c
to
r
m
an
ag
em
en
t
;
L
L
IN
:
lo
n
g
-
la
s
t
in
g
in
se
c
t
ic
id
a
l
n
e
t
;
M
IC
S
:
M
u
lt
ip
le
In
d
ic
a
to
r
C
lu
s
te
r
S
u
rv
e
y
s
;
M
IS
:

M
a
la
r
ia
In
d
ic
a
to
r
S
u
rv
e
y
;
O
TC
:
o
ve
r-
th
e
-c
ou
n
te
r
;
Q
A
:
q
u
a
l
it
y
a
s
su
ra
n
ce
;
Q
C
:
q
u
a
l
it
y
c
on
t
ro
l;
R
D
T
:
r
ap
id
d
ia
g
n
o
s
t
ic
t
e
s
t
.
a

Th
e
p
re
-e
l
im
in
a
t
io
n
p
ro
g
ra
m
m
e
i
s
a
r
eo
r
ie
n
ta
t
io
n
p
h
a
se
.
T
h
e
in
te
rv
en
t
io
n
s
m
en
t
io
n
ed
in
t
h
is
c
o
lum
n
a
re
in
t
ro
d
u
ce
d
d
u
r
in
g
t
h
is
p
ro
g
ra
m
m
e
r
eo
r
ie
n
ta
t
io
n
,
t
o
b
e
f
u
l
ly
o
p
e
ra
t
io
n
a
l
a
t
t
h
e
s
ta
r
t
o
f
t
h
e
e
l
im
in
a
t
io
n

p
ro
g
ra
m
m
e
.
18
MALARIA ELIMINATION: A FIELD MANUAL FOR LOW AND MODERATE ENDEMIC COUNTRIES
Ta
b
le
2
C
.
In
d
ic
a
to
rs
b
y
p
ro
g
ra
m
m
e
t
yp
e
IN
D
IC
A
TO
R

