The Roll Back Malaria strategy of Scaling Up for Impact through universal coverage with effective interventions,1 supported by an increase in malaria funding,2 has achieved low rates of malaria transmission in some areas and consequently a much reduced disease burden.3, 4 Some countries, including several with historically medium-to-high transmission, are nearing a state of controlled low-endemic malaria,5 and policy makers have a decision to make: accept low rates of malaria transmission with a strategy of consolidation of control6 or redirect activities with the aim to eliminate malaria.
During the Global Malaria Eradication Program (GMEP), WHO Expert Committee reports described specific activities of an elimination programme through its defined phases, and provided advice based on years of experience from field campaigns.7, 8, 9, 10 Since the 1970s, when WHO shifted the short-term strategic aim to control11 and relegated eradication to a long-term goal, there has been little scientific inquiry into or strategic thought about the theory, goals, and best approaches for national elimination. At the same time, many countries considering elimination nowadays have higher intrinsic transmission potential than do those that eliminated malaria during the GMEP and have to plan to maintain elimination despite continual importation of infections. Accordingly, the decision to move from controlled low-endemic malaria to elimination needs politicians, policy makers, and programme managers to have an informed understanding of the operational requirements for a contemporary elimination strategy so that they can set realistic goals and timelines that are relevant to malaria epidemiology nowadays.
The decision to convert a malaria programme that has successfully achieved a high level of control, such that malaria is no longer a major public health problem, into an elimination programme is complex12, 13 and should take into account technical, operational, and financial feasibility.14 There is a broad consensus about the strategies that are needed to achieve controlled low-endemic malaria, which are based on universal coverage with prevention and treatment measures—all of which have a strong evidence base from empirical trials, observational studies, and routine monitoring and evaluation.1, 3, 15, 16, 17, 18 However, elimination cannot be achieved by doing more of the same; transition from sustaining control to elimination demands additional activities. In the third paper in this Series, we review the activities needed to achieve and maintain malaria elimination in areas that have already reduced transmission to very low rates by identification of the essential operational changes that have to accompany a switch in focus from burden reduction to interruption of transmission. In doing so, several important knowledge gaps are identified that, in some cases, makes it challenging to provide evidence-based guidance about how to eliminate malaria.
Key messages
- •
The most important operational difference between a control and an elimination programme is the concentration of activities to identify and attack foci of clinical and asymptomatic infections that perpetuate transmission
- •
Detection and curing of the high proportion of infections needed to interrupt transmission requires a robust surveillance system that combines passive and active case detection methods with rapid response, with radical treatment and targeted vector control
- •
Most malaria-endemic countries considering elimination should aim to prevent importation of infections through proactive case detection at the border, screening of high-risk migrants, and implementation of cross-border and regional initiatives that can reduce transmission at the source of migration
- •
Because elimination has a known quantitative goal to end endemic transmission and reduce the number of locally acquired cases to less than a specific threshold, monitoring systems incorporating extremely sensitive laboratory techniques such as PCR, genotyping, and serology have to be put in place to track progress
- •
Malaria elimination cannot be business as usual, but needs a systemic and new programmatic approach supported by political and financial commitment, ideally throughout an entire region of nations