2. Learning objectives
• Describe the malaria elimination strategy and how it
differs from malaria control
• List the programmatic milestones for malaria elimination
• Plan for malaria elimination
• Identify the systems needed for malaria elimination and
how they should be strengthen
• Identify, estimate, and mobilize the resources needed for
develop the capacity to eliminate malaria
• Describe the malaria elimination certification
requirement and process
Thursday, March 29, 2012 2
3. Introduction
• The fundamental planning process applicable to
malaria control also apply for malaria elimination
• For elimination, the program and health services
should be in advance stage:
– Current achievements
– Well established system in place
– Trained staff, active community participation
– Intersectoral collaboration
– Political will
• Re-planning
Thursday, March 29, 2012 3
4. Evolution of the malaria control strategy
• 1970s malaria eradication
• 1978, four general approach (tactical variant) to
malaria control
• 1985, reviewed of the four tactical approach
• Two different strategies for malaria control
– Improvement in general health services
– Strengthening the capability for long term control of
malaria transmission
Thursday, March 29, 2012 4
5. Definition of malaria elimination
• Cessation of local transmission of malaria parasites
from person to person by anopheline mosquitoes
– Does not require the elimination of disease vectors
– Imported cases will continue to be detected
– Elimination cover all Plasmodium species that infect
human
Thursday, March 29, 2012 5
6. Differences between malaria control and eliminatio
• Elimination programs:
– Detect and cure malaria patients
– Interrupt local mosquito-born malaria transmission
– Identify and eliminate residual foci of malaria transmission
– Develop and implement special surveillance system for
maintaining the malaria free status
– Prevent re-establishment of transmission despite
continuing importation of parasites
– Collaborate with neighboring endemic countries to reduce
malaria transmission in the region
Thursday, March 29, 2012 6
7. • Control programs:
– Precise objectives, strategies and targets
– Selection of appropriate intervention
– Access to malaria treatment
– Surveillance
– Facilities for diagnosis and curative activities
– Prevention
– Epidemiological services with component of applied
research and training
– Response to emergency situation
– Community involvement
Thursday, March 29, 2012 7
8. Programmatic milestones for malaria
elimination
• Transition from malaria control to elimination
– High transmission areas
• Prim objective is to reduce malaria mortality and morbidity and
transmission intensity
• Reduce the burden of malaria to less than 5% of all patients with
fibril disease
– Low transmission areas
• First aim at pre-elimination stage, reduce the incidence of malaria
to less than 1 case per 1000 people at risk
• Strong surveillance system is required
– Areas where transmission has been interrupted
• Prevent re-establishment
Thursday, March 29, 2012 8
9. Malaria program phases and milestones
WHO
Certification
SPR < 5% in fever cases < 1 case/1000 0 locally acquired cases 3 years
population at risk/year
Control Pre-elimination Elimination Prevention of
reintroduction
1st program reorientation 2nd program reorientation
Thursday, March 29, 2012 9
10. Planning for malaria elimination
• Malaria case definition in elimination program
– A malaria case is a person in whom, regardless of the
presence or absence of clinical symptoms, malaria
parasites have been confirmed by quality controlled
laboratory diagnosis
Thursday, March 29, 2012 10
11. Classification of malaria cases by origin of
infection
Malaria Infection
Due to mosquito-born Not due to mosquito-
transmission born transmission
Acquired locally Acquired abroad
Imported
Introduced Indigenous Induced
First generation local All cases without e.g. due to blood
transmission; evidence of a direct transmission, congenital
epidemiologically link to an imported malaria
limited to proven case
imported case
Relapsing
History of PV or PO infection within
past 3 years; no epidemiological
Thursday, March 29, 2012 11
linked cases in vicinity
12. Classification of malaria foci for elimination
purpose
• A focus is defined situated in a currently or formerly
malarious area and containing the continuous or
intermittent epidemiological factors necessary for
malaria transmission
Thursday, March 29, 2012 12
13. Shared commonalities between the countries
successfully eliminated malaria
• Political stability
• Good infrastructure
• High quality of training and personnel
• Developed and functional health system
• Absence of internal or external conflict
• Absence of major population movement from
neighboring malaria endemic countries
• Malaria originally unstable or of low grade
intermediate stability
Thursday, March 29, 2012 13
14. Program system needs for malaria elimination
• Malaria elimination evolves from a successful
country wide malaria control program
• At the initial phases elimination program become a
specialized vertical program focuses:
– Spatial distribution of malaria
– Vector control
– Case finding and case investigation
• Once elimination achieved, focus shifts to general
health services, which are vital to a good surveillance
system
Thursday, March 29, 2012 14
15. Feasibility of malaria elimination
• Assess the feasibility of elimination
– Political will supported by adequate fund allocation
– Are legislation, environmental codes, and regulation in place?