CO
N
TR
O
L
P
RO
G
R
AM
M
E

PR
E
-E
L
IM
IN
A
T
IO
N
P
RO
G
R
AM
M
E

E
L
IM
IN
A
T
IO
N
P
RO
G
R
AM
M
E

PR
EV
EN
T
IO
N
O
F
R
E
IN
TR
O
DU
C
T
IO
N
P
RO
G
R
AM
M
E
O
u
tc
om
e

•
P
ro
p
o
r
t
io
n
o
f
p
op
u
la
t
io
n
a
t
r
is
k
t
a
rg
e
te
d
f
o
r
IR
S

•
%
o
f
a
c
tu
a
l
c
a
se
s
r
ep
o
r
te
d

•
%
o
f
a
c
tu
a
l
c
a
se
s
r
ep
o
r
te
d

•
%
o
f
h
ig
h
ly
v
u
ln
e
ra
b
le
f
o
c
i
p
ro
te
c
te
d
b
y

•
P
ro
p
o
r
t
io
n
o
f
t
a
rg
e
t
p
op
u
la
t
io
n
p
ro
te
c
te
d
b
y
IR
S


p
e
r
y
ea
r


p
e
r
y
ea
r


ve
c
to
r
c
on
t
ro
l
a
n
d
e
n
v
ir
on
m
en
ta
l

•
P
ro
p
o
r
t
io
n
o
f
p
op
u
la
t
io
n
a
t
r
is
k
t
a
rg
e
te
d
f
o
r

•
%
o
f
r
ep
o
r
te
d
c
a
se
s

•
%
o
f
r
ep
o
r
te
d
c
a
se
s
in
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.
19
2. PRINCIPLES AND PRACTICE OF MALARIA ELIMINATION
First programme reorientation: the pre-elimination programme
This reorientation starts in areas where:
• health facility data that are representative of the entire target area/country
indicate that the monthly slide or rapid diagnostic test (RDT) positivity rate
among febrile patients with suspected malaria is consistently less than 5%
throughout the year, hence malaria case-loads are becoming manageable;
• population-based surveys in the peak transmission season confi rm a malaria
parasite rate of less than 5% among people of all ages with current fever or a
history of fever in the past 24 hours.
In such areas, it is important that every febrile patient who does not have other
obvious causes of fever is laboratory tested for malaria. From the start of the
pre-elimination programme onwards, 100% diagnosis by Giemsa-stained
microscopy (as opposed to RDT) needs to be phased in, because:
• it is increasingly important to accurately determine parasite species and den-
sities and detect gametocytes;
• some types of RDT can still give positive results for up to two weeks after
parasitological cure;
• the RDT for P. vivax diagnosis can give false negative results in up to 20% of
cases due to the inherent low sensitivity of the test.
Case management should aim to reduce the parasite reservoir through early
diagnosis and treatment and use of effi cacious medicines. For treatment of
P. falciparum, the use of artemisinin-based combination therapy is preferable
because of its effect on gametocyte-carriage rates. Alternatively, primaquine
can be added in a single dose as gametocytocidal treatment. Recent evidence
seems to show the benefi t of single-dose primaquine even when artemisinin-
based combination therapy is used.
During the pre-elimination programme, the following needs to be accom-
plished:
• strengthening the health information system, including entomological
surveillance and immediate notifi cation of all malaria cases;
• improving the effective coverage of good-quality curative and preventive
health services in all transmission areas. This implies that the whole popu-
lation, either nationals or foreigners, is easily accessing and using private
and/or public health-care facilities, whatever their citizenship or conditions
(refugees, displaced, temporary workers, etc.);
• reorientating public and private health service staff towards the new goals of
malaria elimination;
• establishing the national malaria elimination monitoring committee;
• developing the elimination programme;
20
MALARIA ELIMINATION: A FIELD MANUAL FOR LOW AND MODERATE ENDEMIC COUNTRIES
• setting up the elimination database;
• setting up a national register of foci;
• strengthening the programme in terms of personnel, resources and logistics;
• establishing a programme of joint activities in border areas;
• mobilizing domestic funding and necessary assistance from international
and bilateral partners;
• advocacy to assure political commitment and continuous funding for
remaining transmission foci (especially in the decentralized political and
budget context that many countries are experiencing).
The main activities of the national malaria programme staff include:
• collection of data on the parasites, vectors and human population, to assess
and verify previous fi ndings and target interventions;
• epidemiological investigation and case classifi cation;
• detailed assessment of malaria foci;
• geographical reconnaissance and detailed logistic planning;
• drug policy change to include primaquine treatment for P. vivax (radical
treatment) and artemisinin-based combination therapy plus one day game-
tocyte treatment for P. falciparum;
• training and reorientation of personnel;
• setting up of the organization and physical facilities.
Programme reorientation has been achieved when cases are limited to clearly
defi ned foci only, and the following changes have been completed:
• all malaria cases are microscopically confi rmed and treated according to
national policy, including cases diagnosed and treated in the private sector;
• microscopy quality-assurance systems are fully operational;
• all malaria cases are notifi ed, epidemiologically investigated and centrally
registered;
• malarious areas are clearly delimited and an inventory of foci has been
made;
• the elimination database has been set up, including geographic infor-
mation systems-based data on foci, cases, vectors, parasite isolates and
interventions.
Elimination programme
This phase starts in areas where the fi rst programme reorientation has been
achieved, and where health facility data show a malaria incidence of less than
1 infection per 1000 people at risk per year, equal to less than 100 new cases per
year in a district with a population of 100 000 people. This is confi rmed by:
21
• population-based reporting from facilities with known catchment areas,
very high and reliable case notifi cation and full participation of the private
sector (assuming well-developed health services, mandatory reporting of
malaria, and a strong conviction that nothing is being missed); and/or
• active case detection at community level among people with current fever
(either measured directly or with a history of fever within the past 24 hours)
in the expected peak transmission season (“fever survey”).
The goal of the elimination programme is to halt local transmission area- or
countrywide, clear up malaria foci, and reduce the number of locally acquired
cases to zero. To achieve this, the priority is to prevent onward transmission
from existing cases by:
• identifying and treating all malaria cases with effi cacious antimalarial medi-
cines against liver stage and blood stage parasites, including gametocytes;
• reducing human–vector contact and the vectorial capacity of the local
Anopheles mosquito populations in transmission foci by effi cacious vector
control, personal protection and environmental management methods.
Where P. falciparum is still present, this species is usually targeted fi rst (see
Box 2). The operational target for case detection in transmission foci is all
febrile patients who do not have other obvious causes of fever. They should
2. PRINCIPLES AND PRACTICE OF MALARIA ELIMINATION
BOX 2
Why P. falciparum is usually targeted fi rst
P. falciparum usually disappears from an area before P. vivax because:
• P. falciparum has a longer incubation interval than P. vivax, making the species
more responsive to control measures;
• P. vivax strains have a longer incubation period;
• persistent hypnozoites of P. vivax prolong the natural lifespan of the parasite;
• people carrying hypnozoites are diffi cult to detect;
• treatment of hypnozoites is cumbersome, requiring 14 days’ treatment with
primaquine.
Current malaria control tools make P. falciparum elimination programmes more
feasible because:
• rapid diagnostic tests have a higher sensitivity for P. falciparum compared with
those currently available for P. vivax;
• artemisinin-based combination therapy, when given promptly after the onset
of symptoms, is highly eff ective against blood stage asexual and sexual forms of
P. falciparum;
• the duration of artemisinin-based combination therapy for P. falciparum (3 days)
is considerably shorter than the 14 days required for radical treatment of P. vivax
with primaquine.
22
MALARIA ELIMINATION: A FIELD MANUAL FOR LOW AND MODERATE ENDEMIC COUNTRIES
be tested for malaria, irrespective of their point of contact with the health
services.
Routine genotyping of parasite isolates should be introduced early on in this
phase (see Annex 4), to build up a local isolate bank (or, as the case may be, a
genotypic register or databank), and develop a malaria parasite strain profi le
for the country, preferably linked to a regional/global database.
In the elimination programme, the concepts of receptivity and vulnerability
become important, to minimize the risk of losing recent programme gains and
to target interventions at areas at risk of the continuation or resumption of
transmission.
• Areas are receptive when the abundant presence of vector anophelines and
the prevailing ecological and climatic factors favour malaria transmission.
• Areas are vulnerable when they are in proximity to malarious areas or are
prone to the frequent infl ux of infected individuals or groups and/or infec-
tive anophelines.
Vector control methods have to be selected to suit local conditions.
• Depending on feasibility and availability, indoor residual insecticide spray-
ing, long-lasting insecticidal nets or a combination of both interventions is
often the main method to reduce transmission in residual or new active foci.
The insecticide and frequency of application of indoor residual spraying are
determined by the local epidemiological situation. Up-to-date information
is needed on vector resistance to pesticides, especially in conjunction with
their continuing extensive use in agriculture. Planning and operations are
guided by geographical reconnaissance.
• Larviciding may play an important supportive or even leading role in some
special settings such as arid environments where mosquito breeding sites
– often a result of human activity – are few and well identifi ed. Larviciding
may also be used to reduce receptivity in recent foci.
• Long-lasting insecticidal nets and other insecticide-treated materials play a
supportive role as personal protection, including for nationals who travel
abroad to endemic areas.
As the parasite reservoir decreases, full surveillance is instituted. Its purpose is
to discover evidence of the continuation or resumption of transmission, detect
imported cases early and provide a quick, adequate response. The individual
functions of surveillance are:
• case detection (including active case detection);
• treatment of positive cases;
• case investigation and follow-up genotyping of local parasite isolates;
23
• epidemiological investigation of foci to determine their origin, extent and
classifi cation;
• parasitological surveys including active case detection;
• entomological surveys;
• meteorological monitoring;
• remedial action to further eliminate foci by vector control and drug
treatment;
• community awareness and follow-up;
• political mobilization to support continuous funding and investment.
To reach 100% detection and notifi cation of cases, the following are needed:
• engagement of the population, patients and local authorities;
• full cooperation/integration of the private health sector;
• services to diagnose and treat malaria that are free of charge to patients,
whether nationals, temporary or permanent immigrants, people in transit,
or residents of neighbouring countries who live in border areas;
• strict monitoring of the national supply of antimalarial medicines;
• a complete stop to the over-the-counter sale of antimalarial medicines;
• maintenance of health personnel skills.
It is an operational challenge to keep microscopists’ skills and interest at a high
level when cases are few or zero. As the programme nears the elimination target,
laboratory staff may see no positive blood fi lms for months at a time. In such
circumstances, all slides may need to be rechecked by a reference laboratory.
The objectives of the elimination programme have been achieved when:
• locally transmitted malaria cases have been reduced to zero;
• the health services and surveillance operation are fully capable of detecting
and extinguishing malaria transmission should it occur.
Second programme reorientation: from elimination to prevention of
reintroduction of transmission
The second programme reorientation starts in areas where:
• adequate surveillance shows a complete or nearly complete interruption of
local transmission;
• there have been no or only very sporadic cases of local transmission in recent
years;
• the overwhelming majority of malaria cases can be positively identifi ed as of
imported origin.
The orientation of general health service personnel in vigilance activities
should be completed during this phase.
2. PRINCIPLES AND PRACTICE OF MALARIA ELIMINATION
24
MALARIA ELIMINATION: A FIELD MANUAL FOR LOW AND MODERATE ENDEMIC COUNTRIES
Elimination activities including surveillance should not yet be abandoned in
areas where the organization of vigilance activities is not suffi ciently adequate
to prevent the re-establishment of endemicity through imported infection. An
independent assessment by the malaria elimination monitoring committee
should be undertaken to determine whether areas are ready to enter the next
programme phase, based on:
• the status of malaria transmission in the area/country,
• the preparedness of the general health services and other sectors.
Prevention of reintroduction programme
Prevention of the reintroduction of malaria is a responsibility of the general
health services as part of their normal function in communicable disease con-
trol, in collaboration with other relevant sectors (agriculture, environment,
industry, tourism, etc.). Chapter 6 describes this programme in more detail.
Continued importation of cases means that the quality of case detection must
be high. The patterns of vigilance that need to be applied in order to ensure the
successful maintenance of the malaria-free status depend on the vulnerability
and receptivity of an area. If the threat of re-establishment of malaria is con-
siderable, the malaria component of the communicable diseases section of the
general health services should be large enough to deal with it.
When there is clear and convincing proof of an absence of locally acquired
cases for at least three consecutive years, WHO certifi cation of malaria elimi-
nation can be requested. Chapter 7 describes this process in more detail.
3. Feasibility of malaria elimination
3.1 Contextual prerequisites for achieving malaria elimination
Gradual achievement of the required epidemiological profi le and reaching pro-
grammatic milestones for malaria control and pre-elimination programmes
may lead to a desire to proceed with complete malaria elimination. The
following factors will be important:
• strong political commitment evidenced by a dedicated sustained budget at
national and local authority levels, to achieve a greater impact on the malaria
situation, and fi nally interrupt malaria transmission and eliminate the
disease from the country;
• established regional/subregional cooperation in the fi eld of malaria control
and elimination;
• demonstrated technical feasibility of malaria elimination in similar eco-
epidemiological settings in the recent past;
• proven effi cacious technologies and tools to eliminate malaria in a given
eco-epidemiological setting;
• strong and continued intersectoral collaboration.
3.2 Feasibility assessment
The following questions (requiring qualifi ed yes/no answers) should be
answered satisfactorily and, where necessary, problematic issues should be
addressed before elimination can be realistically achieved.
• Is the political decision supported by adequate fund allocation?
• Are legislation, environmental codes and regulations in place?
• Are there adequate national health systems and services aimed at achieving
total health-care coverage (including private sector involvement)?
• Is malaria elimination a component of the country’s socioeconomic devel-
opment plan?
• Is there effective central and peripheral government administration over the
entire national territory?
• Is there a good communication system and infrastructure that allows trans-
port of staff, supplies and equipment into all areas affected by malaria?
25
26
MALARIA ELIMINATION: A FIELD MANUAL FOR LOW AND MODERATE ENDEMIC COUNTRIES
• Is there an established national malaria elimination monitoring committee
to decide on steps to be taken and monitor/report on the progress made in
malaria elimination?
• Is there a thorough knowledge of local malaria epidemiology, including the
history of the problem?
• Is the impact of currently applied interventions (malaria burden, population
at risk, updated malaria stratifi cation, case management, vector control and
malaria surveillance) well documented?
In addition:
• the country’s elimination efforts should preferably be backed up by a regional
policy;
• neighbouring countries should preferably be engaged in the elimination
process (with evidence of cross-border cooperation), especially when
endemic areas spill over international borders.
3.3 Setting realistic targets and timescales
The pre-elimination programme builds upon successful control of malaria
mortality and morbidity. The preparation and planning to reach the fi rst pro-
gramme reorientation and the subsequent programme stages need to be coun-
try- and area-specifi c.
On the basis of the fi ndings of the feasibility assessment and the pre-elimina-
tion programme surveys, countries may opt to set interim targets:
• by parasite species – experience shows that elimination of P. vivax transmis-
sion is more diffi cult than elimination of P. falciparum transmission (see
Box 2);
• by geographical area – most countries approach elimination in stages,
with different parts of the country being at different programme stages
simultaneously.
Malaria elimination is usually undertaken as a time-limited programme,
to minimize the period of intensive fi eld operations. Even in the most ideal
operational environments, a minimum period of 8–10 years is required per
programme zone to achieve elimination. In less ideal circumstances, it will take
