GMAP

[Full Table of Contents]
[Executive Summary]

[Part II: The Global Strategy] PDF version

  1. Introduction to the Global Strategy
  2. Control: Overcoming malaria
    1. Scale Up for Impact: Achieving Universal Coverage
    2. Sustained Control: Maintaining Coverage and Utilization
  3. Elimination and Eradication: Achieving Zero Transmission
  4. The Malaria Research Agenda
    1. Research & Development for New and Improved Tools
    2. Research to Inform Policy
    3. Operational and Implementation Research
  5. Costs and Benefits of Investment in Malaria Control

Part II: The Global Strategy

2. Control: Overcoming Malaria

Elimination and Eradication: Achieving Zero Transmission

Key messages

  • Elimination is officially defined as reducing to zero the incidence of locally acquired malaria infection in a specific geographic area through deliberate efforts.[58]Dowdle W. The principles of disease elimination and eradication from the 1997 Dahlem Workshop. WHO Bulletin, 1998, 76 (supplement 2)
  • The RBM Partnership endorses elimination efforts in countries where appropriate, based on factors specific to the country context. For example, elimination would be more appropriate in countries:
    • that meet epidemiological criteria for low burden;
    • that lie near the natural borders of disease;
    • where the potential for reintroduction via porous borders is being managed;
    • whose leaders are politically and financially committed to elimination;
    • whose health systems and surveillance capacity are sufficient to manage an elimination program; and/or
    • where parasite and vector species and technical factors make elimination feasible.
  • The RBM Partnership encourages support of countries pursuing elimination through collection and dissemination of best-practice approaches, R&D for new tools, and funding and technical assistance by individual partners as desired.
  • Eradication, or reducing the global incidence of malaria to zero, is the long-term goal for RBM and will be achieved through progressive elimination in countries where feasible.

Since the global malaria eradication campaign ended in 1969, several countries have embarked on programs aimed at elimination, and some have succeeded in achieving or nearing that goal. For example, the Maldives, Tunisia, and most recently the United Arab Emirates (UAE) have eliminated malaria from within their borders. Successes can be credited to intense national commitment to achieving zero incidence of infection, together with coordinated efforts by partners.

More recently, a growing number of countries have adopted malaria elimination as a goal. The African Union's 2007 “Africa Malaria Elimination Campaign”, the recent declaration by Bill and Melinda Gates reinstating global eradication as a long-term objective, and its reiteration by Margaret Chan, Director General of WHO, all have reinforced goals of local elimination in some settings, as well as global eradication as a feasible long-term vision.

Elimination is a worthwhile goal in many countries today. It is epidemiologically feasible in more settings than previously thought, specifically in areas of unstable transmission, where over 1 billion people are at risk.[59]Guerra CA et al. The limits and intensity of Plasmodium falciparum transmission: implications for malaria control and elimination worldwide. PLoS Medicine, 2008, 5(2):e38.

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The RBM Partnership endorses elimination efforts in countries where it is feasible with current preventive and curative interventions, and where reintroduction from neighboring countries can be prevented or managed. The RBM Partnership also encourages partners to support countries pursuing elimination through the development of best-practice approaches, research and development of new tools, and funding of country programs by individual donors and partners as desired. This section describes the elimination stages, the recommended short- and long-term international strategy for elimination, and individual countries' approaches and challenges relating to elimination.

Elimination: A Definition, Targets, and Examples

Elimination entails reducing to zero the incidence of locally acquired malaria infection in a specific geographic area as a result of deliberate efforts, with continued measures in place to prevent re-establishment of transmission.[60]Dowdle W. The principles of disease elimination and eradication from the 1997 Dahlem Workshop. WHO Bulletin, 1998, 76 (supplement 2) After three years in this state, countries can request malaria-free certification from WHO; however, they are not required to do so.

While the RBM Partnership's long-term objective is for all countries to eventually eliminate malaria to achieve global eradication, it is premature for the Partnership to set formal international targets specifying when countries should achieve elimination. However, it is expected that 8-10 countries in the elimination stage today may be able to achieve zero locally acquired cases by 2015, with malaria-free certification at least three years later, if their current trajectory is continued.

