1. INRODUCTION TO MALARIA ELIMINATION by Dr Mikhail Ejov
WHO Training in Malaria Elimination in the Greater Mekong Sub-Region, August 2015, Chiang Mai Thailand

2. Definition of malaria control, elimination and eradication
Issues to be presented
Definition of malaria control, elimination and eradication
Malaria eradication and lessons learnt
The concept of malaria elimination
Main differences between malaria control and elimination programmes
The present concept of transition from malaria control to elimination as the continuum process
Recent progress towards malaria elimination
Regional success in eliminating malaria in EURO
Progress made with certification of malaria elimination
Looking ahead
WHO Training in Malaria Elimination in the Greater Mekong Sub-Region, August 2015, Chiang Mai Thailand

3. Definition of malaria control, elimination and eradication
Reduction of the malaria disease burden to a level at which it is no longer a public health problem
Malaria elimination
The interruption of local mosquito-borne malaria transmission; reduction to zero of the incidence of infection caused by human malaria parasites in a defined geographical area as a result of deliberate efforts: continued measures to prevent re-establishment of transmission are required
Malaria eradication
Permanent reduction to zero of the worldwide incidence of infection caused by a particular malaria parasite species: measures against malaria are no longer needed once eradication has been achieved
WHO Training in Malaria Elimination in the Greater Mekong Sub-Region, August 2015, Chiang Mai Thailand

4. Malaria eradication and lessons learnt
A major breakthrough in malaria control occurred at the end of the Second World War, with the advent of DDT as an anti-vector tool and a novel drug - chloroquine followed by a number of other drugs by making it possible to interrupt malaria transmission within 2 or 3 seasons, in temperate or sub-tropical climates;
In 1947, the 1st WHO Expert Committee on malaria mentioned a feasibility of malaria eradication;
In 1954, the Pan-American Sanitary Conference adopted a programme for malaria eradication for the Americas, and in 1955 the 8th World Health Assembly adopted a resolution on a transition from malaria control to its eradication;
In 1956, the 6th Expert Committee on malaria developed malaria eradication strategy and WHO launched the Global Malaria Eradication Programme.
WHO Training in Malaria Elimination in the Greater Mekong Sub-Region, August 2015, Chiang Mai Thailand

5. Malaria eradication and lessons learnt (cont.)
The Global Programme aimed at “the ending of the transmission of malaria and the elimination of the reservoir of infective cases, in a campaign limited in time and carried out to such a degree of perfection that, when it comes to an end, there is no resumption of transmission”;
The population covered by the Global Eradication Programme peaked at 1.4 billion people in 1969;
The strategy focused on:
(1) targeting adult malaria vectors through large-scale indoor residual spraying operations, and
(2) intensive surveillance, which included treatment of cases detected. Gradually, the development of improved health services to provide treatment and better surveillance data came to be recognized. In some areas, where progress was deemed too slow, mass drug administration was added.
WHO Training in Malaria Elimination in the Greater Mekong Sub-Region, August 2015, Chiang Mai Thailand

6. Malaria eradication and lessons learnt (cont.)
A stepwise approach was adopted, with four phases:
(1) preparatory (after the signature of elimination plan by concerned parties,
(2) attack (it consisted of the attack and evaluation operations to determine whether transmission has been interrupted or not),
(3) consolidation (it consisted in deploying all efforts to discover any possible continuation of transmission and its causes, eliminate them and ascertain if/when elimination has achieved),
(4) maintenance (with a focus on preventing reintroduction of malaria and consequent resumption of transmission);
Once eradication was achieved, governments would request a visit by a WHO certification team. The team’s findings were subject to confirmation by the WHO Expert Committee on Malaria, and the ensuing additions to the official register of areas where malaria eradication has been achieved were published in the Weekly Epidemiological Record.
WHO Training in Malaria Elimination in the Greater Mekong Sub-Region, August 2015, Chiang Mai Thailand

7. Malaria eradication and lessons learnt (cont.)
Part of the justification for a time-limited global programme was race against insecticide resistance. In reality, vectors and parasites developed resistance at an early stage;
This urgency clashed with the need for planning based on knowledge of local epidemiological, ecological and social conditions, and the need for efficient organization to carry out the Programme, which was beyond the capabilities of many endemic countries;
Acceleration of interventions at global level led to over-simplification and standardization, in conflict with the need to improve local knowledge and validate approaches.
Where success in the ‘attack’ phase was achieved, the ‘consolidation’ and ‘maintenance’ phases often proved more difficult, as decision-makers shifted financial resources to other health programmes;
In 1969, the WHA concluded that “due to various administrative, financial and technical reasons, the goal of global eradication could not be achieved at the present time.”
WHO Training in Malaria Elimination in the Greater Mekong Sub-Region, August 2015, Chiang Mai Thailand