considerably longer.
Recent experience from countries such as Armenia, the Islamic Republic of
Iran, Morocco, Oman, Saudi Arabia, Tajikistan and Turkmenistan shows that
the last remaining foci before achieving malaria elimination are, not surpris-
ingly, characterized by some or all of the following:
27
3. FEASIBILITY OF MALARIA ELIMINATION
• more effi cient vectors and a longer transmission season than in the rest of
the country;
• poor overall development, marginalized populations and weak health sys-
tems with inadequate coverage;
• common borders with neighbouring countries with a high burden;
• intense cross-border population movement and a high immigration rate
from well-identifi ed endemic countries;
• inaccessibility due to geographical or political constraints.
The duration of the programmes will not abide by any arbitrary time sched-
ule, but will be determined by the epidemiological effect of the measures
employed. Programme phases should be planned with suffi cient fl exibility in
the budget. The programme for prevention of reintroduction of transmission
has an unlimited duration.
4. Tools and approaches specifi c
to elimination programmes
National expertise in malaria epidemiology and entomology drives the suc-
cess in elimination. In-depth knowledge of the local epidemiology of malaria
parasites, vectors and transmission patterns forms the basis for targeting all
interventions.
Some malaria control methods that were applied in the 1950s–1960s during
the Global Malaria Eradication Programme have considerably accelerated the
development of drug resistance. These include especially the direct or indi-
rect distribution of antimalarial medicines to whole populations irrespective
of disease status or history of disease, and the use of medicines in subcurative
doses. These obsolete methods should be avoided in modern elimination pro-
grammes. For more details, see Annex 5.
The most important tools that are specifi c to malaria elimination or take on
more prominence compared with control programmes are listed below.
4.1 Detection of cases
Tools for the detection of cases include:
• legislation supporting the identifi cation and notifi cation of all malaria cases,
irrespective of their place of residence or their fi rst point of contact with
public/private health services;
• active case detection though house-to-house visits during the transmission
season;
• epidemiological investigation of every confi rmed case;
• parasite genotyping and isolate banks;
• national malaria case register;
• continuing education and quality control for all public and private clinical
services that diagnose and/or treat malaria;
• quality control of all laboratory services that diagnose malaria;
• use of microscopy only (i.e. not RDT) from the pre-elimination programme
onwards, for species identifi cation, detection of gametocytes and determina-
tion of parasite densities.
28
29
4. TOOLS AND APPROACHES SPECIFIC TO ELIMINATION PROGRAMMES
4.2 Prevention of onward transmission
Tools for the prevention of onward transmission include:
• vector control aimed at reducing human–vector contact and the vectorial
capacity of local mosquito vectors;
• case management (radical treatment) aimed at reducing the period of infec-
tivity and the occurrence of secondary infections by:
– use of artemisinin-based combination therapy and gametocytocidal
medicines (e.g. primaquine) for P. falciparum infections;
– primaquine antirelapse treatment for 14 days for all P. vivax infections;
– treatment of uncomplicated malaria on an in-patient basis (an option in
the later stages of the elimination programme).
4.3 Management of malaria foci
Tools for the management of malaria foci include:
• vigilance;1
• malaria surveys;1
• geographical reconnaissance;1
• vector control and entomological investigations;
• involvement of local authorities (such as local authorities taking over pro-
gramme responsibilities for vector control);
• community involvement.
4.4 Management of importation of malaria parasites
Tools for the management of importation of malaria parasites include:
• intercountry coordination mechanisms;
• prevention of malaria in nationals who travel to endemic countries, includ-
ing chemoprophylaxis, prevention of mosquito bites, standby emergency
treatment and case management;
• screening, health education, easy access to free-of-charge diagnosis and
treatment and other measures to cope with the continuing importation of
parasites by international travellers and migrants.
4.5 Selected interventions
Vigilance
At the end of the elimination programme, a malaria alert and response sys-
tem replaces regular malaria surveillance activities. This vigilance system is
1
Described in more detail in section 4.5.
30
MALARIA ELIMINATION: A FIELD MANUAL FOR LOW AND MODERATE ENDEMIC COUNTRIES
operated through the general health services. It is the only protection against
re-establishment of transmission and the appearance of rebound epidemics. It
must be highly effi cient and supported by local authorities, health personnel
and the general population. Vigilance relies on the early and universal notifi ca-
tion of suspected and confi rmed malaria cases.
Malaria surveys
Malaria surveys, described below, provide information to guide programme
management and programme reorientation.
• Contact surveys and active case detection can provide information for the
classifi cation of cases and foci. Contacts are people who share the living and/
or working environment with a malaria case, or who have been otherwise
potentially exposed to the same sources of infection.
• Clinic-based blood surveys using RDT or thick blood smears can provide
information on the proportion of febrile patients who have malaria.
• Population-based blood surveys can provide information on malaria preva-
lence, the level of endemicity, and high-risk population groups.
• Blood bank safety checks that routinely include testing for the presence of
malaria parasites by microscopy or polymerase chain reaction (PCR), or
tetravalent antibody detection by enzyme-linked immunosorbent assay
(ELISA) for signs of past or current malaria infection can provide informa-
tion on a wider population group than would be reached by targeted surveys.
It should be remembered, however, that:
– positive ELISA fi ndings do not necessarily indicate continuing local
transmission, due to persistence of malaria antibodies in the blood over
time, and the possibility that infection has been acquired abroad;
– negative ELISA fi ndings do not necessarily indicate an absence of con-
tinuing local transmission, due to the sampling frame of the blood bank.
Surveys using invasive procedures should be kept to a minimum. All people
with positive test results should receive prompt and complete treatment as per
the national antimalarial drug policy.
Geographical reconnaissance
Geographical reconnaissance is defi ned as the operation that provides the basis
for the choice of fi eld centres and depots, for detailed schedules and itineraries
of spraying and surveillance personnel, for the fi nal deployment of transport,
and for the numerical control of the completeness of the work accomplished or
reported. It includes collection of information on the number, type, location
and means of access to all houses and fi eld shelters, as well as on communica-
31
tions, health units, vehicle repair facilities, population movements and other
relevant factors.
Its objectives are to:
• determine the number of houses in the malaria foci, their characteristics
and the materials used in the construction of their walls; and to give them a
reference number;
• record the number of inhabitants of the houses;
• map all the houses, health units and other important structures, and show
the access route on the map, where relevant.
Current hand-held global positioning system devices, computerized mapping
and geographic information systems, including satellite images such as those
from Google Earth, facilitate the task of geographical reconnaissance. How-
ever, it remains a large and expensive undertaking, needing careful prepara-
tion and organization. Its fi ndings must be constantly kept up to date.
4. TOOLS AND APPROACHES SPECIFIC TO ELIMINATION PROGRAMMES
5. Monitoring and evaluation
of progress towards malaria
elimination
5.1 Purpose and objectives
Progress towards elimination of malaria from a country involves two impor-
tant programme reorientations:
1. from a control programme to an elimination programme;
2. from an elimination programme to a programme focused on prevention of
reintroduction of malaria.
In each reorientation, substantial changes in activities, priorities and program-
matic focus must take place. During each programmatic reorientation, some
strategies, activities and specifi c interventions will be phased out while new ones
are phased in; staff will need to be retrained and new routines established.
The monitoring and evaluation components of the programme have to be
developed to:
• document and guide the reorientation process of the malaria programme
– from a control programme to an elimination programme, and from an
elimination programme to a programme focusing on prevention of reintro-
duction of malaria;
• document progress towards achievement of goals and objectives to support
each programmatic shift;
• establish a credible information database for ultimate certifi cation of malaria
elimination.
5.2 Recording and reporting
Good record keeping is an essential element of a successful programme.
Completeness, accuracy and timeliness of data are essential because the deci-
sions to change to the next phase of the programme are guided by the progress
made in epidemiological indicators. These indicators are initially population-
and health facility-based, and narrow down to foci and ultimately to individual
cases as the programme evolves from a control programme into an elimina-
tion programme.
32
33
5. MONITORING AND EVALUATION OF PROGRESS TOWARDS MALARIA ELIMINATION
Key requirements for monitoring this progress are:
• accurate record keeping,
• regular and complete reporting of cases,
• regular data audits to ensure completeness of timely information,
• regular analysis of data,
• regular feedback to all staff involved.
5.3 Establishment of a malaria elimination database
Early in the shift to an elimination programme (i.e. during the pre-elimination
programme), a malaria elimination database has to be established. This data-
base will serve as the national repository of all information related to malaria
elimination, including the following major components.
• National malaria case register – a single database of all individual case
information from identifi ed sources in the whole country, including unique
identifi ers (required to allow tracking of subsequent infections in individu-
als), demographic information (age, sex, occupation and other aspects that
may infl uence a person’s malaria risk) and location (including global posi-
tioning system coordinates) (see Annex 6). This register allows detailed
analysis and synthesis of epidemiological information and trends that help
guide the elimination programme over time.
• Malaria patient register – a central repository of all malaria patient records,
including copies of public and private health facility/hospital records, case
investigation record forms (see Annex 7) and any other pertinent informa-
tion regarding individual cases.
• Laboratory register – a single database, linked to the patient register, which
contains all pertinent information regarding malaria diagnosis of the patient
(see Annex 8). Comparison of these two registers allows cross–checking for
completeness of case data. This register should also be linked to the parasite
strain bank.
• Parasite strain bank – samples of parasites from individual cases should be
stored in a central strain bank. These samples are retained in order to:
– genetically characterize locally circulating parasite strains, potentially to
be used later to differentiate a case probably related to local transmission
from a case of imported malaria or related to an imported case;
– allow genetic comparisons of parasites in an individual, for example, to
assist in identifying a potential relapse of P. vivax from a new infection in
a person with a recent (within three years) history of P. vivax infection.
Alternatively, a genotypic register or databank should be established. This is
easier to maintain.
34
MALARIA ELIMINATION: A FIELD MANUAL FOR LOW AND MODERATE ENDEMIC COUNTRIES
• Entomological monitoring/vector control records – a central repository of
information related to entomological monitoring and application of chosen
vector control interventions, including but not limited to breeding site map-
ping, foci investigation, indoor residual spraying, larviciding and/or stock-
ing of larvivorous fi sh.
5.4 Establishment of a national independent malaria elimination
monitoring committee
Ideally, management and maintenance of the malaria elimination database
would be the responsibility of a national committee that is independent of the
malaria programme. It would ensure proper maintenance and organization of
the national database, and perform periodic data audits to ensure complete-
ness and accuracy of records. This is especially useful for countries with a
desire for eventual offi cial WHO certifi cation of malaria elimination, because
it removes any real or perceived confl ict of interest introduced when the entity
that is responsible for eliminating malaria is also responsible for maintaining
the records by which success will be evaluated.
5.5 Monitoring and evaluation – recommended indicators, data
sources and methodologies
Monitoring and evaluation concentrate on four key issues:
• monitoring the operational aspects of the programme and measuring impact
or process indicators to ensure that the activities are yielding desired results
and moving the programme towards achieving its operational targets and
objectives;
• monitoring changes in epidemiological indicators resulting from the activi-
ties implemented;
• appropriately interpreting results and informing revisions in policies or
strategies, when needed, to help ensure progress;
• documentation of progress towards malaria elimination.
Table 3 presents a monitoring framework of possible indicators to be consid-
ered as part of pre-elimination and elimination programmes.
In choosing indicators, emphasis is placed on evaluation of foci, evaluation of
case detection and management, and evaluation of entomological monitoring
and vector control activities, as outlined below.
35
5. MONITORING AND EVALUATION OF PROGRESS TOWARDS MALARIA ELIMINATION
Table 3. Monitoring framework for pre-elimination and elimination programmes
COMPONENT ACTIVITY INDICATOR METHOD/ COMMENTS
DATA SOURCE
Enabling Political Offi cial Record Describe nature of endorsement (offi cial
environment commitment endorsement review proclamation, authorizing legislation,
etc.)
Legal/regulatory Record Describe nature of framework (malaria is
framework review a notifi able disease, legal/regulatory
authorities of the malaria programme,
etc.)
Specifi c domestic Record —
funding earmarked review
Regional/ Regional/subregional Record —
subregional malaria elimination review
cooperation strategy in place
Cross-border agree- Record —
ment in place review
Evidence of Record Active exchange of information
collaboration (cross- review (including on cases and case investiga-
border/regional/ tions); joint research/programmatic
subregional) activities; regular cross-border meetings
between malaria programmes; joint
training/workshops; etc.
Adoption of Updated Record —
enabling treatment review
health policies Policies
Malaria diagnosis and Record —
treatment available at review
no charge to patient
Regulation of anti- Record —
malarial medicines review
Epidemiology Stratifi cation — Record Detailed stratifi cation maps available
(geographical review
information)
Foci Number of active foci Record —
investigation reported per year review
Proportion of Record Full investigation assumes inclusion of
reported foci fully review information such as geographical
investigated location, additional case detection
(active), entomological assessments, etc.
Proportion of Record —
reported foci review
correctly classifi ed
Continued on page 36
36
MALARIA ELIMINATION: A FIELD MANUAL FOR LOW AND MODERATE ENDEMIC COUNTRIES
Table 3. Continued
COMPONENT ACTIVITY INDICATOR METHOD/ COMMENTS
DATA SOURCE
Number of cases Record —
within focus review
Total population at Record Using as elimination defi nition for
risk within focus review denominator: smallest political unit that
corresponds to approximately
75 000–150 000 population
(e.g. a district)
Surveillance National Timeliness: time Standardized Would expect decrease in time between
malaria between diagnosis, assessment diagnosis, reporting and investigation
surveillance reporting and
system investigation
(NMSS)a
Completeness: Standardized —
proportion of cases assessment,
reported to surveil- special study
lance system (e.g. capture–
recapture)
Inclusion of Protocol for private Record —
private sector clinics review
Proportion of private Survey of Pre-elimination programme: assumes a
facilities reporting to private census of private health providers exists
NMSS facilities and malaria is a reportable disease. Zero
reporting should be used where possible
Elimination programme: assumes
complete integration of private-sector
health facilities in NMSS
Tracking of Total number of NMSS annual Would expect consistent decline in
malaria cases reported per reports number of cases reported over time
burden year
Proportion of Record Pre-elimination programme: would
reported cases that review expect proportion of reported cases fully
are fully investigated investigated to increase to/be
maintained at high level (>90%)
Elimination programme: would expect
proportion of reported cases fully
investigated to be maintained at high
level (100%)
Number of cases by NMSS annual —
classifi cation reports
a
In the pre-elimination programme, the national malaria surveillance system transitions from aggregate reporting to
