CERTIFICATION OF MALARIA ELIMINATION by Dr Mikhail Ejov WHO Training in Malaria Elimination in the Greater Mekong Sub-Region, 10-21 August 2015, Chiang Mai Thailand WHO Training in Malaria Elimination in the Greater Mekong Sub-Region, 10-21 August 2015, Chiang Mai, Thailand

A country can request certification of malaria elimination when there has been all the available evidence that local transmission by Anopheles mosquitoes fully interrupted throughout the entire country for at least 3 consecutive years WHO Training in Malaria Elimination in the Greater Mekong Sub-Region, 10-21 August 2015, Chiang Mai Thailand

Definition of certification The concept of certification of malaria elimination was first formulated by WHO at the onset of the malaria eradication campaign Certification of malaria elimination is the official recognition of malaria elimination achieved in a specific country Eliminating malaria does not require the elimination of malaria vectors or complete absence of malaria cases - imported cases related to international travel will be probably reported WHO Training in Malaria Elimination in the Greater Mekong Sub-Region, 10-21 August 2015, Chiang Mai Thailand

Requirements and procedures for certification When interruption of malaria transmission is achieved throughout a country and the absence of local malaria transmission has been maintained for at least three consecutive years, the country may request WHO to begin the process of certifying its territory as malaria-free Any government can declare that malaria has been eliminated from its territory, but to obtain international recognition of such a declaration it is expected that WHO will certify it by including the country in an official register of areas where malaria elimination has been achieved WHO Training in Malaria Elimination in the Greater Mekong Sub-Region, 10-21 August 2015, Chiang Mai Thailand

Requirements and procedures for certification A country asking WHO to certify its malaria-free status: Must made a defensible and plausible argument that, beyond reasonable doubt, malaria transmission has ended throughout the entire territory of the country, and Must submit the necessary evidence that the local transmission of malaria has been absent for at least three consecutive years and that the country has an effective system for epidemiological surveillance of malaria which is able to detect any signs of possible malaria transmission The burden of prof of elimination falls on the country requesting certification WHO Training in Malaria Elimination in the Greater Mekong Sub-Region, 10-21 August 2015, Chiang Mai Thailand

Requirements and procedures for certification Certification of malaria confirms both that local malaria transmission has been interrupted throughout the country and that the existing health system country is strong enough to prevent malaria re-introduction and re-establishment of local transmission WHO Training in Malaria Elimination in the Greater Mekong Sub-Region, 10-21 August 2015, Chiang Mai Thailand

Requirements and procedures for certification In order to be confident that interruption of transmission has been achieved, a number of the following key pre-conditions must be met: High-quality system of malaria surveillance covering all areas of the country with immediate reporting and compulsory notification of all cases by the public, private health and community-based sectors; Adequate system of early detection, quality-assured parasitological diagnosis and effective treatment of cases and their subsequent clinical and epidemiological monitoring throughout the entire country; Established mechanism for epidemiological investigation and classification of each case and foci; Complete national elimination database including malaria case register; National plan of action aimed at preventing the re-introduction of malaria and possible re-establishment of local transmission, supported by the national government. WHO Training in Malaria Elimination in the Greater Mekong Sub-Region, 10-21 August 2015, Chiang Mai Thailand

Principles of certification Certification is done for a country as a whole, and for all four human malaria species (verification of malaria elimination in a defined geographical area is under consideration); Inspection of the certification process and evaluation of its implementation is carried out by expert teams led by WHO; Upon completion of the inspection, the team of independent experts submits its report and recommendations to the Director-General of WHO; The final decision on certification is taken by the Director-General of WHO, and a Member State is duly informed about this decision; Registration of malaria elimination certification is published in the WHO Weekly Epidemiological Record as well as in an official register of Member States where malaria elimination has been achieved WHO Training in Malaria Elimination in the Greater Mekong Sub-Region, 10-21 August 2015, Chiang Mai Thailand

Weekly epidemiological record, 18 July 2014, No. 29 , 321-336 http://www.who.int/wer WHO Training in Malaria Elimination in the Greater Mekong Sub-Region, 10-21 August 2015, Chiang Mai Thailand

Stages of the certification process Request to start the certification process Establishment of the national certification committee and its activities Preparation of documents recommended by WHO for the certification process Preparation of a national report on the elimination of malaria in the country Visit by WHO certification teams and a group of independent experts Final evaluation by the WHO Expert Committee Final decision Publication of information about the certification Post-certification period WHO Training in Malaria Elimination in the Greater Mekong Sub-Region, 10-21 August 2015, Chiang Mai Thailand

