Country-Owned, Country-Driven: Perspectives from the World Health Organization on Malaria Elimination

Abstract

Malaria has infected and killed humans since long before history began recording evidence of the parasite’s pernicious influence. The extraordinary discoveries of the Plasmodium parasite by Charles Louis Alphonse Laveran in 1880, and the role of the Anopheles mosquito in transmission of the parasite to humans by Sir Ronald Ross in 1897, led to an understanding of the parasite life cycle and ultimately to the development of interventions that would interrupt disease transmission. Almost as soon as the insecticidal properties of dichlorodiphenyltrichloroethane (DDT) were discovered in 1939, the public health profession began battling to achieve a world free of malaria. That vision persists as the aim of all malariologists and, increasingly, the goal of all nations that remain endemic for malaria. This chapter recounts the history of malaria eradication and elimination efforts throughout the world and focuses on the current status of country-led and country-driven malaria elimination programs, along with the technical strategies recommended by the World Health Organization (WHO) for achievement of malaria elimination.

Appendix: Changes in Criteria for WHO Certification of Malaria-Free Status Over Time

Source document	Criteria	Reasons for changes
Expert Committee on Malaria, 6th report [52]	1. Proof that an adequate surveillance system has operated in the area for at least 3 years, in at least 2 of which no specific anopheline control measures have been carried out 2. Evidence that no indigenous cases were discovered 3. All cases detected are either imported, relapsed, induced, or introduced
Expert Committee on Malaria, 8th report [45]	Further elaborate the proof of adequate surveillance, role of passive detection system, active detection, annual blood examination rate >10%, quality of laboratory service	Definition of what constituted “adequate surveillance” and its relation to the discontinuation of vector control led to difficulties in applying the criteria
Expert Committee on Malaria, 10th report [46]	Annual blood examination rate can be less than 10%, adequacy of general health service and of the system of notification, and epidemiological follow-up should be taken into account	Recognition that general health services will be responsible for the implementation of vigilance activities
Expert Committee on Malaria, 12th report [53]	Recommended that a system of vigilance should be in place	Recognition that the risk of imported malaria always exists until the global eradication goal has been achieved
Expert Committee on Malaria, 16th report [51]	A detailed plan for vigilance activities to maintain the achieved malaria eradication that tailors to the local context should be in place and should be updated regularly to adapt to changes in receptivity and vulnerability	Recognition that the resurgence of malaria in some areas resulted largely from faulty forecasting of the general health service’s ability to maintain eradication
Malaria elimination: a field manual for low and moderate Endemic countries [20]	1. A good surveillance mechanism with full coverage of all geographical areas 2. A national malaria case register, notification, and full immediate reporting by public and private health services 3. Adequate health services for early detection and effective treatment and follow-up of imported malaria cases 4. High-quality laboratory services to diagnose malaria, based on microscopy 5. Epidemiological investigation of every malaria case 6. A national, comprehensive plan of action with continued political and financial support to carry out activities needed to prevent re-establishment of transmission 7. A system for awareness, prevention of mosquito bites, and chemoprophylaxis for travelers to prevent imported malaria 8. A central computerized geo-referenced database of cases and latest foci 9. Entomological surveillance and monitoring of insecticide resistance in areas with high receptivity 10. A functional border coordination system, wherever relevant 11. Capacity for early detection of and rapid response to epidemics 12. Sero-epidemiological surveys can support validation of the interruption of local transmission	The criteria related to surveillance after the withdrawal of vector control was deleted due to recognition that premature withdrawal of vector control would likely result in a resurgence of transmission More guidance on what constituted proof of adequate surveillance was added Emphasized a high quality of entomological surveillance as a prerequisite of certification
A Framework for Malaria Elimination [33]	1. Local malaria transmission by Anopheles mosquitoes has been fully interrupted, resulting in zero incidence of indigenous cases for at least the three past consecutive years 2. An adequate surveillance and response system for preventing re-establishment of indigenous transmission is fully functional (in particular the curative and preventive services and the epidemiological service) throughout the territory of the country	Criteria were grouped into two major categories, with additional details on the type of proof that would be required to establish each criterion. Sero-epidemiological data was not included as laboratory procedures have yet to be validated and standardized