increasing use of case-based surveillance, with increasing reporting and investigation of individual cases. In the elimination
programme, surveillance should be fully case-based, with complete reporting and investigation of all cases.
37
5. MONITORING AND EVALUATION OF PROGRESS TOWARDS MALARIA ELIMINATION
Table 3. Continued
COMPONENT ACTIVITY INDICATOR METHOD/ COMMENTS
DATA SOURCE
Evaluation of Total population at NMSS annual Would expect consistent decline in total
population risk within country reports population at risk over time
at risk
Case Diagnosis Proportion of cases Clinic reports, —
management confi rmed by case investi-
microscopy gation reports
Microscopy QA/QC QA reports Describe how the QA/QC system works,
in place which laboratories are participating,
level of expertise of reference
laboratories, etc.
Treatment Proportion of cases Case investi- —
treated according to gation reports
guidelines
Vector IRS Number and Vector In the pre-elimination programme, this
control proportion of at-risk control refers to area-wide vector control
households that records activities. As the programme progresses
have been sprayed towards elimination, would expect
number of households at-risk to
decrease and proportion covered to
increase to/be maintained at high level
(>90%)
Number and Vector Refers to the situation late in the
proportion of control pre-elimination programme when
reported active records transmission has been reduced to
foci that were occurrence primarily in discrete foci.
sprayed As a programme progresses towards
elimination, would expect the number
of active foci to decrease and the
proportion sprayed to increase to/be
maintained at high levels (>90%)
Larval Proportion of known/ Vector Assumes the malaria programme has
control potential breeding control investigated and mapped breeding sites
sites treated with records throughout receptive areas. Would
chemicals/fi sh expect high proportion covered (>90%)
Entomo- Larviciding Proportion of Entomological Assumes the malaria programme has
logical breeding sites surveillance investigated and mapped breeding
surveillance positive for mosquito records, sites throughout receptive areas. Would
larvae vector control expect an eff ective programme to
records achieve/maintain very low levels of
breeding sites positive for mosquito
larvae (<5%)
QA: quality assurance; QC: quality control; IRS: indoor residual spraying.
38
MALARIA ELIMINATION: A FIELD MANUAL FOR LOW AND MODERATE ENDEMIC COUNTRIES
Evaluation of foci
Transition of the functional status of foci should be monitored, with an
emphasis on detection of new potential or new active foci. Regarding the qual-
ity of information on foci, the following questions (requiring yes/no answers)
should be answered satisfactorily.
• Is the national register of foci complete?
• Are visits to the foci regular (i.e. every two weeks or as locally appropriate)?
• Are all the foci completely and regularly covered by case detection?
• Are all the cases completely and rapidly investigated?
• Is this investigation conducted correctly?
• Is the characterization of foci correct?
An example of information to be included in a malaria foci investigation record
form is included in Annex 9. The evaluation of foci is discussed in more detail
in the Guidelines on the elimination of residual foci of malaria transmission (2).
Evaluation of case detection and management
The following questions (requiring qualifi ed yes/no answers) should be
answered satisfactorily for evaluation of case detection and management.
• Are all fever cases who do not have other obvious causes of fever tested for
the presence of malaria parasites?
• Does the quality of the laboratory examination meet the accepted norms
and is there an organized quality-control/quality-assurance system?
• Is the detection and reporting of the cases timely?
• Was the quality of the treatment, in terms of dosage, regimen, complete-
ness, supervision and follow-up, in accordance with current established
guidelines?
Detailed analysis of the timeliness of case detection will allow calculation
of the average delay between the onset of symptoms and inactivation of the
source of infection by treatment, and identifi cation of bottlenecks. Analysis of
the time spans of possible patient, doctor and laboratory delays is important.
These delays are indicated in Figure 6.
39
5. MONITORING AND EVALUATION OF PROGRESS TOWARDS MALARIA ELIMINATION
Evaluation of entomological monitoring and vector control activities
The following questions (requiring qualifi ed yes/no answers) should be
answered satisfactorily for evaluation of entomological monitoring and vector
control activities.
• Are suitable vector control interventions being applied completely, appropri-
ately and in a timely fashion?
• Are vector control interventions effective?
• Is transmission under full control?
Figure 6. Possible patient, doctor and laboratory delays in malaria
diagnosis and treatment
Symptoms begin
First contact with health services
First blood collection
for malaria diagnosis
Blood specimen arrives
in the laboratory
Blood examined for
malaria parasites
Results transmitted
to treating clinician
patient’s delay
doctor‘s delay
laboratory’s delay
Radical treatment
given
Registration of case in the
national elimination database
1
2
3
4
5
6
7
8
6. Prevention of the re-establishment
of malaria1
During the advanced stages of the programme, when the complete interrup-
tion of malaria transmission has been achieved, the activities will be directed
at preventing any re-establishment of malaria in the area covered by the pro-
gramme. The essential activities include the continuous reduction of vulner-
ability by the universal access of the whole population, including visitors, to
diagnostic and treatment facilities. Under exceptional circumstances, espe-
cially when importation of malaria is intensive, the activities may include the
screening of immigrants for malaria and the use of radical treatment.
Increasing numbers of imported cases of malaria result in an increasing threat
to those countries that have eliminated malaria and still remain receptive to
the disease. Contributing factors include:
• increasing number of international travellers;
• increasing exposure of travellers to infection as a result of locally deteriorat-
ing malaria situations and changing patterns of travel;
• immigration fl ows from various places of origin.
Migrants and refugees arriving in large numbers from malarious countries
or areas may present a severe threat to the maintenance of malaria elimina-
tion. If possible, they should be directed to areas of zero receptivity. If not,
energetic measures may be required to prevent onward transmission, includ-
ing indoor residual spraying and mosquito-proofi ng of reception areas and
living quarters.
The dedication of both the government and programme personnel that was
necessary to eliminate malaria must be continued so that the requisite knowl-
edge and skills are maintained and the health service so organized that these
attributes can be used as and when necessary.
1
This chapter is adapted from (7), Black RH. Malaria in Australia 1981. Canberra,
Australian Government Publishing Service, 1982 (Tropical Medicine Technical
Paper No. 8):39–50, copyright Commonwealth of Australia reproduced by permis-
sion.
40
41
The world is increasingly interconnected. Non-malarious countries, whether
previously malarious or not, must be concerned about malarious countries
and support their efforts against the disease.
6.1 Probability of malaria becoming re-established
The probability of malaria becoming established or re-established in a malaria-
free area varies with the product of the degrees of receptivity and vulnerability
of the area.1 If either of these factors is zero, the probability of malaria becom-
ing re-established is zero even if the other factor has a high value. Both fac-
tors may change. For example, vulnerability may increase with the arrival of a
group of refugees, migrant workers, international civil servants, exchange stu-
dents, etc. from a malarious country. Receptivity will be increased by develop-
mental projects that create favourable conditions for the vectors and increase
human–vector contact. Large development projects usually also attract exter-
nal workers, thus possibly increasing vulnerability simultaneously. Irrigation
projects, mining and clearing of forests for agriculture are typical examples.
Receptivity may have seasonal and cyclic variations.
An indication of the degree of receptivity of an area may be derived from its
malaria history:
• original degree of endemicity;
• vectorial capacity before the implementation of intensive control measures;
• response of vector to withdrawal of insecticide spraying after the application
of intensive control measures;
• environmental changes as a result of developments, which may affect the
vector population.
Particular attention would need to be paid to areas with appreciable degrees
of vulnerability.
An indication of the degree of vulnerability will be available from knowledge
of traditional patterns of travel into the area as well as recent changes that will
be apparent from the epidemiological investigation of cases in the recent past.
The number of people arriving, their origin, the categories of people involved
as well as their local destination and length of stay are factors that are relevant
to estimating future changes in vulnerability.
1
There are as yet no defi nite criteria for establishing the exact levels of vulnerability
and receptivity of an area.
6. PREVENTION OF THE RE-ESTABLISHMENT OF MALARIA
42
MALARIA ELIMINATION: A FIELD MANUAL FOR LOW AND MODERATE ENDEMIC COUNTRIES
6.2 Patterns of vigilance
After having achieved the complete interruption of malaria transmission,
the objective of the ensuing phase is the prevention of the re-establishment
of malaria in an area from which the disease and the parasites have been
eliminated.
Except in the rare situation where the vector has been eliminated, the area
under consideration will still be receptive to malaria. The source of parasites is
another area or another country; the parasites usually arrive as liver or blood
stage parasites of people entering the given area.
Because the probability of malaria becoming re-established varies from area to
area, a pattern of vigilance appropriate to each particular area will be neces-
sary. In the absence of appropriate action, the area is likely to become malarious
again and the time until this happens is determined by the levels of receptivity
and vulnerability.
• At low levels of receptivity and vulnerability, early case detection by a vigi-
lant general health service, complemented by epidemiological investigation
of every case and focus and appropriate curative and preventive measures,
may be suffi cient to prevent re-establishment of transmission.
• At increasing levels of receptivity and vulnerability, it may be necessary
to supplement these activities by active case detection, which may possibly
be combined with other regularly repeated health activities involving house
visits.
• In localities of high vulnerability, it may be possible or even necessary to
reduce receptivity by the use of appropriate vector control measures such as
indoor residual spraying, long-lasting insecticidal nets or larviciding, based
on continued updating of the information on the local situation.
6.3 Organization of the health service
Freedom from malaria may have two important consequences.
• Lack of an enabling environment – there will be increasing reluctance to
commit personnel, time and expenditure to a disease that does not occur
anymore. The general public and politicians forget about malaria and the
ravages it caused in the past.
• The disease is no longer recorded – the absence of cases may result in loss
of skills in clinical and microscopy diagnosis of malaria and epidemiological
investigation of cases. There may be little opportunity for training based on
actual cases.
43
6. PREVENTION OF THE RE-ESTABLISHMENT OF MALARIA
The situation will be particularly precarious and harbour a high risk of resump-
tion of malaria transmission in receptive areas exposed to a massive infl ux of
imported malaria cases from abroad.
Resistance to a continued effort against malaria can be expected both within
the health services and among the general population. For this reason, a high-
level technical nucleus where knowledge and skills are maintained must be
kept up in the country. This nucleus should:
• consist of the central offi ce of the former malaria control programme and its
specialized technical sections;
• function in the framework of the directorate of preventive health services
and thereby have free lines of communication with the general health serv-
ices at central and intermediate levels;
• exercise overall oversight of the country’s vigilance activities and case notifi -
cation, and maintain the national malaria case register;
• be responsible for quality control and quality assurance of diagnostic labo-
ratory operations as well as the regular updating of the antimalarial drug
policy for:
– the management of malaria cases,
– chemoprophylaxis for residents travelling to endemic areas;
• be responsible for planning and quality control of entomological investiga-
tions and essential vector control operations directed at reducing the recep-
tivity of an area for malaria.
A highly practical way of maintaining the technical nucleus and its compe-
tence is the extension of its responsibilities to the control of other vector-borne
infectious diseases, e.g. dengue, Japanese B encephalitis, leishmaniasis, Rift
Valley fever, chikungunya, etc.
The maintenance of the malaria-free status will depend increasingly on the
local authorities (who control the resources), the general health services includ-
ing the private sector of health care, and other sectors such as environment,
industry, agriculture, etc. Necessary activities may vary in different areas and
over time, as determined by the epidemiological situation. The health service
must be organized in such a way that appropriate activities can and will be car-
ried out rapidly, with adequate skilled guidance from and supervision by the
technical nucleus at the central level. Adequate supplies and equipment must
be maintained and kept in good order.
As an example of the organization and operations involved in securing a
malaria-free status, the appropriate plan for the United Arab Emirates is
included in Annex 10.
44
MALARIA ELIMINATION: A FIELD MANUAL FOR LOW AND MODERATE ENDEMIC COUNTRIES
6.4 Training
Within the health service itself, it is necessary to maintain adequate levels of
malaria training, which can be guided by the technical nucleus. Such training
is aimed at:
• all relevant personnel in areas where there is a possibility of re-establishment
of the disease; the training focuses on the technical aspects related to main-
taining the malaria-free status;
• all relevant personnel in the public health service; the training raises aware-
ness of factors that are likely to cause increases in vulnerability and receptiv-
ity, so that appropriate measures can be taken to lessen their effects on an
eventual re-establishment of malaria;
• the general medical profession and undergraduate medical students; they
require continued education in:
– the diagnosis and treatment of malaria,
– prevention measures, including those for international travellers.
It is also necessary to maintain an adequate level of competence in the labora-
tory diagnosis of malaria. The technical nucleus can play a part in the relevant
teaching and training and also by acting as the cross-checking centre for blood
fi lms; this can identify personnel who need re-training.
Some of this training can be done locally, some at academic institutions or a
school of public health, but key personnel will require experience in malarious
countries. The malaria epidemiology courses conducted by WHO have been
particularly useful in this last category. In return, areas where malaria elimi-
nation has been successfully maintained can be used for training in vigilance
activities. Regional malaria courses and institutions can help in maintaining
the required academic standard and stimulating operational research.
The publication of an annual report on the national malaria situation will stim-
ulate and maintain interest and will also be a useful educational medium.
7. WHO certifi cation of malaria
elimination
7.1 Requirements – burden of proof
When a country has zero locally acquired malaria cases for at least three con-
secutive years, it can request WHO to certify its malaria-free status.
Certifi cation of malaria elimination requires proving beyond reasonable
doubt1 that the chain of local human malaria transmission by Anopheles mos-
quitoes has been fully interrupted in the entire country. The burden of proof of
elimination falls on the country requesting certifi cation. The bolder a claim of
malaria elimination appears to be, the higher the standard of proof that will be
required and the less it will be taken for granted or assumed to be true without
additional investigation.
Absolute mathematical certainty of elimination can never be obtained. Thus,
a defensible, plausible argument must be made that, beyond reasonable doubt,
malaria transmission has ended in a given place and at a given time. This
implies that all the available evidence has been evaluated and has been found
to be consistent with the assertion that malaria elimination has been achieved
and that good-quality surveillance systems are in place that would be capable
of detecting local transmission if it were occurring.
In order to be confi dent that interruption of transmission has been achieved, a
number of preconditions must be met. These include:
• a good surveillance mechanism with full coverage of all geographical areas;
• a national malaria case register, notifi cation and full immediate reporting by
public and private health services;
• adequate health services for early detection and effective treatment and fol-
low-up of imported malaria cases;
• high-quality laboratory services to diagnose malaria, based on microscopy;
• epidemiological investigation of every malaria case;