Key chapters with essential documents to be prepared Strategy and Plan of action for the prevention of re-introduction of malaria Organizational structure of the malaria department/malaria activities in general health services, with detailed budget and staff information Annual malaria surveillance reports over the past years Full information about active foci of malaria in the 5 years before the last indigenous case, with supporting maps National malaria case register with case investigation forms for the past 5 years Reports of quality-aasurance activities for malaria diagnosis Recent antimalarial drug policy Detailed entomological and vector control activities Reports of independent committees on malaria, surveillance system/activities, entomological and vector control activities Recent published/unpublished research reports on malaria epidemiology and control/elimination Legislation/regulations related to malaria and vector control Reports of inter-sectoral collaboration Reports of community involvement/participation in malaria prevention Reports of border coordination activities, if relevant Key chapters with essential documents to be prepared Past and existing national strategies and plans aimed at control, elimination and prevention of re-establishment of malaria; Organizational structure of the specialized malaria programme and public health services and their activities at all levels; Annual malaria surveillance reports in the previous ten years; A complete database of all malaria foci during the five years before the last reported autochthonous case of malaria; A national malaria case register during the past five years before the last reported autochthonous case of malaria; Reports on the monitoring of the quality of malaria diagnosis; Existing national policy and recommendations for the treatment of malaria; Reports on the entomological situation and vector control activities; Reports of the national malaria elimination committee responsible for overall coordination and monitoring; Recent scientific publications on malaria; Past and existing legal framework and administrative acts related to malaria; Reports on community-based activities related to malaria prevention; Reports on inter-sectoral collaboration for malaria; Reports on cross- border cooperation related to malaria, if relevant WHO Training in Malaria Elimination in the Greater Mekong Sub-Region, 10-21 August 2015, Chiang Mai Thailand

Follow-up of certification Countries are requested to continue reporting on an annual basis to WHO on the maintenance of their malaria-free status (cases and deaths due t malaria reported and preventive measures carried out); Outbreaks of malaria in a malaria-free country should be reported to WHO immediately, so that WHO can provide the necessary assistance; Because certification is the recognition of a considerable operational achievement, countries will remain listed as having achieved malaria elimination even if they subsequently suffer a temporary occurrence of local transmission. WHO Training in Malaria Elimination in the Greater Mekong Sub-Region, 10-21 August 2015, Chiang Mai Thailand

Global and regional guidelines on prevention of re-introduction and certification of malaria elimination WHO Training in Malaria Elimination in the Greater Mekong Sub-Region, 10-21 August 2015, Chiang Mai Thailand

by Dr. Mikhail Ejov & Prof. Vladimir Davidyants LESSONS LEARNT/CASE STUDY: FROM EPIDEMIC CONTAINMENT TO ELIMINATION, PREVENTION OF RE-INTRODUCTION AND CERTIFICATION OF MALARIA ELIMINATION IN ARMENIA, 1998-2011 by Dr. Mikhail Ejov & Prof. Vladimir Davidyants

Number of Autochthonous Cases of Malaria in Armenia, 1994 – 2006 Containment of an epidemic Malaria elimination

Number of autochthonous cases of malaria in Armenia,1998 ²Ù³ëdz ²ßáóù ¶ÛáõÙñÇ ²ñÃÇÏ ²ÝÇ êåÇï³Ï êï»÷³Ý³í³Ý î³ßÇñ ³ÉÇÝ ²ßï³ñ³Ï ¶áõ·³ñù ì³Ý³Óáñ ²É³í»ñ¹Ç ÂáõÙ³ÝÛ³Ý Üá»Ùµ»ñÛ³Ý ºñí³Ý¹³ß³ï ²ñÙ³íÇñ ²å³ñ³Ý ܳÇñÇ ¾çÙdzÍÇÝ ºðºì²Ü ²ñ³·³Í Ðñ³½¹³Ý â³ñ»Ýó³í³Ý ê¨³Ý ´»ñ¹ Æç¨³Ý Îñ³ëÝáë»ÉëÏ ì³ñ¹»ÝÇë سëÇë سñïáõÝÇ ¶³í³é ²ñï³ß³ï ²ñ³ñ³ï ºÕ»·Ý³Óáñ ì³Ûù æ»ñÙáõÏ êÇëÇ³Ý ¶áñÇë γå³Ý Ø»ÕñÇ ²µáíÛ³Ý ¸ÇÉÇç³Ý Yerevan Imported Acquired locally

Number of autochthonous cases of malaria in Armenia, 2001 ²Ù³ëdz ²ßáóù ¶ÛáõÙñÇ ²ñÃÇÏ ²ÝÇ êåÇï³Ï êï»÷³Ý³í³Ý î³ßÇñ ³ÉÇÝ ²ßï³ñ³Ï ¶áõ·³ñù ì³Ý³Óáñ ²É³í»ñ¹Ç ÂáõÙ³ÝÛ³Ý Üá»Ùµ»ñÛ³Ý ºñí³Ý¹³ß³ï ²ñÙ³íÇñ ²å³ñ³Ý ܳÇñÇ ¾çÙdzÍÇÝ ºðºì²Ü ²ñ³·³Í Ðñ³½¹³Ý â³ñ»Ýó³í³Ý ê¨³Ý ´»ñ¹ Æç¨³Ý Îñ³ëÝáë»ÉëÏ ì³ñ¹»ÝÇë سëÇë سñïáõÝÇ ¶³í³é ²ñï³ß³ï ²ñ³ñ³ï ºÕ»·Ý³Óáñ ì³Ûù æ»ñÙáõÏ êÇëÇ³Ý ¶áñÇë γå³Ý Ø»ÕñÇ ²µáíÛ³Ý ¸ÇÉÇç³Ý Yerevan Imported Acquired locally