8. Malaria eradication and lessons learnt (cont.)
The programme worked well in most of the areas with low and moderate endemicity, but it became clear by 1970 that an interruption of malaria transmission in tropical Africa is not achievable;
Nevertheless, the ensuing anti-malaria campaign was dubbed a “global” campaign, which was not true, as the core of the malaria problem in sub-Saharan Africa was left over.
This led to a misunderstanding while evaluating the programme results - malaria had not been eradicated worldwide by 1970s and it was characterized as a “failure”.
WHO Training in Malaria Elimination in the Greater Mekong Sub-Region, August 2015, Chiang Mai Thailand

9. Malaria eradication and lessons learnt (cont.)
In fact, malaria eradication campaign was a success: by 1970 about one billion of people were freed from the risk of malaria, transmission interrupted in most of the temperate belts and subtropical zones in the Americas, Asia and Europe, and malaria mortality dramatically decreased even in a number of tropical countries outside tropical Africa;
Of the 143 countries that were endemic in 1950, 37 were free from malaria by 1978, including 27 in Europe and the Americas;
In India, the annual number of malaria cases declined from an estimated 110 million in 1955 to about reported in 1965, while reported malaria mortality dropped to zero;
Sri Lanka reduced the incidence of malaria from an estimated 2.8 million cases in 1946 to 18 reported cases in 1966.
WHO Training in Malaria Elimination in the Greater Mekong Sub-Region, August 2015, Chiang Mai Thailand

10. The concept of malaria elimination
Until the late 1990s,”eradication” in relation to malaria was used in a broad sense for the global, regional, national or even sub-national level. Using present-day terminology, the malaria eradication campaign of could be seen as a series of national elimination efforts.
The distinction between eradication and elimination, unfortunately was not made explicit at the outset of “a campaign carried out to such a degree of perfection that, when it comes to an end, there is no reservoir of infection and there is no need for any measures” would be perfectly rational in relation to global eradication, but not for elimination in a particular country or geographical region, which requires continued efforts to prevent malaria re-introduction and re-establishment of transmission as a result of importation from neighbouring countries where malaria is still a problem;
Malaria elimination does not require a complete elimination of disease vectors or a complete absence of reported malaria cases in the country - imported malaria cases will continue to be detected.
WHO Training in Malaria Elimination in the Greater Mekong Sub-Region, August 2015, Chiang Mai Thailand

11. Main differences between malaria control and elimination programmes
The fundamental difference between malaria elimination and control is that:
A malaria control programme is concerned with malaria as a disease and reducing the burden of disease is a primary goal, whereas
A malaria elimination is concerned with malaria as a parasitic infection and reducing locally acquired cases and active foci of malaria to zero.
This difference is of a paramount significance, and other differences between these two types of the programmes are derived from this one.
WHO Training in Malaria Elimination in the Greater Mekong Sub-Region, August 2015, Chiang Mai Thailand

12. Main differences between control and elimination programmes
Items
Control programme
Elimination programme
Programme goal
Reduce morbidity and mortality due to malaria
Halt local transmission nationwide
Epidemiological objective
Reduce the burden of malaria
Reduce number of active foci to zero
Reduce number of locally acquired cases to zero
Transmission objective
Reduce transmission intensity
Reduce onward transmission from existing (locally acquired and imported) cases
Unit of interventions
The entire country or area-wide approach
All foci and cases (locally acquired and imported)
Minimum acceptable standard of operations
Good: reduce transmission to a level at which malaria is not longer a major public health problem
Perfect: interrupt transmission within the entire area
Duration of operations
Without limit, or until malaria disappears spontaneously
Time-bound approach to be considered to halt local transmission nationwide
Prioritization based on malariological stratification
Areas with high malaria rates of mortality, severity and morbidity as well as technical problems (drug resistance) to be addressed on a priority basis
All foci and cases, irrespective whether locally acquired and imported to be dealt with across the entire country
Programme phasing
To reduce transmission intensity/malaria burden to a level at which elimination can be considered.
Phase-in approach to move gradually from control to elimination within a country, particularly for large countries.
Integration with other health programmes and other non-health sectors
Often convenient and feasible as an integrated public health programme
Less feasible largely because elimination has a highly specific and usually time-bound objective. However, inter-sectoral collaboration is crucial for success of malaria elimination.
Economic aspects
Expenditures for malaria control are usually high
As a result of malaria elimination, expenditures substantially decreased to maintain malaria-free status and prevent re-establishment of local transmission
WHO Training in Malaria Elimination in the Greater Mekong Sub-Region, August 2015, Chiang Mai Thailand