• a national, comprehensive plan of action with continued political and fi nan-
1
Reasonable doubt is defi ned as actual and substantial doubt reasonably arising from
evidence, from the facts or circumstances shown by the evidence, or from the lack of
evidence.
45
46
MALARIA ELIMINATION: A FIELD MANUAL FOR LOW AND MODERATE ENDEMIC COUNTRIES
cial support to carry out activities needed to prevent re-establishment of
transmission;
• a system for awareness, prevention of mosquito bites and chemoprophylaxis
for travellers to prevent imported malaria;
• a central computerized geo-referenced database of cases and latest foci;
• entomological surveillance and monitoring of insecticide resistance in areas
with high receptivity;
• a functional border coordination system, wherever relevant;
• capacity for early detection of and rapid response to epidemics.
Sero-epidemiological surveys to detect malaria antibodies can support valida-
tion of the interruption of local transmission.
• In situations where elimination was achieved at least eight years previ-
ously, people’s malaria antibodies could be expected to have disappeared.
Surveys among local stable populations (who have no history of travel to
endemic areas abroad in the period since elimination was achieved) should
be negative.
• In situations where elimination was achieved more recently, sero-epidemio-
logical surveys among children aged three months and older who were born
after the interruption of transmission should be negative.
The value of sero-epidemiological surveys is limited by the sensitivity of the
test methods available. It is also not 100% certain when malaria antibodies are
no longer detectable among populations who have previously been exposed to
local transmission. All people with positive test results during sero-epidemio-
logical surveys should be fully assessed, including diagnosis by microscopy,
treated for current infection, and a full case investigation carried out.
Details of the aspects to be covered by the evaluation teams are provided in
the chapter on assessment of malaria elimination in Informal consultation on
malaria elimination: setting up the WHO agenda (8), pp. 38–39 (see Box 3). The
parameters that will be verifi ed by the evaluation teams are also of interest to
national staff in the later stages of the elimination programme.
47
7. WHO CERTIFICATION OF MALARIA ELIMINATION
BOX 3
Assessment of malaria eliminationa
The following criteria for achieving and maintaining malaria elimination should be
assessed:
• extensive coverage by high-quality public and private curative and preventive
health services,
• a high-quality surveillance system,
• direct measurements of potential local transmission,
• supportive operational research activities.
Assessing coverage by high-quality public and private curative and
preventive health services
Core demographic indicators can provide a good idea of the overall health situa-
tion and coverage by high-quality public and private curative and preventive health
services. These include the crude mortality rate, the mortality rates for infants and for
children aged under fi ve years, and the maternal mortality rate. Coverage by health
services with specifi c capacity for malaria diagnosis and treatment and the propor-
tion of the population covered by those facilities (living within a distance of less than
5 km or 1 h by foot) and by antimalarial interventions (such as indoor residual spray-
ing, larviciding and adequate treatments) should be known, especially in former
transmission foci and newly receptive areas.
Assessing the quality of a surveillance system
Recognized methods for assessing the quality of a surveillance system are based
on criteria such as usefulness, simplicity, fl exibility, data quality (completeness and
validity of data collected by the surveillance system), acceptability, sensitivity (pro-
portion of cases detected by the system; ability to monitor changes in the number
of cases over time), positive predictive value (proportion of cases reported by the
surveillance system that actually have the disease), representativeness (ability of the
system to describe the occurrence of a health-related event accurately over time and
its distribution in the population by place and person), timeliness (ability of the sys-
tem to identify and investigate or intervene quickly) and stability.
Proxy indicators to monitor the quality of surveillance systems are used, for example,
in the poliomyelitis eradication programme, which relies on the ability of the system to
detect at least one case of acute fl accid paralysis that is not poliomyelitis per 100 000
population under 15 years of age. Another proxy indicator might be the proportion of
reporting units supplying surveillance reports on a regular basis even when no cases
are reported. Special eff orts should be made to cross-check surveillance reports with
health facility records and antimalarial drug supply fi gures in former or current areas
of transmission. Special attention should be paid to the assessment of laboratory and
diagnostic quality-assurance systems for microscopy, serology, molecular assessment,
a
Adapted from the chapter on assessment of malaria elimination in Informal consultation on malaria elimina-
tion: setting up the WHO agenda (8), pp. 38–39 .
Continued on page 48
48
MALARIA ELIMINATION: A FIELD MANUAL FOR LOW AND MODERATE ENDEMIC COUNTRIES
and clinicians’ knowledge and practices. The assessment should also include the pro-
portion of reported cases and foci fully investigated.
An indicator of timeliness of diagnosis and treatment specifi c for malaria is the pro-
portion of cases of P. falciparum infection with gametocytes. Gametocytes usually do
not appear if cases are treated within six days of the onset of symptoms. To use this
indicator, a laboratory must specify the stage of P. falciparum diagnosed, which is in
any case good practice.
Direct measurements of potential local transmission
Direct measurements of potential local transmission include entomological moni-
toring activities, such as the abundance of vector species, proportion of nulliparous
mosquitoes (or other measures indicating physiological age), mapping of risk areas
and monitoring resistance of vectors to insecticides. Other direct measurements
are specifi c parasitological surveys with blood slides or rapid diagnostic tests; sero-
epidemiological surveys to evaluate the size of the risk for importation, to identify
high-risk immigrants and to evaluate former foci of transmission; and genetic charac-
terization to distinguish single-source local infection from imported sources as well
as searching for the origin(s) of parasites.
Supportive operational research activities
The priorities for supportive operational research activities depend on the phase of
the programme, as shown in the following examples.
Elimination programme:
• vector classifi cation
• suitable malaria survey methodologies
• early detection of importation of parasites.
Prevention of reintroduction programme:
• development or selection of eff ective methods to improve use of preventive meas-
ures, including chemoprophylaxis among residents travelling abroad to endemic
countries;
• improving prevention in recent immigrants travelling to their country of birth to
visit friends and relatives;
• quantifi cation of the risk of reintroduction of malaria from individual imported
cases and determining whether expensive screening programmes are justifi ed
and cost eff ective;
• validation of rapid methods for screening immigrants and temporary workers on
arrival.
General:
• validation of molecular tools for genetic characterization and verifi cation of local
transmission.
Box 3 Continued
49
7.2 Procedures for certifi cation1
The general principles of certifi cation are:
1. certifi cation is for a country as a whole and for all four human malaria
species;
2. inspection and evaluation are carried out by a team led by WHO, which
then recommends certifi cation, if appropriate;
3. the fi nal decision rests with the WHO Director-General;
4. certifi cation is published in the Weekly Epidemiological Record.
On the basis of the experience with certifi cation of malaria elimination in the
United Arab Emirates (9) and in line with the draft WHO criteria and pro-
cedures for certifi cation of malaria elimination, which still need to be offi -
cially endorsed by the World Health Assembly, eight steps need to be taken to
reach the fi nal stage of recognition and certifi cation of malaria elimination by
WHO.
1. Request sent to WHO: the national government sends a request for certifi -
cation to the WHO Regional Director. WHO responds by communicating
the elimination criteria, certifi cation process and the documents necessary
to provide clear and convincing evidence that malaria transmission has
been interrupted throughout the country (see Annex 11).
2. Formulation of a plan of action: the WHO Secretariat, external experts and
the national government jointly prepare a plan of action for certifi cation.
3. Implementation of the plan and submission of the supporting documen-
tation: the national government prepares the necessary documentation.
4. Evaluation visit(s)/development of the evaluation report: a WHO-led
evaluation team, which is preferably made up of experts from WHO head-
quarters and regional offi ces as well as experts from outside WHO, visits
the country, verifi es the documents, makes site visits and examines any-
thing else of relevance. The evaluation team prepares a fi nal report with
a recommendation to WHO on the possible granting of certifi cation (see
Annex 12 for an outline of the content of the fi nal report).
5. Final report review by a wider group of experts: the WHO Secretariat
shares the fi nal report with WHO and non-WHO experts on malaria elim-
ination for critical review.
7. WHO CERTIFICATION OF MALARIA ELIMINATION
1
This section is adapted from the chapter on administrative procedures and criteria
for certifi cation of malaria elimination by WHO in Informal consultation on malaria
elimination: setting up the WHO agenda (8), pp. 40–41.
50
MALARIA ELIMINATION: A FIELD MANUAL FOR LOW AND MODERATE ENDEMIC COUNTRIES
6. Final review by the WHO Expert Committee on Malaria: the outcome of
the wider review is compiled by the WHO Secretariat and sent with a rec-
ommendation for certifi cation, along with the accompanying documents,
to the Chairman of the most recent meeting of the WHO Expert Committee
on Malaria. The Chairman communicates directly with the national gov-
ernment for further clarifi cations on the dossier if needed and consolidates
a recommendation to the Director-General of WHO for a fi nal decision.
7. Final decision: the Director-General of WHO takes the fi nal decision on
granting malaria-free status and communicates this in an offi cial letter to
the national government.
8. Publication of certifi cation in the WHO Weekly Epidemiological
Record: the WHO Secretariat publishes positive decisions in the Weekly
Epidemiological Record.
7.3 Follow-up of certifi cation
Certifi cation of malaria elimination is based on an assessment of the current
situation and the likelihood that elimination can be maintained. Countries
are requested to continue reporting on an annual basis to WHO on the main-
tenance of their malaria-free status. Information to be included in the annual
report to WHO is included in Annex 13.
Outbreaks of falciparum malaria in a normally or recently malaria-free coun-
try should be reported to WHO immediately, so that WHO can provide assist-
ance where needed and can alert international travellers visiting the affected
areas that they should take suitable preventive measures. In certain circum-
stances, malaria may be notifi able under the International Health Regulations
of 2005 (see Box 4).
Because certifi cation is the recognition of a considerable operational achieve-
ment, countries will remain listed as having achieved malaria elimination even
if they subsequently suffer a temporary occurrence of local transmission.
An indication of the re-establishment of transmission would be the occurrence
of three or more introduced and/or indigenous malaria infections linked in
space and time to local mosquito-borne transmission in the same geographi-
cal focus, for two consecutive years for P. falciparum, and for three consecutive
years for P. vivax.
Re-establishment of transmission will be reported in the annual updates of
the WHO publication International travel and health. To protect international
travellers, reports of falciparum malaria outbreaks in “malaria-free” countries
will be posted on an ad hoc basis in the Weekly Epidemiological Record.
51
BOX 4
International Health Regulations (2005)a
On 15 June 2007, the International Health Regulations (2005) or IHR (2005) entered
into force. The IHR (2005) are the world’s fi rst legally binding agreement in the fi ght
against public health emergencies of international concern, such as those caused by
new and re-emerging diseases with epidemic potential, as well as those associated
with acute chemical or radionuclear events.
The 2005 revision of the 1969 version of the IHR broadens the scope of notifi cation
of cases of cholera, plague and yellow fever to all events that may constitute public
health emergencies of international concern and the reporting of other serious inter-
national health risks, irrespective of origin or source.
The main aims of the IHR (2005) are to prevent, protect against, control and respond
to the international spread of disease while avoiding unnecessary interference with
international traffi c and trade.
Under the IHR (2005), States are required to notify WHO of all events that may con-
stitute public health emergencies of international concern, based on the following
criteria.
• Is the public health impact of the event serious?
• Is the event unusual or unexpected?
• Is there a signifi cant risk of international spread?
• Is there a signifi cant risk of international restriction(s) to travel and trade?
a
For further information, see http://www.who.int/csr/ihr/en/
7. WHO CERTIFICATION OF MALARIA ELIMINATION
References
1. WHO Expert Committee on Malaria. Sixth report. Geneva, World Health
Organization, 1956 (http://whqlibdoc.who.int/malaria/WHO_Mal_180.
pdf):10–11.
2. Guidelines on the elimination of residual foci of malaria transmission. Cairo,
World Health Organization Regional Offi ce for the Eastern Mediterranean,
2007 (EMRO Technical Publications Series, No. 33; http://www.emro.who.
int/dsaf/dsa742.pdf).
3. Malaria control in complex emergencies, and inter-agency fi eld handbook.
Geneva, World Health Organization, 2005 (WHO/HTM/MAL/2005.1107;
http://www.who.int/malaria/docs/ce_interagencyfhbook.pdf):1–13.
4. Life cycle of Plasmodium spp. Atlanta, GA, Division of Parasitic Diseases,
United States Centers for Disease Control and Prevention, updated 5 May
2004 (http://www.dpd.cdc.gov/DPDx/HTML/Malaria.htm, accessed 20
August 2007).
5. Sullivan S. P. vivax life cycle. New York, NY, vivaxmalaria.com, 2006 (http://
www.vivaxmalaria.com/images/vivax_lifecycle.jpg, accessed 20 August
2007).
6. International travel and health: situation as on 1 January 2007. Geneva, World
Health Organization, 2007:88 (http://whqlibdoc.who.int/publications/
2007/9789241580397_5_eng.pdf).
7. Black RH. Malaria in Australia 1981. Canberra, Australian Government
Publishing Service, 1982 (Tropical Medicine Technical Paper No. 8):39–50.
8. Informal consultation on malaria elimination: setting up the WHO agenda.
Geneva, World Health Organization, 2006 (WHO/HTM/MAL/2006.1114;
http://www.who.int/malaria/docs/malariaeliminationagenda.pdf).
9. United Arab Emirates certifi ed malaria-free. Weekly Epidemiological Record,
2007, 82(4):30–32 (http://www.who.int/wer/2007/wer8204.pdf).
52
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Guidelines for the treatment of malaria. Geneva, World Health Organization,
2006 (http://www.who.int/malaria/docs/TreatmentGuidelines2006.pdf).
Guidelines on the prevention of the reintroduction of malaria. Cairo, World
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1981_59(4)_537–548.pdf).
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Provisional agenda item 2.4. Re-examination of the Global Strategy of Malaria
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Region 2006–2015. Copenhagen, World Health Organization Regional Offi ce
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Surveillance. Atlanta, GA, United States Centers for Disease Control and
Prevention (http://www.bt.cdc.gov/episurv/, accessed 16 July 2007).
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Warrell DA, Gilles HM. Essential malariology, 4th ed. London, Hodder &
Stoughton, 2003.
WHO Expert Committee on Malaria. Fourteenth report. Geneva, World Health
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Zahar AR. Vector bionomics in the epidemiology and control of malaria. Geneva,
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between 1984 and 1996):
– The WHO African Region and the southern WHO Eastern Mediterranean
Region: http://whqlibdoc.who.int/hq/1984/VBC_84.6_eng.pdf;
– The WHO African Region and the southern WHO Eastern Mediterranean
Region (West Africa): http://whqlibdoc.who.int/hq/1985-86/VBC_85.1_
eng.pdf;
– The WHO African Region and the southern WHO Eastern Mediterranean
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hq/1985-86/VBC_85.2_eng.pdf;
– The WHO African Region and the southern WHO Eastern Mediterranean
Region (East Africa, eastern outer islands, south-western Arabia): http://
whqlibdoc.who.int/hq/1985-86/VBC_85.3_eng.pdf;
– The WHO European Region and the WHO Eastern Mediterranean Region
I: http://whqlibdoc.who.int/hq/1988/VBC_88.2_eng.pdf;
– The WHO European Region and the WHO Eastern Mediterranean Region
II: http://whqlibdoc.who.int/hq/1990/VBC_90.1_eng.pdf;
– The WHO European Region and the WHO Eastern Mediterranean Region
(the Mediterranean Basin): http://whqlibdoc.who.int/hq/1990/VBC_90.2_
eng.pdf;
– The WHO European Region and the WHO Eastern Mediterranean Region
(Asia west of India): http://whqlibdoc.who.int/hq/1990/VBC_90.3_eng.
pdf;
55
– The WHO South-East Asia Region and the WHO Western Pacifi c Region I:

