Dr Pedro Alonso, Director of the Global Malaria Programme and Dr Gawrie Loku Galappaththy, Medical Officer, Elimination Unit, Global Malaria Programme
The malaria landscape has changed significantly since the first framework for malaria elimination was released in 2007. Over the last 10 years, funding has increased, access to core malaria interventions has improved, new tools and strategies have been developed, and the malaria burden has dramatically decreased, putting more countries on the path to elimination.
In May 2015, the World Health Assembly adopted a new Global Technical Strategy for Malaria 2016–2030, a landmark document that sets ambitious new goals for the malaria community. All of these advances have led to new global guidance and policy recommendations by WHO, which are reflected in the new WHO Framework for malaria elimination.
2007 framework was intended for countries with low to moderate malaria transmission, and provided guidance for countries to assess whether or not malaria elimination was a feasible goal. But this concept of feasibility created a dichotomy that is no longer seen as useful: we think that every country can achieve elimination.
While it is true that elimination is a longer-term goal for countries with a high malaria burden, it is still the ultimate end goal. Instead of asking if a country can achieve elimination, the new framework outlines the critical requirements needed to achieve and maintain elimination at every level of malaria transmission intensity in every endemic country.
Malaria transmission can vary widely within a country. To be effective, programmes must select strategies and tools that are appropriate for the malaria situation in a targeted geographic area. The new framework facilitates this planning by identifying recommended programmatic actions along the continuum of malaria transmission, from high transmission to very low.
Areas with high malaria transmission intensity, for example, should focus on scaling up vector control and universal access to diagnosis and treatment, while strengthening surveillance systems as they go. In areas where transmission is very low, elimination activities can be accelerated and additional new methods can be applied. When an area is very close to having zero malaria cases, any cases that do occur should be investigated to clear remaining areas of infection.
Our framework is now aligned with the three pillars of the Global Technical Strategy for Malaria 2016–2030: ensuring universal access to malaria prevention, diagnosis and treatment; accelerating efforts towards elimination and attainment of malaria-free status; and transforming malaria surveillance into a core intervention. Surveillance in particular plays a key role in the fight against malaria, and this is highlighted throughout the document. Elimination cannot be achieved without quality surveillance systems.
Other updates include an overview of the requirements for achieving and maintaining elimination, such as national surveillance systems, quality data management, and robust human and financial resources.
There is a new, streamlined process for WHO certification of malaria elimination, which occurs after a country has had three years without a locally transmitted case of malaria. We’ve also introduced the concept of subnational elimination, which is particularly relevant for large countries like China, Mexico, and Brazil. The framework offers guidance on setting targets and systems to verify malaria-free areas within a country’s borders, which can be an important building block for future national certification. This will help countries document and motivate progress.
This framework is primarily intended for malaria programme managers to inform the development of national strategic plans for malaria elimination. It’s important to mention that this is a framework, not a prescriptive document. The recommended actions and interventions can and should be adapted according to national and sub-national needs.
Several countries and regions have eliminated malaria, including Sri Lanka, Maldives, Kyrgyzstan, and the European region. WHO has now recognized an additional 21 countries that are on track to reduce malaria transmission to zero by 2020, and is supporting these countries to reach this target. Even high burden countries have started thinking about elimination. It’s a good trend, and helps put us on the right track to achieving global elimination of the disease.