13. Key differences in case management, disease prevention and malaria surveillance between control and elimination programmes
Items
Control programme
Elimination programme
Case management
Universal coverage of all at-risk populations with early diagnosis of symptomatic cases by RDTs or microscopy and effective treatment of all detected cases, based mainly on PCD.
ACD in high-risk groups, especially migrants
Early detection, mandatory notification, and effective treatment of all malaria cases, including asymptomatic through PCD and ACD.
All positive cases should be re-confirmed by microscopy paying particular attention to QA of microscopy.
Disease prevention
Universal coverage of all at-risk populations with LLINs or IRS and supplementary measures where appropriate (e.g. long-lasting hammock nets, larval control, repellents) with special emphasis on mobile and migrant populations
Full coverage (100%) of all populations in active foci of malaria, with a view of interrupting transmission in a focus as soon as possible
Malaria surveillance
To allow targeting of interventions, detecting of outbreaks and tracking of progress
To discover any evidence of the continuation or resumption of transmission.
To detect locally acquired and imported cases as early as possible.
To investigate and classify each case and focus of malaria.
To provide a rapid and adequate response.
To monitor progress towards malaria elimination.
To establish a national malaria elimination database.
WHO Training in Malaria Elimination in the Greater Mekong Sub-Region, August 2015, Chiang Mai Thailand

14. The present concept of transition from control to elimination as the continuum process
Progression towards malaria-free status is a continuous process, and not a set of independent stages. Countries and sub-national areas of a particular country may be situated at different points on the path towards malaria elimination: from control via pre-elimination to elimination and further to prevention of re-introduction;
The rate of progress will differ and depend on epidemiological determinants related to the affected human populations, the parasites and vectors and their interrelationships, environmental factors, the strength of health systems as well as social, demographical, political and economic realities;
Pre-elimination refers to a phase of transition from malaria control to elimination. It is characterized by building the capacities at local and national level, which are necessary for elimination. A pre-elimination programme may be launched, when a feasibility analysis has shown that elimination is a realistic objective in a country or an area.
WHO Training in Malaria Elimination in the Greater Mekong Sub-Region, August 2015, Chiang Mai Thailand

15. World Health Organization
26 April, 2017
From malaria control to elimination for low and moderate endemic countries, WHO GMP 2007: programme phases and indicative milestones
the % malaria patients among febrile patients at clinics = SPR
SPR should remain below 5% for all months of the year as reported by health facilities, and subsequently be confirmed in population-based survey in peak transmission season among people of all ages with current or recent (<24hrs) fever.
< 1 case reported per 1000 population at risk = per year
WHO Training in Malaria Elimination in the Greater Mekong Sub-Region, August 2015, Chiang Mai Thailand

16. The present concept of the control-elimination continuum
Pre-elimination
Prevention of re-introduction
Control
Elimination
WHO Training in Malaria Elimination in the Greater Mekong Sub-Region, August 2015, Chiang Mai Thailand

17. The present concept of transition from control to elimination as the continuum process
A country may decide to plan for the species-specific
elimination of one species first, and the achievement would still be a major milestone. Historically, a number of countries achieved Pf elimination , fighting malaria “in general”, whereas they failed to interrupt Pv transmission or did so years later;
Current definitions of elimination do not exclude the possibility of malaria elimination at sub-national level. Countries in which national elimination cannot be feasible at present, could consider the phase-in approach with sub-national elimination
Malaria elimination is usually undertaken as a time-bound programme, to minimize the period of intensive field operations. Even in the most ideal operational environments, a minimum period between 6-10 years required for programme zone to achieve elimination
WHO Training in Malaria Elimination in the Greater Mekong Sub-Region, August 2015, Chiang Mai Thailand