http://whqlibdoc.who.int/hq/1994/CTD_MAL_94.1.pdf;
– The WHO South-East Asia Region and the WHO Western Pacifi c Region II:
http://whqlibdoc.who.int/hq/1996/CTD_MAL_96.1.pdf.
BIBLIOGRAPHY
ANNEX 1
Countries and areas with malarious
zones1
The following list shows all countries and areas where malaria occurs. In some
of these countries, malaria is present only in certain zones or up to a particular
altitude. In many countries, malaria has a seasonal pattern.
1
The countries where there is P. vivax risk only are marked *. The year in parentheses
indicates the point since when no more indigenous malaria cases have been report-
ed. Adapted from International travel and health: situation as on 1 January 2007 (1).
56
Afghanistan
Algeria* (2005)
Angola
Argentina*
Armenia* (2006)
Azerbaijan*
Bangladesh
Belize
Benin
Bhutan
Bolivia
Botswana
Brazil
Burkina Faso
Burundi
Cambodia
Cameroon
Cape Verde
Central African
Republic
Chad
China
Colombia
Comoros
Congo
Costa Rica
Côte d’Ivoire
Democratic People’s
Republic of Korea*
Democratic Republic
of the Congo
Djibouti
Dominican Republic
Ecuador
Egypt (1998)
El Salvador
Equatorial Guinea
Eritrea
Ethiopia
French Guiana
Gabon
Gambia
Georgia*
Ghana
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
India
Indonesia
Iran (Islamic
Republic of)
Iraq*
Kenya
Kyrgyzstan*
Lao People’s
Democratic
Republic
Liberia
Madagascar
Malawi
Malaysia
Mali
Mauritania
Mauritius* (1998)
Mayotte
Mexico
Morocco* (2005)
Mozambique
Myanmar
57
ANNEX 1. COUNTRIES AND AREAS WITH MALARIOUS ZONES
Namibia
Nepal
Nicaragua
Niger
Nigeria
Oman (2000)
Pakistan
Panama
Papua New Guinea
Paraguay*
Peru
Philippines
Republic of Korea*
Rwanda
Sao Tome and
Principe
Saudi Arabia
Senegal
Sierra Leone
Solomon Islands
Somalia
South Africa
Sri Lanka
Sudan
Suriname
Swaziland
Syrian Arab
Republic* (2005)
Tajikistan
Thailand
Timor-Leste
Togo
Turkey*
Turkmenistan* (2006)
Uganda
United Republic of
Tanzania
Uzbekistan*
Vanuatu
Venezuela (Bolivarian
Republic of)
Viet Nam
Yemen
Zambia
Zimbabwe
References
1. International travel and health: situation as on 1 January 2007. Geneva,
World Health Organization, 2007:166, 177–205.
58
ANNEX 2
Key for epidemiological
classifi cation of cases1
1. How was the case contracted?
• By blood Induced case
• By mosquito Go to 2
2. Where was the case contracted?
• Outside this place Imported case
• In this place Go to 3
3. Which parasite causes the case?
• P. vivax or P. ovale Go to 4
• P. falciparum or P. malariae Go to 5
4. When was the case contracted?
• Long ago (e.g. from 6 months to 3 years ago)2 Relapsing case3
• Recently (e.g. up to 6 months ago)2 Go to 5
5. From whom was the case contracted?
• From an imported case Introduced case
• From any other case Indigenous case
References
1. Guidelines on the elimination of residual foci of malaria transmission. Cairo,
World Health Organization Regional Offi ce for the Eastern Mediterranean,
2007 (EMRO Technical Publications Series, No. 33):24–28, 46.
1
Adapted from Guidelines on the elimination of residual foci of malaria transmission
(1).
2
The exact duration of the period should be decided by the programme.
3
Relapsing cases cannot be distinguished from indigenous cases in areas with con-
tinuing local transmission and epidemiologically linked cases in the vicinity: recent
infection or reinfection has to be assumed.
ANNEX 3
Key for operational classifi cation
of malaria foci1
1. Are the conditions suitable for the transmission of malaria?
• No, none throughout the year Pseudo-focus
• Yes, for a period that is suffi cient Go to 2
for the maturation of sporozoites
2. Is there a history of recent transmission (e.g. during the past two years)?2
• No Go to 3
• Yes (presence of introduced and/or Go to 7
indigenous cases)
3. Are cases present?
• Yes Go to 4
• No Cleared-up focus
4. Is effective infection of mosquitoes possible?
• Yes Go to 5
• No (e.g. an imported case arrived Cleared-up focus
during a seasonal break of transmission
and received an antigametocyte treatment
before the onset of effective infectivity)
5. Which categories of cases are present?
• Only induced or imported or New potential focus
relapsing cases
• Other categories also present Go to 6
1
Adapted from Guidelines on the elimination of residual foci of malaria transmission
(1).
2
The exact duration of the period should be decided by the programme.
59
Continued on page 60
60
MALARIA ELIMINATION: A FIELD MANUAL FOR LOW AND MODERATE ENDEMIC COUNTRIES
6. Are indigenous cases present?
• No New active focus
– only introduced
cases present
• Yes New active focus
– indigenous cases
present
7. Are indigenous cases present?
• No Residual non-active
focus
• Yes Go to 8
8. How effectively is transmission controlled?1
• Transmission is effectively controlled Residual active
focus
• No effective control Endemic focus
References
1. Guidelines on the elimination of residual foci of malaria transmission. Cairo,
World Health Organization Regional Offi ce for the Eastern Mediterranean,
2007 (EMRO Technical Publications Series, No. 33):28–30, 47.
1
Criteria for the effectiveness of control should be specifi ed by the programme.
ANNEX 4
Laboratory techniques for parasite
strain identifi cation
Advanced molecular biology leading to fi ngerprinting of malaria parasites can
help elimination programmes towards more precise classifi cation of malaria
cases based on geographical origin. Ideally, in a context of absence of local
transmission, the programme should be in a position to check any suspected
new indigenous cases against preserved, pedigreed isolates of previous indig-
enous infections. This would allow a judgment to be made on whether the
origin of any new infection is local and thus whether there may be (previously
undetected) continuing local transmission.
There are several direct and indirect approaches or methods to determine
genotype differences in malaria parasites. Parasitic genotype characteristics
are expressed or revealed through specifi c phenotypes, for example, in protein
composition, drug susceptibility pattern and isozymes. The parasitic genotype
can also be directly investigated thanks to specifi c genetic markers linked to
parasite clones. Several molecular biology tools have been developed for and
might contribute to this purpose, including the analysis of simple sequence
repeats, microsatellites, amplifi ed fragment length polymorphisms and single
nucleotide polymorphisms.
The malaria parasite is a fast-evolving organism due to the sexual reproduc-
tion stage in the mosquito. Two or more molecular techniques may be needed
either in parallel or in sequence to cope with its highly polymorphic popula-
tion structure.
At present, the preferred methodology or agreed-upon combination of tech-
niques for identifying the geographical origin of malaria parasites has not been
established. Also, before selecting laboratory methods to be used systematically
across countries for phenotypic or genotypic characterization, there are several
factors to be taken into account. These include the complexity and number of
steps of laboratory procedures, cost per analysed sample, informativeness, sen-
sitivity, reproducibility, complexity of equipment, and time needed. Moreover,
in the near future, some of the existing molecular techniques could be further
developed into more effi cient automated silicon-based chips.
61
62
MALARIA ELIMINATION: A FIELD MANUAL FOR LOW AND MODERATE ENDEMIC COUNTRIES
The following actions relating to the molecular characterization of parasite
strains in the context of malaria elimination are recommended.
• National malaria programmes should start to develop a parasite strain bank
at the planning stage of elimination, as a future reference point on the char-
acteristics of local parasite strains. The parasite samples in such a strain bank
can be cryopreserved or preserved on fi lter paper (properly dried and stored
with desiccants) or electronically stored as fully sequenced genomes.
• National and regional laboratories need to collaborate on establishing and
maintaining common databases to store, manage and analyse isolate banks,
and allow standardized comparison over time and by geographical area.
• WHO should stimulate the development of a global collaborative network
of laboratory networks for molecular subtyping of malaria parasites. This
would:
– provide a framework for real-time sharing of molecular epidemiological
information;
– enhance the capacity of countries to detect, respond to and prevent out-
breaks of malaria in areas where the disease has been eliminated.
ANNEX 5
Obsolete control methods from the
Global Malaria Eradication Programme
A5.1 Mass drug administration
During mass drug administration (MDA), every individual in a given popula-
tion or geographical area was treated with antimalarial medicines regardless
of whether they had a current or recent malaria infection or not. MDA can be
direct, giving antimalarial tablets to every individual. MDA can also be indi-
rect through medicated salt programmes (“Pinotti’s method”) and similar
schemes.
WHO does not recommend direct or indirect MDA because:
• previous experience does not point to a clear benefi t. MDA may result in
an important short-term reduction in the parasite reservoir but has little
impact on transmission rates over time;
• primaquine, which was often employed in MDA, carries a risk of life-threat-
ening haemolysis in people who have the genetic trait of glucose-6-phosphate
dehydrogenase defi ciency, which is particularly prevalent in malaria-endemic
regions;
• the indiscriminate use of medicines in MDA increases the risk of the parasite
developing drug resistance.
A5.2 Presumptive treatment
During presumptive treatment, the patient was given medicines in a subcura-
tive dose, usually chloroquine in a single dose (as opposed to the full doses
over three days), before the results of the blood examination were available.
Its principle objectives were to relieve clinical symptoms and prevent trans-
mission. The term was used in contrast to full treatment, which was given to
patients with positive test results.
WHO does not recommend presumptive treatment with subcurative doses of
antimalarial medicines, because of the risk of:
• inducing or enhancing drug resistance
• rapid progression of clinical symptoms.
63
64
MALARIA ELIMINATION: A FIELD MANUAL FOR LOW AND MODERATE ENDEMIC COUNTRIES
If laboratory test results cannot be obtained in a timely manner (within three
to six hours), suspected malaria patients should be treated with full curative
doses of effective antimalarial medicines while the test is being processed. If
the test is negative and another cause for the fever has been diagnosed, malaria
treatment can be stopped.
ANNEX 6
National malaria case register
Most countries keep partially overlapping registers of malaria cases, for exam-
ple, at the ministry of health malaria programme and statistics offi ce, the noti-
fi cation offi ce, clinic/hospital registrations, laboratory records including those
from the reference laboratory, research institutes and surveys.
A national malaria case register serves to centralize information about all
malaria cases detected in the national territory, irrespective of their location
or source of diagnosis and treatment. At the same time, it allows all investiga-
tion reports related to a single occurrence of malaria infection to be linked
together (patient records, laboratory register entry, case investigation, foci
investigation).
The national register allows detailed analysis and synthesis of epidemiologi-
cal information and trends, to guide the malaria elimination programme.
Completeness of the register can be periodically assessed with standard
capture–recapture methods.
An example of the type of information that can be included in the register is
shown on the next page.
65
66
MALARIA ELIMINATION: A FIELD MANUAL FOR LOW AND MODERATE ENDEMIC COUNTRIES

