A framework for malaria elimination Dr Pedro Alonso, GMP Director
Rationale for new elimination framework The malaria landscape has changed dramatically since 2007 Increased funding Large-scale implementation of interventions Impressive reductions in burden Increasing number of countries eliminating or considering elimination Changes in policy recommendations and available tools Development of new Global technical strategy for malaria (GTS) 2016-2030
Malaria elimination reflected in GTS structure
GTS vision: A world free from malaria Global Technical Strategy (GTS) goals, milestones, and targets Goals Milestones Targets 2020 2025 2030 1. Reduce malaria mortality rates globally compared with 2015 2. Reduce malaria case incidence globally compared with 2015 >40% >75% >90% >40% >75% >90% 3. Eliminate malaria from countries in which malaria was transmitted in 2015 At least 10 countries At least 20 countries At least 35 countries 4. Prevent re-establishment of malaria in all countries that are malaria-free Re-establishment prevented Re-establishment prevented Re-establishment prevented
Key changes from 2007 field manual Framework addresses all malaria-endemic countries Programme actions are highlighted across the continuum of transmission, from high to very low/zero Elimination feasibility replaced by critical requirements to achieve and maintain elimination Critical role of information systems and surveillance as an intervention Planning for next step has to be done early RDTs and light microscopy recommended for malaria diagnosis Simplified focus classification Updated strategies for different transmission intensities (e.g. MDA) Emphasis on the verification of malaria elimination at the subnational level on the way to national certification of malaria elimination Streamlined process for WHO certification of malaria elimination Clarified threshold for re-establishment of transmission
Overview of A Framework for malaria elimination 2017
WHO definition of malaria elimination Malaria elimination: the interruption of local transmission (reduction to zero incidence of indigenous cases [vs locally acquired]) of a specified malaria parasite species in a defined geographic area as a result of deliberate efforts. Continued measures to prevent re-establishment of transmission are required. [Certification of malaria elimination in a country will require that local transmission is interrupted for all human malaria parasites.]
Which settings are targeted? All countries should work towards the ultimate goal of malaria elimination, regardless of their malaria burden The previous concept of elimination feasibility has been replaced by critical requirements for all countries to achieve and maintain elimination. Suggested programme actions are highlighted across the continuum of malaria transmission intensity, from high to very low or zero.
Indicative metrics for transmission intensity Transmission intensity High Moderate Low Very low Zero Annual parasite incidence (API) of ~ 450 cases per 1,000 P. falciparum prevalence rate of 35% API of 250 450 cases per 1,000 Prevalence of P. falciparum/p. vivax malaria of 10 35% API of 100 250 cases per 1,000 Prevalence of P. falciparum/p. vivax malaria of 1 10% API of < 100 cases per 1,000 Prevalence of P. falciparum/p. vivax malaria > 0% but < 1%
Local stratification by transmission intensity Most countries have diverse transmission intensity National maps should be stratified into discrete areas based on receptivity and transmission characteristics. Stratification allows for better targeting and improved efficiency of malaria interventions.
Illustrative intervention packages There is no one size fits all strategy National malaria programmes should determine the appropriate package of interventions for an area based on the stratification of transmission intensity, as well as a good understanding of the epidemiological, ecological and social features of an area. Interventions should be adapted and tailored to specific geographical areas within a country.
Illustrative intervention packages The following set of recommended interventions have been identified for deployment and enhancement over time as malaria transmission intensity is systematically reduced: A: Enhancing and optimizing vector control and case management B: Increasing the sensitivity and specificity of surveillance C: Accelerating transmission reduction D: Investigating and clearing individual cases
Illustrative intervention packages
What else is new?
Simplified classification of foci To facilitate programme planning, there are now three instead of seven types of foci: active, residual non-active or cleared. Malaria foci: A defined and circumscribed area situated in a currently or formerly malarious area that contains the epidemiologic and ecological factors necessary for malaria transmission. Type of focus Active Definition A focus with ongoing transmission Operational criteria Locally acquired case(s) have been detected within the current calendar year. Residual non-active Cleared Transmission interrupted recently (1 3 years ago) A focus with no local transmission for more than 3 years The last locally acquired case was detected in the previous calendar year or up to 3 years earlier. There has been no locally acquired case for more than 3 years, and only imported or/and relapsing or/and recrudescent cases or/and induced cases may occur during the current calendar year.
Diagnostic testing in elimination settings All suspected malaria cases should be tested with rapid diagnostic tests (RDTs) or light microscopy RDTs should be available at all levels in health facilities and community services, while quality-assured microscopy should be available in hospitals and designated laboratories. RDTs and microscopy can be used to detect almost all symptomatic infections and many, but not all, asymptomatic infections. More sensitive methods, such as polymerase chain reaction (PCR) and other molecular techniques are not recommended for routine case management or surveillance.
WHO certification of elimination Certification of malaria elimination requires proof that: local malaria transmission has been fully interrupted, resulting in zero incidence of indigenous cases for at least the three past consecutive years, and an adequate surveillance and response system for preventing re-establishment of indigenous transmission is fully functional throughout the country.
Preventing re-establishment of transmission A minimum indication of possible re-establishment of transmission would be the occurrence of three or more indigenous malaria cases of the same species per year in the same focus, for three consecutive years. Imported, introduced and indigenous cases
Streamlined national certification process The 2017 framework introduces a streamlined process for WHO certification of malaria elimination: Country submits official request for certification after 3 years with zero indigenous cases Country formulates plan of action and timeline with WHO Country finalizes national elimination report and submits to WHO Certification Elimination Panel (CEP) verifies findings CEP develops and submits final report to WHO Malaria Policy Advisory Committee (MPAC) with recommendation to certify now or postpone WHO MPAC makes final recommendation to WHO Director-General WHO Director-General makes final decision and officially informs the national government
Subnational verification of elimination Subnational verification of elimination is now an option for large countries that have interrupted local transmission in certain parts of the country Subnational verification can be an important building block for future national certification. It is led by countries and should be as rigorous as the WHO national-level certification scheme, using the same criteria for documentation, validation, and assessment. Independent national malaria elimination advisory committees should help monitor and verify work, document progress, and strengthen political support.
Countries certified as malaria-free by WHO GTS targets 20 countries 35 countries 1955 1972 1987 2007 None 7 countries and 1 territory 2015 10 countries (2016: Kyrgyzstan and Sri Lanka) Global Malaria Eradication Programme : 15 countries and 1 territory 2020 2025 2030 5 countries (Armenia, Maldives, Morocco, Turkmenistan and United Arab Emirates)
Thank you