Number of autochthonous cases of malaria in Armenia, 2005 ²Ù³ëdz ²ßáóù ¶ÛáõÙñÇ ²ñÃÇÏ ²ÝÇ êåÇï³Ï êï»÷³Ý³í³Ý î³ßÇñ ³ÉÇÝ ²ßï³ñ³Ï ¶áõ·³ñù ì³Ý³Óáñ ²É³í»ñ¹Ç ÂáõÙ³ÝÛ³Ý Üá»Ùµ»ñÛ³Ý ºñí³Ý¹³ß³ï ²ñÙ³íÇñ ²å³ñ³Ý ܳÇñÇ ¾çÙdzÍÇÝ ºðºì²Ü ²ñ³·³Í Ðñ³½¹³Ý â³ñ»Ýó³í³Ý ê¨³Ý ´»ñ¹ Æç¨³Ý Îñ³ëÝáë»ÉëÏ ì³ñ¹»ÝÇë سëÇë سñïáõÝÇ ¶³í³é ²ñï³ß³ï ²ñ³ñ³ï ºÕ»·Ý³Óáñ ì³Ûù æ»ñÙáõÏ êÇëÇ³Ý ¶ áñÇë γå³Ý Ø»ÕñÇ ²µáíÛ³Ý ¸ÇÉÇç³Ý Yerevan Imported Acquired locally

The country requested WHO to be certified in 2010 Cases of imported malaria in Armenia, 2006-2010 2006 ²Ù³ëdz ²ßáóù ¶ÛáõÙñÇ ²ñÃÇÏ ²ÝÇ êåÇï³Ï êï»÷³Ý³í³Ý î³ßÇñ ³ÉÇÝ ²ßï³ñ³Ï ¶áõ·³ñù ì³Ý³Óáñ ²É³í»ñ¹Ç ÂáõÙ³ÝÛ³Ý Üá»Ùµ»ñÛ³Ý ºñí³Ý¹³ß³ï ²ñÙ³íÇñ ²å³ñ³Ý ܳÇñÇ ¾çÙdzÍÇÝ ºðºì²Ü ²ñ³·³Í Ðñ³½¹³Ý â³ñ»Ýó³í³Ý ê¨³Ý ´»ñ¹ Æç¨³Ý Îñ³ëÝáë»ÉëÏ ì³ñ¹»ÝÇë سëÇë سñïáõÝÇ ¶³í³é ²ñï³ß³ï ²ñ³ñ³ï ºÕ»·Ý³Óáñ ì³Ûù æ»ñÙáõÏ êÇëÇ³Ý ¶ áñÇë γå³Ý Ø»ÕñÇ ²µáíÛ³Ý ¸ÇÉÇç³Ý Yerevan The country requested WHO to be certified in 2010 Imported

Conclusions of the WHO certification mission Is it proven “beyond reasonable doubt” that there is no longer any malaria transmission in Armenia? Robust management of last foci occurred once they detected in 2005 Only a few imported cases detected afterwards and managed appropriately and in a timely manner Systems for ACD and PCD remained in place with adequate ABER coverage and QA Health services fully functional, motivated and supervised Intense education activities on malaria prevention promoted Strong inter-sectoral and community collaboration with better management of water resources, rational use of irrigated and drained land and widespread larval control mainly based on use of larvivorous fish

Annual blood slide examination rate, 2001—2010

Conclusions of the WHO certification mission Will the National Health System be able to prevent malaria re-establishment? There has been a comprehensive national plan to prevent the malaria re-introduction and re-establishment of local transmission supported by the MoH commitment with well functioning surveillance and response and sufficient national health budget as well (SES funding of SES has increased 9-10% annually)

WHO Certification Mission of Independent Experts, June-July, 2011 ALL THESE ELEMENTS SEEN TOGETHER INDICATE, IN OPINION OF MISSION, THAT THERE IS NO LONGER ANY MALARIA TRANSMISSION IN THE COUNTRY CURRENT SUCCESSES, POLITICAL AND FINANCIAL COMMITMENT NATIONAL PLAN FOR PREVENTION, WELL MAINTAINED SURVEILLANCE AND RESPONSE, FUNCTIONING INTERSECTORAL COLLABORATION, ALL FAVOR PREVENTION OF REINTRODUCED TRANSMISSION 1

Armenia certified as free from malaria, 07.10.2011