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ANNEX 7
Sample malaria case
investigation record form
Case no.
Case history
Date history taken .......................................................... Location history taken .......................................................
History provided by (name, relation to patient) ...........................................................................................................
Name of patient ............................................................................................................................................................
Sex ....................................Age ...................................... Current nationality ............................................................
Full present home address (including global positioning system coordinates) ...........................................................
.......................................................................................................................................................................................
To answer the questions: WHERE, HOW and FROM WHOM did the infection possibly take place?
Length of residence at present home address ..............................................................................................................
If residence at present home is less than one year: previous home addresses within past year, including dates .......
.......................................................................................................................................................................................
.......................................................................................................................................................................................
Current occupation and place of work ..........................................................................................................................
Recent travel history to known endemic area (including residual active or new active foci) in the country, in as far
as this included possible dusk–dawn exposure to mosquito bites ..............................................................................
.......................................................................................................................................................................................
Travel to foreign endemic country (provide details) ....................................................................................................
• within the past three years (for P. vivax infection) YES 􏲉 NO 􏲉
• within the past year (for P. falciparum infection) YES 􏲉 NO 􏲉
Type of preventive measures taken during above-mentioned travel to endemic areas/countries..............................
.......................................................................................................................................................................................
Blood transfusion within past three months YES 􏲉 NO 􏲉
Recent contact with known imported malaria cases (provide details) ........................................................................
.......................................................................................................................................................................................
Preliminary conclusion: Malaria infection likely acquired at (specify locality and source) ....................................
.......................................................................................................................................................................................
67
68
MALARIA ELIMINATION: A FIELD MANUAL FOR LOW AND MODERATE ENDEMIC COUNTRIES
To summarize the clinical and diagnostic history of this malaria episode and answer the question:
WHEN did the infection possibly take place?
Current clinical episode
Reason for diagnostic test
􏲉 Passive case detection 􏲉 Active case detection 􏲉 Contact survey 􏲉 Population-based survey
Symptoms .....................................................................................................................................................................
Date of onset of fi rst symptoms of current clinical episode ..........................................................................................
Diagnosis
Method ..........................................................................................................................................................................
Date ...............................................................................................................................................................................
Place ..............................................................................................................................................................................
Name of health facility and clinician (if applicable) .....................................................................................................
Slide taken by (name) ................................................................................................................................................
Rapid diagnostic test
Performed by (name) ....................................................................................................................................................
Type of test ..................................................................... Batch no. ............................................................................
Result ............................................................................................................................................................................
Laboratory examination of blood slide
Date ...............................................................................................................................................................................
Performed by (name) ....................................................................................................................................................
Staining method ...........................................................................................................................................................
Plasmodium species ....................................................... Parasite density .................................................................
Gametocytes present YES 􏲉 NO 􏲉
Polymerase chain reaction results
Geographical origin of infection ...................................................................................................................................
Link to previous attacks ................................................................................................................................................
Antimalarial treatment provided
Type of medicine ...........................................................................................................................................................
Doses .............................................................................. Dates ..................................................................................
Treatment outcome ......................................................................................................................................................
69
Previous clinical episodes
Date ................................................................................ Locality ..............................................................................
Symptoms .....................................................................................................................................................................
Laboratory test results ..................................................................................................................................................
Antimalarial treatment
Type of medicine ...........................................................................................................................................................
Doses .............................................................................. Dates ..................................................................................
Outcomes ......................................................................................................................................................................
.......................................................................................................................................................................................
Possible onward transmission
Information for planning the management of possible onward spread of the current malaria infection
Did the patient travel overnight away from home since the onset of the current clinical episode and
before completion of treatment? YES 􏲉 NO 􏲉
(If yes, provide exact places visited, dates) ...................................................................................................................
.......................................................................................................................................................................................
.......................................................................................................................................................................................
House of patient (type of construction, indoor residual spraying) ...........................................................................
.......................................................................................................................................................................................
Entomological studies
Carried out YES 􏲉 NO 􏲉
By (name) ......................................................................................................................................................................
Remarks ......................................................................................................................................................................
.......................................................................................................................................................................................
.......................................................................................................................................................................................
.......................................................................................................................................................................................
History taken by (name, rank/title, signature)
.......................................................................................................................................................................................
.......................................................................................................................................................................................
ANNEX 7. SAMPLE MALARIA CASE INVESTIGATION RECORD FORM
70
MALARIA ELIMINATION: A FIELD MANUAL FOR LOW AND MODERATE ENDEMIC COUNTRIES
Classifi cation of the case
Date of onset of symptoms .....................................................................................................................................
Plasmodium species ..................................................................................................................................................
Case category .............................................................................................................................................................
Classifi ed by (name, including rank/title) ..................................................................................................................
.......................................................................................................................................................................................
Reviewed by (name, including rank/title) .................................................................................................................
.......................................................................................................................................................................................
Follow-up actions
Actions taken .............................................................................................................................................................
.......................................................................................................................................................................................
.......................................................................................................................................................................................
.......................................................................................................................................................................................
.......................................................................................................................................................................................
.......................................................................................................................................................................................
Date form completed ...............................................................................................................................................
71
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ANNEX 9
Sample malaria foci investigation
record form
The following information will be useful for the classifi cation of malaria foci
and for planning the interventions needed to interrupt transmission.
Geographical location
Description of locality
Type of environment in relation to possible receptivity (e.g. urban/rural, altitude, main geographical features)
and vulnerability (e.g. in close proximity to endemic area across international border) .............................................
.......................................................................................................................................................................................
.......................................................................................................................................................................................
.......................................................................................................................................................................................
Type of population in relation to possible vulnerability (e.g. migration patterns, presence of relatively large
numbers of temporary workers, typical travel histories, etc.) .....................................................................................
.......................................................................................................................................................................................
.......................................................................................................................................................................................
.......................................................................................................................................................................................
Map available
Geographical map of focus and its limits ......................................................................................................................
.......................................................................................................................................................................................
Location of health facilities ...........................................................................................................................................
.......................................................................................................................................................................................
.......................................................................................................................................................................................
Vector species – possible breeding sites marked for presence/absence of vector larvae ............................................
.......................................................................................................................................................................................
.......................................................................................................................................................................................
Location of households with malaria cases during past three years ............................................................................
.......................................................................................................................................................................................
.......................................................................................................................................................................................
72
73
ANNEX 9. SAMPLE MALARIA FOCI INVESTIGATION RECORD FORM
Geographical reconnaissance information
Total no. of houses and their inhabitants .....................................................................................................................
.......................................................................................................................................................................................
Map with houses, health units and other important structures as well as access routes ............................................
.......................................................................................................................................................................................
Vector control interventions applied
Type of intervention ......................................................................................................................................................
Date carried out .............................................................................................................................................................
Results of surveys, including active case detection ..........................................................................................
.......................................................................................................................................................................................
Number of reported malaria cases during past fi ve years ...............................................................................
Relationship of locality to the malaria case that prompted focus investigation (in time, space and
circumstances, e.g. the person’s place of residence, work, etc.) ..................................................................................
.......................................................................................................................................................................................
Status of focus
Operational classifi cation of focus using foci classifi cation key ............................................................................
.......................................................................................................................................................................................
Names (including rank/title) of responsible offi cers (vector control, epidemiology) ............................................
.......................................................................................................................................................................................
.......................................................................................................................................................................................
.......................................................................................................................................................................................
Follow-up actions taken ..........................................................................................................................................
.......................................................................................................................................................................................
.......................................................................................................................................................................................
.......................................................................................................................................................................................
.......................................................................................................................................................................................
Date form completed ...............................................................................................................................................
Name (including rank/title) of principal investigator ...........................................................................................
.......................................................................................................................................................................................
Signature of principal investigator .......................................................................................................................
.......................................................................................................................................................................................
74
ANNEX 10
Recommendations for the
United Arab Emirates malaria
programme, post-certifi cation period1
A10.1 Surveillance of malaria cases
Surveillance of malaria cases should be continued by including early detection
of malaria cases, prompt treatment and case management.
Early detection of malaria cases
Early detection of malaria cases should be strengthened by the following.
Case notifi cation
All cases of suspected malaria should continue to be mandatorily notifi ed to