Regional organizations also have set specific objectives regarding elimination. In 2007, the African Union launched the “Africa Malaria Elimination Campaign” to focus countries on reducing their malaria burden through universal free access to prevention and treatment interventions. Targets for 2015 are to “stop transmission” in low-transmission countries (Algeria, Botswana, Namibia, South Africa, Swaziland, Comoros, Sao Tome and Principe, and Cape Verde), while reducing malaria morbidity and mortality in high transmission countries by 75 percent.[61]Africa Malaria Elimination Campaign by the African Union Advocacy Strategy Document. African Union, April 2007.

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The Southern African Development Community's (SADC's) Council of Ministers of Health approved a regional elimination strategy, which states that by 2012 at least five SADC countries will implement elimination strategies and by 2015 at least six SADC countries will have eliminated malaria (though not achieved malaria-free certification).[62]SADC Malaria Strategic Plan. 2007. Includes Botswana, Swaziland, South Africa, and Namibia. Lesotho is already designated malariafree. While Mauritius was certified malaria-free in the mid-1970’s, a cyclone led to an outbreak. Mauritius has reported 0 locally transmitted malaria cases for several years. Achieving the elimination target by 2015 with current tools and approaches in some of these transmission settings will require intensive control (including optimal implementation of current tools), improvements in health systems, and cross-border collaboration.

Several countries have achieved success in their pre-elimination and elimination campaigns. In 2005, Morocco and Syria reported zero locally acquired malaria cases. On the other hand, some countries have experienced setbacks: the Russian Federation and Jamaica had been considered non-malarious, but subsequently experienced local outbreaks. Oman has requested malaria-free certification, but because of a recent outbreak will have to wait at least three additional years for certification. Mauritius, while still considered malarious, reported its last case in 1997.[63]See WHO website.

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According to WHO, 21 countries or territories fall within the pre-elimination and elimination stage, with an addition 6 countries in the prevention of reintroduction stage.[64]According to the WHO World Malaria Report 2008, 11 countries fall into the pre-elimination stage: Mexico, Iran, Azerbaijan, Georgia, Kyrgyzstan, Tajikistan, Turkey, Uzbekistan, DPR Korea, Sri Lanka, and Malaysia. 10 countries fall into the elimination stage: Algeria, Argentina, El Salvador, Paraguay, Egypt, Iraq, Saudi Arabia, Armenia, Turkmenistan, and the Republic of Korea. While Egypt is officially categorized in the elimination stage according to the WHO World Malaria Report 2008, its last reported case was in 1998, and the country is awaiting verification of malaria-free status to enter into the prevention of reintroduction stage. 6 countries are in the prevention of reintroduction stage: Mauritius, Jamaica, Morocco, Oman, Syria, and the Russian Federation. Country status can change. For current status, check with WHO or the country’s malaria control program.

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Additionally, according to experts in the Malaria Elimination Group (MEG),[65]The Malaria Elimination Group (MEG) is a group of over 40 experts that supports countries which are embarking, or are considering embarking on, a pathway to malaria elimination. 11 countries on the natural borders of malaria, explained later in this section, have either embarked on elimination programs or are contemplating doing so.[66]In addition to some of the countries designated pre-elimination or elimination by the WHO World Malaria Report 2008, other countries are the island nations of the Comoros, the Philippines, Sao Tome and Principe, Solomon Islands, and Vanuatu; Asian countries of Bhutan and China, as well as the sub-Saharan African countries of Botswana, Namibia, South Africa, and Swaziland.

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Elimination Readiness

Several factors indicate when countries are ready to begin to pursue elimination as a goal. The RBM Partnership recommends that countries assess their own readiness on the basis of the combination of factors most relevant to their situation. Although there is no agreed-upon set of criteria that definitively determine a country's readiness, experts agree that initiation of an elimination campaign must be driven by the country.[67]Based on experts present at the RBM Working Group Consultation Meeting, Washington DC, April 2008. Furthermore, every successful national elimination effort requires significant political will to focus on malaria elimination over the long term, as well as significant financial commitment. Below are some of the key considerations in the quest for elimination. Please note that this list is neither exhaustive nor intended to serve as a checklist.

