Operational strategies to achieve and maintain malaria elimination

Bruno Moonen, Justin M Cohen, Robert W Snow, Laurence Slutsker, Chris Drakeley, David L Smith, Rabindra R Abeyasinghe, Mario Henry Rodriguez, Rajendra Maharaj, Marcel Tanner, Geoffrey Targett, Bruno Moonen, Justin M Cohen, Robert W Snow, Laurence Slutsker, Chris Drakeley, David L Smith, Rabindra R Abeyasinghe, Mario Henry Rodriguez, Rajendra Maharaj, Marcel Tanner, Geoffrey Targett

Abstract

Present elimination strategies are based on recommendations derived during the Global Malaria Eradication Program of the 1960s. However, many countries considering elimination nowadays have high intrinsic transmission potential and, without the support of a regional campaign, have to deal with the constant threat of imported cases of the disease, emphasising the need to revisit the strategies on which contemporary elimination programmes are based. To eliminate malaria, programmes need to concentrate on identification and elimination of foci of infections through both passive and active methods of case detection. This approach needs appropriate treatment of both clinical cases and asymptomatic infections, combined with targeted vector control. Draining of infectious pools entirely will not be sufficient since they could be replenished by imported malaria. Elimination will thus additionally need identification and treatment of incoming infections before they lead to transmission, or, more realistically, embarking on regional initiatives to dry up importation at its source.

Copyright © 2010 Elsevier Ltd. All rights reserved.

Figures

Figure 1
Figure 1
Effect of passive case detection on transmission is limited by a cascade of factors The percentage of infections identified through passive case detection depends on the proportion of new infections that produce clinical symptoms, the proportion of clinical cases that seek treatment in a reporting facility, the proportion of treatment-seeking cases that are tested for malaria, and the sensitivity and quality (performance) of diagnostic tests. Furthermore, the effect of passive case detection on transmission will depend on the proportion of infections identified by diagnostics that are prescribed and receive appropriate treatment, the proportion of those receiving treatment that adhere to it, and the efficacy of the drug.
Figure 2
Figure 2
Residual malaria transmission foci in the states of Oaxaca and Chiapas, Mexico Localities are depicted as dots; blue dots indicate localities where transmission has been interrupted.
Figure 3
Figure 3
Residual transmission focus in southern Oaxaca state, Mexico The annual parasite index (API) is depicted by municipality. Localities are shown as dots with risk of transmission from low to high.

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