the Central Malaria Control Department (CMD) from both the private and
the government sectors. The notifi cations for suspected malaria cases should
reach the CMD from the district preventive medicine departments, which in
turn will be receiving notifi cations from the government and the private sec-
tor. These notifi cations can be done via fax/telephone or e-mail.
Toll-free helpline number and web site
It will be useful to establish a 24-hour, toll-free notifi cation/helpline phone
line at the CMD to provide counselling, guidance and referral to suspect cases
of malaria and provide more information to the public regarding malaria case
management.
The case notifi cation form should also be hosted on the web site of the CMD
so that the public and private health providers can obtain the form for notifi ca-
tion to the CMD.
Private sector involvement
It is important to involve the private sector in notifi cation, reporting and refer-
ral of all suspected malaria cases to the CMD for case management, which
1
Adapted, by permission of the publisher, from Recommendations for malaria pro-
gram in United Arab Emirates (post malaria-free certifi cation) (1).
75
ANNEX 10. RECOMMENDATIONS FOR THE UNITED ARAB EMIRATES MALARIA PROGRAMME
includes confi rmation of the diagnosis and receiving the proper treatment
from the CMD.
Selective screening of migrants
Since malaria continues to be endemic in many parts of the world, travellers
coming from endemic areas should be provided with health education mate-
rials at immigration desks in airports, seaports, etc., regarding symptoms of
malaria and contact information of the CMD.
Prompt treatment and case management
Free-of-charge (to the patient) case management
The management of malaria should continue to be free of charge, which should
include laboratory confi rmation of diagnosis and treatment of cases.
Free-of-charge chemoprophylaxis
Chemoprophylaxis for the type of malaria, depending on the place of travel,
should be provided free of charge at travellers’ clinics to people going to
endemic areas.
Antimalarial medicines available only at government health facilities
To ensure that malaria treatment is completed and the surveillance system
remains effective, antimalarial medicines should be available only in govern-
ment facilities. Therefore, all cases of malaria should be treated in the govern-
ment sector so that the diagnosis is confi rmed in a timely manner to ensure
that proper treatment is administered and that appropriate measures are initi-
ated to prevent renewed continued transmission.
National Malaria Register and Annual Reports
All cases of malaria should be reported in the National Register and followed
up until cure is ascertained. Each year, the CMD should continue to publish an
annual report of all the activities conducted for maintaining the malaria-free
status of the country.
Laboratory support for correct diagnosis of cases
Strengthening the diagnostic tools in all government health institutions –
primary health centres, hospitals, etc. – is essential for correct diagnosis of
cases.
76
MALARIA ELIMINATION: A FIELD MANUAL FOR LOW AND MODERATE ENDEMIC COUNTRIES
Drug policy
The drug policy for antimalarial medicines should be revised every two years
so that it remains updated with the epidemiology of the disease and as per glo-
bal standards. Adequate stock of medicines for the treatment of malaria should
be maintained, keeping in mind possible emergency situations.
Epidemiological investigation
After a case of malaria has been confi rmed by blood smear and the history sug-
gests no alternative explanation, full investigation of a locally acquired mos-
quito-transmitted case should be conducted. The investigation should include
an epidemiological, environmental and laboratory component. This should be
the responsibility of the CMD, Ministry of Health.
A10.2 Surveillance of vector
To maintain the malaria-free status, the vector surveillance activities should
continue. These should include monitoring of breeding sites for larvae, sur-
veying the presence of adult mosquitoes (both indoors and outdoors), regu-
lar performance of insecticide susceptibility tests and recording of any major
changes in environmental parameters, especially meteorological features that
may favour malaria transmission, such as rainfall and temperature.
A10.3 Vector control
Chemical and biological control with other sectors
Vector control activities as per the National Malaria Plan should be contin-
ued in the form of chemical and biological larval control in coordination with
other sectors, such as municipalities.
Mobile survey teams
Entomological mobile teams should continue monitoring the breeding sites
and inform the relevant department of the results regularly.
International Health Regulations guidelines for fumigation of aircraft and
ships to prevent port malaria
A remote possibility of a source of malaria is an infective mosquito transported
on an aircraft, ship or in baggage that arrived from an area where malaria is
endemic. Thus, for this, fumigation of aircraft and ships should be done as per
the International Health Regulations issued by WHO to prevent transmission
of malaria and other mosquito-borne diseases.
77
A10.4 Health education
The role of health education should be enhanced after the malaria-free certi-
fi cation of the country. Leafl ets/brochures regarding signs and symptoms of
malaria, availability of treatment and chemoprophylaxis free of charge to the
patients/travellers, publicity of toll-free helpline numbers and web site, etc.
should be available for distribution in travellers’ clinics at government health
facilities and immigration desks of airports, seaports, etc.
A10.5 Expanding the Malaria Control Department to become a vector-
borne disease control department
After the successful achievement of malaria-free status for the country, the
Ministry of Health of the United Arab Emirates should consider the expan-
sion of the responsibilities of the CMD to cover the control of vector-borne
diseases in general (and particularly in view of the recent westward movement
of dengue and Japanese B encephalitis from affected areas in Southern Asia) as
a logical consequence.
A10.6 Regional training and demonstration centre for malaria
Considering the achievement of the country and the steps taken to maintain
the status, it shall be useful to demonstrate the process of obtaining malaria-
free status by establishing regular training programmes for the WHO Eastern
Mediterranean Region. An annual training calendar can be prepared by the
CMD in consultation with the WHO Malaria department to showcase the
United Arab Emirates’ systems and establish the regional training hub for
malaria control activities.
References
1. Recommendations for malaria program in United Arab Emirates (post
malaria-free certifi cation). Abu Dhabi, United Arab Emirates, Ministry of
Health, 2006.
ANNEX 10. RECOMMENDATIONS FOR THE UNITED ARAB EMIRATES MALARIA PROGRAMME
78
ANNEX 11
Key documents to be prepared by
the national government for the
certifi cation evaluation team
1. Plan of action for the prevention of reintroduction of malaria.
2. Organizational structure of the malaria department/malaria activities in
general health services, with detailed budget and staff information.
3. Annual malaria surveillance reports over the past 10 years.
4. Full information about active malaria foci in the fi ve years before the last
indigenous case, with supporting maps.
5. National malaria case register with case investigation forms for the past
three years.
6. Reports of quality-assurance activities for diagnosis.
7. Recent antimalarial drug policy.
8. Detailed entomological and vector control activities.
9. Reports of independent committees on malaria, surveillance system, ento-
mological and vector control activities.
10. Recent published/unpublished research reports on malaria epidemiology
and malaria vectors.
11. Legislation/regulations related to malaria and vector control.
12. Reports of intersectoral collaboration.
13. Reports of border coordination activities, if relevant.
ANNEX 12
Outline of the content of the
fi nal report by the certifi cation
evaluation team
SECTION Number of pages
Introduction 1
1. General information
1.1 Geography 1
1.2 Physiography 1
1.3 Climate and vegetation 1
1.4 Some cultural characteristics 1
1.5 Population 2
1.6 Administration 1
1.7 Economics 1
1.8 General health profi le 3–4
1.9 Public and private health-care delivery system 3–4
2. Malaria in the country
2.1 History of malaria 3–4
2.2 Epidemiology of malaria 8–10
2.3 Entomological aspects 3–5
2.4 Present status (past four to fi ve years) 3–5
2.5 Surveillance 2–4
3. Organization, planning, description of general health
services 5–7
4. Organization, function of malaria service 5–7
5. Collaboration with other departments/
community awareness of malaria 2–4
6. Comments on fi eld visits 5–7
7. Imported malaria, legislation 5–7
8. Conclusions 3–5
9. Acknowledgements 1
10. Selected bibliography 1–2
79
80
ANNEX 13
Information to be included
in annual report for follow-up
of WHO certifi cation
1. Confi rmed malaria cases discovered during the reporting period
• by species and case classifi cation
• imported cases by species and country of origin.
2. Brief histories on all reported malaria deaths and other unusual events
(congenital malaria, transfusion malaria, etc.)
3. Brief report on preventive measures carried out
• to reduce importation of parasites
• to reduce receptivity in recent transmission foci.
Glossary
Active case detection: operation carried out by surveillance agents who visit
every locality in a defi ned area at regular intervals (usually monthly during the
transmission season), in order to enquire for fever cases through individual
house visits, and to test for malaria (and treat if positive) each suspected per-
son so discovered.
Case, imported: a case, the origin of which can be traced to a known malari-
ous area outside the country in which the case was diagnosed.
Case, indigenous: a case, the origin of which from local transmission cannot
be disproved. It includes delayed fi rst attacks of P. vivax due to locally acquired
parasites with a long incubation period.
Case, induced: a case, the origin of which can be traced to a blood transfusion
or other form of parenteral inoculation, but not to normal transmission by a
mosquito.
Case, introduced: a case in which it can be proved that the infection is a fi rst
step (fi rst generation) of local transmission subsequent to a proved imported
case, i.e. in which the mosquito was infected from an imported case.
Case investigation: gathering enough information to allow classifi cation of a
malaria case by origin of infection. It includes, but is not limited to, adminis-
tration of a standardized questionnaire to a person diagnosed with a malaria
infection.
Case, malaria (as defi ned in elimination programmes): a person in whom,
regardless of the presence or absence of clinical symptoms, malaria parasites
have been confi rmed by quality-controlled laboratory diagnosis.
Case management: diagnosis, treatment, clinical care and follow-up of malaria
cases.
Case notifi cation (compulsory): reporting of detected cases of malaria by all
medical units and medical practitioners, to either the health department or the
malaria elimination service (as laid down by law or regulation).
81
82
MALARIA ELIMINATION: A FIELD MANUAL FOR LOW AND MODERATE ENDEMIC COUNTRIES
Case, relapsing: case shown by the history of the patient to be a probable
relapse if careful epidemiological investigation shows that the infection was
contracted before interruption of transmission was claimed in the locality and
if there are no epidemiologically related malaria cases in the neighbourhood.
Certifi cation of malaria elimination: granted by WHO after proving beyond
reasonable doubt that the chain of local human malaria transmission by
Anopheles mosquitoes has been fully interrupted in an entire country for at
least three consecutive years.
Elimination: reduction to zero of the incidence of infection caused by a specifi ed
agent in a defi ned geographical area as a result of deliberate efforts. Continued
measures to prevent re-establishment of transmission are required.
Endemic: applied to malaria when there is a constant measurable incidence of
cases and mosquito-borne transmission in an area over a succession of years.
Epidemic: occurrence of cases in excess of the number expected in a given
place and time period.
Eradication: permanent reduction to zero of the worldwide incidence of infec-
tion caused by a specifi c agent as a result of deliberate efforts. Intervention
measures are no longer needed once eradication has been achieved.
Evaluation: a process that attempts to determine as systematically and objec-
tively as possible the relevance, effectiveness and impact of activities in relation
to their objectives.
False negative (or false positive): when a test shows a negative (or positive)
result, despite the opposite being true.
Focus: a defi ned and circumscribed locality situated in a currently or former
malarious area and containing the continuous or intermittent epidemiological
factors necessary for malaria transmission. Foci can be classifi ed as residual
active, residual non-active, cleared up, new potential, new active, endemic or
pseudo-foci.
Gametocytes, person carrying: person who has malaria gametocytes in the
peripheral blood, making him or her a potential source of infection.
Geographical reconnaissance: the operation that provides the basis for the
choice of fi eld centres and depots, for detailed schedules and itineraries of
spraying and surveillance personnel, for the fi nal deployment of transport,
and for the numerical control of the completeness of the work accomplished or
reported. It includes collection of information on the number, type, location
and means of access to all houses and fi eld shelters, as well as on communica-
tions, health units, vehicle repair facilities, population movements and other
relevant factors.
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Health services coverage: use of the health services by those who need it.
Incubation interval: the period between the occurrence of infective gameto-
cytes in the primary case and their reappearance in a secondary case.
Incubation period: the time between infection (by inoculation or otherwise)
and the fi rst appearance of clinical signs, of which fever is the most common.
Intensity of transmission: rate at which people in a given area are inoculated
with malaria parasites by mosquitoes (usually expressed by the annual ento-
mological inoculation rate).
Local mosquito-borne malaria transmission: occurrence of human malaria
cases that are acquired in a given area through the bite of infected Anopheles
mosquitoes.
Malaria elimination: a reduction to zero of the incidence of infection caused
by human malaria parasites in a defi ned geographical area as a result of delib-
erate efforts. Continued measures to prevent re-establishment of transmission
are required.
Malaria-free: an area where there is no continuing local mosquito-borne
malaria transmission, and the risk of acquiring malaria is limited to intro-
duced cases only.
Malaria incidence: the number of newly diagnosed malaria cases during a
specifi ed time period in a specifi ed population.
Malaria prevalence: the number of malaria cases existing at any given time in
a specifi ed population, measured by positive laboratory test results.
Monitoring (of programmes):
• episodic measurement of the effect of an intervention on the health status
of a population or the environment; not to be confused with surveillance,
although surveillance techniques may be used in monitoring;
• the process of collecting and analysing information about the implementa-
tion of a programme for the purpose of identifying problems, such as non-
compliance, and taking corrective action;
• in management, this refers to the episodic review of the implementation of
an activity, seeking to ensure that inputs, deliveries, work schedules, targeted
outputs and other required actions are proceeding according to plan.
National foci register: centralized computerized database of all malaria foci
in a country.
National malaria case register: centralized computerized database of all
malaria cases registered in a country, irrespective of where and how they were
GLOSSARY
84
MALARIA ELIMINATION: A FIELD MANUAL FOR LOW AND MODERATE ENDEMIC COUNTRIES
diagnosed and treated. It allows detailed analysis and synthesis of epidemio-
logical information and trends, to guide the malaria elimination programme.
Parasite strain: subtype of parasites with similar properties. Properties that
are strain-specifi c include immune response in the human host, infectiousness
for a given species of vectors and antimalarial drug resistance.
Passive case detection: detection of malaria cases among patients who on
their own initiative went to a health post to get treatment, usually for a febrile
disease.
Population at risk: population living in a geographical area where locally
acquired malaria cases occurred in the current and/or previous year. The
measurement unit for elimination milestones among populations at risk is a
political unit corresponding to approximately 75 000–150 000 people (e.g. a
district).
Population-based blood survey: survey in which a blood slide is prepared for
every individual in a given population (i.e. irrespective of history of fever) once
or more, for the thorough assessment of the prevailing conditions in the area,
to provide additional proof of the interruption of transmission. The goal is to
detect asymptomatic infections usually associated with low parasite densities.
Rapid diagnostic test (RDT) positivity rate: the proportion of RDTs found
positive among RDTs performed.
Receptivity: the abundant presence of anopheline vectors and the existence of
other ecological and climatic factors favouring malaria transmission.
Re-establishment of transmission: renewed presence of a constant measur-
able incidence of cases and mosquito-borne transmission in an area over a
succession of years. An indication of the possible re-establishment of transmis-
sion would be the occurrence of three or more introduced and/or indigenous
malaria infections in the same geographical focus, for two consecutive years
for P. falciparum and for three consecutive years for P. vivax.
Relapse: renewed manifestation (of clinical symptoms and/or parasitaemia)
of malaria infection separated from previous manifestations of the same infec-
tion by an interval greater than that related to the normal periodicity of the
paroxysms. The term is used mainly for renewed manifestation due to the sur-
vival of hypnozoites (exo-erythrocytic forms) of P. vivax or P. ovale.
Sensitivity (of a test): the proportion of true positives among all the positives
it detects.
Slide positivity rate: the proportion of slides found positive among the slides
examined.
85
Specifi city (of a test): the proportion of true negatives among all the negatives
it detects.
Surveillance: that part of the programme aimed at the discovery, investigation
and elimination of continuing transmission, the prevention and cure of infec-
tions, and the fi nal substantiation of claimed elimination.
Transmission season: period of the year during which mosquito-borne trans-
mission of malaria infection can normally take place.
Vector control: measures of any kind directed against a vector of disease and
intended to limit its ability to transmit the disease.
Vector effi ciency: ability of a mosquito species, in comparison with another
species in a similar climatic environment, to transmit malaria in nature.
Vectorial capacity: number of new infections the population of a given vector
would distribute per case per day at a given place and time, assuming con-
ditions of non-immunity. Factors affecting vectorial capacity include: (i) the
density of female anophelines relative to humans; (ii) their longevity, frequency
of feeding and propensity to bite humans; and (iii) the length of the extrinsic
cycle of the parasite.
Vigilance: a function of the public health service during the programme for
prevention of re-introduction of transmission, consisting of watchfulness for
any occurrence of malaria in an area in which it had not existed or from which
it had been eliminated, and the application of necessary measures against it.
Vulnerability: either proximity to malarious areas or resulting from the fre-
quent infl ux of infected individuals or groups and/or infective anophelines.
GLOSSARY
MALARIA ELIMINATION
A field manual for low and
moderate endemic countries
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Malaria elimination – the interruption of local mosquito-borne
malaria transmission – is the end goal in the fight against the
disease. In addition to being vital for public health and part of
overall development efforts, malaria elimination has a profound
impact on other sectors, such as business and tourism. In this
increasingly interconnected world, no country can afford to be
complacent about the disease. Whether previously malarious or not,
non-malarious countries must support the efforts of endemic
countries to eliminate the disease. This manual has been developed
to provide guidance to the increasing number of countries that have
decided to eliminate malaria from their territory.
An elimination programme builds on the successful control of
malaria mortality and morbidity. The evolution of the programme,
from control to elimination to preventing re-establishment of
malaria, is described in detail, along with the important programme
reorientations.
Drawing on recent experience from various countries with malarious
areas, the feasibility of malaria elimination is discussed, helping
countries to set realistic targets and timescales. Descriptions are
provided of tools and approaches that are specific or particularly
relevant to elimination: case detection, prevention of onward
transmission, and management of malaria foci and of importation
of malaria parasites.
As monitoring and evaluation are essential components of the
programme, recommended indicators, data sources and metho-
dologies are outlined. Monitoring and evaluation not only allow the
progress of the programme to be assessed and documented, but also
allow a credible information database to be established, which is
needed for ultimate certification of malaria elimination.
Certification of malaria elimination – the recognition of a conside-
rable operational achievement – is granted by the World Health
Organization to countries that have successfully maintained their
malaria-free status for at least three consecutive years. Requirements
and procedures for certification are described, along with details of
the follow-up of certification.