– Coverage of health system (including private sector)
– Is malaria elimination part of country's socioeconomic development
plan?
– Effective government administration at central and periphery
– Good communication system and infrastructure
– Established national malaria elimination monitoring committee
– Adequate knowledge of local malaria epidemiology
– Documentation of the impact of currently applied interventions
– Malaria control program in bordering countries
Thursday, March 29, 2012 15
16. Resource needs for malaria elimination
• Considerable additional resources will be required
• The most imported resources include:
– Well trained and motivated staff at all level and each
category
– Active and knowledgeable managers
– Long term training plan (must include continuing
education)
– Adequate financial resources for operation, supplies and
equipment, monitoring and evaluation, education and
training, operational research
– Cost will change in different phases of elimination
Thursday, March 29, 2012 16
17. Certification of malaria elimination
• Has economic benefits
• Country is the minimum geographical area for
certification
• Criteria for local malaria transmission by mosquitoes:
– “cluster of 3 or more cases of malaria infection that can be
traced with high likelihood to one source of mosquito
transmitted infection within the territory”
• A country is consider malaria free when there is no
case of locally transmitted malaria for three
consecutive years
Thursday, March 29, 2012 17
18. Requirement for certification
• Good surveillance
• Case register, mandatory immediate reporting (both
in public and private sector)
• Adequate facilities for the detection, treatment and
follow-up of imported cases
• Quality microscopy
• Epidemiological investigation of every case
• National comprehensive plan with adequate financial
allocation for the prevention of re-establishment
Thursday, March 29, 2012 18
19. Requirement for certification cont.
• A system for awareness, prevention of mosquito bites
and chemoprophylaxis for travelers to prevent imported
cases
• A central computerized geo-referenced database of
cases and latest foci
• Entomological surveillance and monitoring insecticide
resistance
• Functional border coordination system
• Capacity for early detection and response to epidemics
• Sero-epidemiological surveys
Thursday, March 29, 2012 19
20. Procedures for certification
• General principle of certification:
– Certification is for a country
– Certification is for all four species
– Inspection and evaluation are carried out by a team led by
WHO
– If appropriate, evaluation team recommend certification
– The final decision is made by WHO Director General
– Certification is published in the WHO weekly
Epidemiological Record
Thursday, March 29, 2012 20
21. Procedures for certification cont.
• Established procedure for certification:
– Government request
– WHO secretariat, external experts and national
government jointly formulate a certification action plan
– The government implement the action plan, prepare
supporting documentation and submits it to WHO
– A WHO led team of experts conduct the external
evaluation
– External evaluation team submit its report with
recommendation to WHO for wider review
Thursday, March 29, 2012 21
22. Procedures for certification cont.
• WHO expert committee on malaria makes the final
review and submits the final recommendation to
Director General of WHO
• DG WHO makes the final decision based on the
recommendations
• Certification of malaria elimination in the country is
published in the WHO Weekly Epidemiological
Record
Thursday, March 29, 2012 22
23. Maintenance of malaria free status
• Health system must remain vigilant to possible
reintroduction of the disease
• Countries are requested to report the malaria free status
annually to WHO
• PF outbreak should be reported immediately
• Indication of the reestablishment of the transmission:
– Occurrence of 3 or more introduced and/or indigenous malaria
infections linked in space and time to local mosquito born
transmission in the same geographical focus, for two
consecutive years for PF, and for three consecutive years for
PV
Thursday, March 29, 2012 23