Epidemiological milestones. WHO recommends indicative epidemiological milestones for determining when a low- or medium-transmission country has an incidence low enough to begin the rigorous surveillance required during elimination. When the slide positivity rate (SPR) of all febrile patients with suspected malaria is less than 5% or the incidence is less than 5 per 1000 people at risk[68]A "manageable" case load for the intensive follow-up required per case during this phase. , the country, or district in some cases, could consider transitioning into “pre-elimination” if other factors are in place as well. The ability of a country to measure and know definitively its incidence rate is in itself an indication of the country's readiness to enter pre-elimination. This is the stage where the control program reorients itself to further emphasize surveillance, reporting and information systems. (For more details, see Malaria Elimination: A Field Manual for Low and Moderate Endemic Countries. Geneva, World Health Organization, 2007).

Figure II.10: Epidemiological milestones

Source: “Malaria Elimination: A Field Manual for Low and Moderate Endemic Countries” WHO 2007

According to Figure II.10, after program reorientation enables a country to achieve an incidence rate of less than 1 per 1000 people-at-risk, the country enters into the elimination stage. Here the goal is to halt local transmission and eliminate foci. Once surveillance shows a reduction of locally acquired cases to zero (all remaining malaria cases being positively identified as from imported origin), the program enters the “prevention of reintroduction” stage. A country can be declared malaria-free by the WHO after proving there has been no local transmission for at least three years.

The milestones prior to zero incidence are not rigid, but rather serve as guidelines to indicate when a country might be able to aggressively monitor and track every case. The incidence level at which it would be appropriate to transition between stages may vary, depending on each country's situation. For example, if a country in pre-elimination has more than 1 case per 1,000 people-at-risk per year, but the cases are very concentrated and easily tracked and treated, the country may be able to move into elimination. On the contrary, if another country has less than 5% slide positivity rate (SPR), but the cases are widespread and difficult to track, that country may want to wait until it achieves an even lower incidence or improves its readiness systems before considering an aggressive pre-elimination campaign.

Formerly or naturally high transmission areas that have achieved a low incidence thanks to successful control efforts are encouraged to enter a “consolidation phase” between sustained control and elimination. During this period, the area sustains its gains while assessing the feasibility of reorienting its program to elimination. Once feasibility is confirmed, the country is encouraged to move into pre-elimination.

Malarious borders. Another criterion on which a country's ability to eliminate malaria is assessed is its location relative to the endemic borders of the disease. Many countries along the geographic borders of the endemic zone are more likely to eliminate malaria with today's tools due to latitude, altitude, climate, and other factors making transmission less efficient and malaria less prevalent.[69]Feachem R, Sabot O. A new global malaria eradication strategy. The Lancet, 2008, 371: 1633.

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The edges of endemic regions have lower vulnerability to reintroduction of malaria due to fewer malarious borders, minimizing chances for reintroduction compared to areas surrounded by malaria. For example, historically elimination in the United States was the precursor to beginning elimination in Mexico, as elimination in South Africa today prepares the way for elimination in Zimbabwe and Mozambique.

For today's highest-burden countries to eventually embark on elimination, it will be necessary for elimination to have occurred in many of the countries at the endemic borders. Shrinking the malaria map is an important dimension of moving toward elimination in the heartland and eventually to global eradication.

If incidence levels of neighboring countries are significantly higher, a country should initiate cross-border initiatives where appropriate or wait until its neighbors have controlled malaria to avoid risk of reimportation. For example, Rwanda has reached low incidence levels, but because it is surrounded by countries with high transmission rates and low control, elimination would likely not be sustainable. Cross-country collaboration can help achieve sustainable malaria control and elimination.

Strength of health systems and surveillance. Countries must also have strong surveillance systems to facilitate immediate detection, notification and response to all foci as well as outbreaks, epidemics, and individual malaria cases. Such systems work in tandem with strong health systems and developed infrastructure to enable appropriate preventive measures (e.g. spraying in foci) and prompt case management (including appropriate diagnosis with microscopy, treatment with ACTs, and follow-up of each case). This includes having skilled human resource capacity to effectively manage and deliver programs. Many experts recommend that countries not attempt elimination until the intensive surveillance systems needed to track each case are place.

Population movement. Countries with porous borders, as well as islands that experience an influx of people from high transmission settings, are continuously at risk for reimportation of malaria. In these situations, countries need to institute initiatives addressing foreign carriers before embarking on elimination campaigns. Such initiatives could include malaria screening at borders or ports of entry, as is the case with Oman and the airport screening of foreigners from malaria-endemic regions.

