Planning for malaria elimination

Planning for Malaria Elimination

Najibullah Safi, MD, MSc. HPM

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

Tuesday, April 11, 2023 2

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


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


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


Differences between malaria control and elimination programs • 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


• 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


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


Malaria program phases and milestones

Control Pre-elimination Pre-elimination Elimination Elimination Prevention of reintroduction

SPR < 5% in fever cases < 1 case/1000 population at risk/year

0 locally acquired cases 3 years

WHO Certification

1st program reorientation 2nd program reorientation


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


Classification of malaria cases by origin of infection Malaria Infection

Due to mosquito-born transmission

Not due to mosquito-born transmission

Induced e.g. due to blood

transmission, congenital malaria

Acquired locally Acquired abroad

Relapsing History of PV or PO infection within

past 3 years; no epidemiological linked cases in vicinity

IntroducedFirst generation local

transmission; epidemiologically limited to proven

imported case

IndigenousAll cases without

evidence of a direct link to an imported

case

Imported


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


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


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


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


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


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


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


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


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


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


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


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



Health & Medicine

Planning for malaria elimination