18. Recent progress towards malaria elimination
Over the past 15 years impressive accomplishments have been made in eliminating malaria in Southern Africa, Mesoamerica, Central Asia, the South Caucasus and the Asia-Pacific Region with five countries have been certified as malaria free:
1997: EMRO supported North-African initiative on malaria elimination in 5 countries (EMRO/AFRO meeting in Tunis );
2000 : EMRO included interruption of local transmission in areas with low transmission, in addition to other RBM objectives;
2002: EMRO supported Malaria elimination campaign in Socotra island (Yemen);
EMRO/EURO Conference on malaria eradication took place in Morocco that reviewed and updated the principles of malaria eradication and elimination;
: EURO “Tashkent Declaration” and a new regional strategy to eliminate
malaria in the entire Region by 2015;
: WHO Informal Consultation, Tunisia and Technical Review Meeting, to set the elimination agenda, Geneva, and EMR RC adopted resolution for malaria elimination in EMRO.
WHO Training in Malaria Elimination in the Greater Mekong Sub-Region, August 2015, Chiang Mai Thailand

19. WHO GMP consultations on malaria elimination, 2006-2008
Informal Consultation, Tunis 2006
Technical review meeting, Geneva 2008
WHO Training in Malaria Elimination in the Greater Mekong Sub-Region, August 2015, Chiang Mai Thailand

20. Regional Guidelines (EMRO & EURO) on Elimination and Prevention of Re-Introduction of Malaria, and Certification of Malaria Elimination,
ПРАКТИЧЕСКОЕ
РУКОВОДСТВО
ПО ЭЛИМИНАЦИИ
МАЛЯРИИ
ДЛЯ СТРАН ЕВРОПЕЙСКОГО РЕГИОНА ВОЗ
WHO Training in Malaria Elimination in the Greater Mekong Sub-Region, August 2015, Chiang Mai Thailand

21. WHO GMP guidelines on malaria elimination, 2007-2014
WHO Training in Malaria Elimination in the Greater Mekong Sub-Region, August 2015, Chiang Mai Thailand

22. Regional success in eliminating malaria in EURO: Tashkent Declaration on Malaria Elimination 2005-06
WHO Training in Malaria Elimination in the Greater Mekong Sub-Region, August 2015, Chiang Mai Thailand

23. Regional success in eliminating malaria in EURO: Regional Elimination Strategy 2006-2015
TO INTERRUPT TRANSMISSION OF MALARIA BY 2015 AND ELIMINATE THE DISEASE WITHIN ALL AFFECTED COUNTRIES OF THE REGION
TO PREVENT RE- ESTABLISHMENT OF MALARIA TRANSMISSION IN COUNTRIES WHERE IT HAS BEEN ELIMINATED
WHO Training in Malaria Elimination in the Greater Mekong Sub-Region, August 2015, Chiang Mai Thailand

24. Progress towards malaria elimination in EURO, 1996-2014
WHO Training in Malaria Elimination in the Greater Mekong Sub-Region, August 2015, Chiang Mai Thailand

25. Eliminating P. falciparum malaria in EURO, 2009
The transmission of autochthonous P. falciparum malaria in Tajikistan and the entire Region interrupted in 2009

26. Regional success in eliminating malaria in EURO: Regional Publications 2010-2014
WHO Training in Malaria Elimination in the Greater Mekong Sub-Region, August 2015, Chiang Mai Thailand

27. Progress made with certification of malaria elimination, 2007-2012
Five countries, namely the United Arab Emirates (2007), Morocco (2010), Turkmenistan (2010), Armenia (2011) and Kazakhstan (2012) have been certified as malaria free
WHO Training in Malaria Elimination in the Greater Mekong Sub-Region, August 2015, Chiang Mai Thailand

28. Looking ahead: Vision, Goals, Milestones and Targets for GTS for Malaria, 2016-2030
Vision: A World Free from Malaria
By 2020: Eliminate malaria from at least 10 countries in which local transmission reported in 2015
By 2025: Eliminate malaria from at least 20 countries in which local transmission reported in 2015
By 2030: Eliminate malaria from at least 35 countries in which local transmission reported in 2015
WHO Training in Malaria Elimination in the Greater Mekong Sub-Region, August 2015, Chiang Mai Thailand

29. Looking ahead
It is expected that Kyrgyzstan (transmission interrupted in 2011, and requested WHO certification in 2013) and Argentina (transmission interrupted in 2012, and requested WHO certification in 2014) will be certified by WHO in 2015 and 2016, respectively
WHO Training in Malaria Elimination in the Greater Mekong Sub-Region, August 2015, Chiang Mai Thailand

30. THANK YOU
WHO Training in Malaria Elimination in the Greater Mekong Sub-Region, August 2015, Chiang Mai Thailand