Parasite species.[70]Lines J, Whitty CJM, Hanson, K. Prospects for Eradication and Elimination of Malaria: A Technical Briefing for DFID. December 2007. In regions with P. falciparum, but where P. vivax is the predominant species (e.g. the Middle East), elimination of P. falciparum is likely achievable with current tools. While P. vivax elimination has been achieved in some settings (e.g. in the United Arab Emirates), it may require different tools and approaches to reach this goal in other settings. Countries with both species must also consider the relative increase in P. vivax cases once P. falciparum has been eliminated.

Intervention effectiveness in targeted area.[71]Lines J, Whitty CJM, Hanson, K. Prospects for Eradication and Elimination of Malaria: A Technical Briefing for DFID. December 2007. Some areas have factors such as drug and/or insecticide resistance or vectors with outdoor and/or early biting, which make current interventions less effective and elimination more difficult (e.g. in Southeast Asia). New and improved interventions may be needed for elimination to be feasible in these settings.

Country commitment. As introduced above, countries must assess their own readiness to undertake an elimination campaign. To be successful, countries should demonstrate success of prior control efforts and experience significant decreases in incidence. However, it is critical that governments understand and are committed to an elimination campaign from a financial and policy/regulatory standpoint over the long term, even when changes are not so drastic. That commitment includes collaboration across several ministries including health, finance, agriculture, industry and education.

In tandem with commitment, countries should consider the portfolio of health problems they are facing and their ability to tackle multiple issues simultaneously. They may need to determine new ways to justify high levels of spending on malaria, which by this time accounts for only a few cases, when other diseases still comprise significant morbidity and mortality in the country.

Elimination Program Components[72]Malaria Elimination: A Field Manual for Low and Moderate Endemic Countries. Geneva, World Health Organization, 2007.

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Once a country has decided to move forward with an elimination campaign, the country must maintain the improvements achieved in sustained control while reorienting the health system toward elimination. The challenges to elimination should not be underestimated. Reorientation requires developing or strengthening several program elements, particularly surveillance and responsiveness to malaria cases.

Surveillance. The cornerstone of a successful elimination campaign is strong surveillance of foci and disease. WHO recommends the creation of an elimination database during the pre-elimination stage to aid in the efficient monitoring and reporting of malaria cases. Additionally, a national register of foci should be set up to organize information relating to the identification, treatment and monitoring of foci and potential outbreaks.[73]Malaria Elimination: A Field Manual for Low and Moderate Endemic Countries. Geneva, World Health Organization, 2007.

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More details regarding specific surveillance activities are listed in the “Vector Control” and “Case Management” sections below.

Vector control in active foci. All foci should be identified and intensely monitored for potential malaria transmission. Targeted, customized vector control interventions should be used to control outbreaks and protect areas receptive to transmission, including areas exposed to importation of malaria parasites.[74]Malaria Elimination: A Field Manual for Low and Moderate Endemic Countries. Geneva, World Health Organization, 2007.

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In many areas, current interventions such as long-lasting insecticidal nets, indoor residual spraying, and larviciding would be appropriate.

In areas of outdoor and/or early biting (e.g. forest fringe areas), traditional interventions such as LLINs are not as effective but can still be employed. Further operational research is needed to understand best approaches for elimination in these and other areas with challenging technical situations such as pesticide resistance. R&D for new tools in these situations will also be beneficial.

Case detection and management. All people who carry malaria parasites need to be identified and treated to reduce transmission. Entire populations, including nationals, migrants and citizens of neighboring countries, should have access to timely malaria diagnosis and treatment. All suspected cases of malaria should be confirmed through parasite-based diagnosis. WHO recommends microscopy for confirmation of parasitaemia. Prophylaxis should be readily available for residents who travel abroad to malarious areas.

Changing epidemiology due to successful sustained control efforts will have an impact on case management strategies. Previously high transmission districts which may have been organized to target populations under 5 (as these carried most of the burden), will have to reorient their program as more adults (who will have less and less immunity) get the disease. Another consideration is that reduced immunity could lead to a higher percentage of cases turning into severe cases, making immediate detection even more important.

Although not recommended by WHO, Mass Drug Administration (MDA) has been attempted in the past with mixed outcomes. In some instances, it has had poor long-term results and undesired consequences, including exacerbation of drug resistance. However, some believe that MDA can be used effectively to eliminate parasites in asymptomatic carriers. For instance, primaquine is used for mass chemoprophylaxis in DPR Korea against P. vivax. More operational research is needed to determine when and where MDA is appropriate and which drugs work best while minimizing resistance.

National steering committees. Countries may want to consider organizing a national malaria committee to oversee and guide progress towards elimination goals.[75]Malaria Elimination: A Field Manual for Low and Moderate Endemic Countries. Geneva, World Health Organization, 2007.

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This should be separate from the National Malaria Control Program, which manages day-to-day program operations and implementation of the elimination campaign. One of the key responsibilities of the committee could include the ongoing monitoring and evaluation of the program against objectives, and revising overarching strategies to fit changing epidemiological settings. A second key responsibility would be to ensure the continued financing and support for the elimination campaign.

Optimizing public and private sector roles. While the private sector often plays a crucial, albeit less formal, role during the scale-up and sustained control stages, more formal integration with the national control program is necessary to ensure that all cases are identified and responded to appropriately. Countries should consider ways to involve the sectors that are most effective for delivering malaria control (for example, outsourcing elements of the program to the private sector when appropriate). Countries should strive to ensure full reporting of all malaria cases to one centralized source: WHO recommends that final reporting be maintained within the public sector. An example of a successful public-private sector collaboration enabling central reporting is Oman. The government in Oman requires all malaria treatment to be provided by the public sector for tracking purposes.[76]Dr. Majed S. Al-Zedjali, Director, Directorate of Malaria Eradication, Ministry of Health, Oman, personal communication, 2008. Although many people are still diagnosed in the private sector, they are then referred for treatment to a public-sector facility, which is thereby able to conduct the appropriate surveillance and reporting.

Advocacy and IEC / BCC[77]Information, Education and Communication/Behavior Change Communication. to combat elimination fatigue. As is the case with sustained control, political fatigue is one of the most difficult challenges to overcome. During elimination, malaria is no longer a public health burden, but it still requires significant financial and human resources. Gaining the political support to provide significant funding despite minuscule reductions in incidence, especially when other diseases such as HIV/AIDS and tuberculosis may have high burdens, will be challenging. International and national advocacy will be essential to set expectations regarding the duration and challenges of elimination (including the risks of relaxing control), and to help government leaders and donors understand the importance of maintaining support.

As with government leaders, support among populations at risk for malaria control may also dwindle as the burden declines. As cases become rarer, the use of preventive measures (LLINs and IRS) and the prompt detection and reporting of new cases may decrease. Significant communication and education are necessary to ensure that populations understand the ongoing risk and support case management activities while malaria is still present.

Similarly, educational programs and continuous re-training of health workers will also be necessary to ensure health workers are well versed in preventive and curative measures. Particularly essential is the continuing ability to rapidly diagnose malaria through microscopy and / or RDTs, and provide the recommended treatment, particularly when cases are rare. Ensuring workers have constant access to diagnostic tools and drugs for immediate treatment is part of this.

Cross-border initiatives to lower the risk of reintroduction. Another major challenge to sustaining elimination is addressing the potential reintroduction of cases, either via border areas or from migrant populations. Although the United Arab Emirates has achieved elimination, vigilant surveillance is necessary to minimize re-importation via immigrants from Pakistan and India. Continued arrival of cases from mainland Tanzania has kept Zanzibar from maintaining low incidence levels in the past, and re-importation of cases is also seen on South Africa's border with Zimbabwe and Mozambique.

It is important to take a two-pronged approach, focusing both internally (on cases that have been imported) and externally (on cross-border initiatives). Oman has been able to reduce imported cases through mass screening of individuals arriving at the airport from East African countries;[78]Dr. Majed S. Al-Zedjali, Director, Directorate of Malaria Eradication, Ministry of Health, Oman, personal communication, 2008. those who test positive are treated for free and monitored for two weeks. Both Oman and the United Arab Emirates provide free treatment to everyone who tests positive, whether they are nationals or foreigners.

While cross-border collaboration should be considered early in the control process, its importance in managing re-importation is highly evident in the elimination stage. This is particularly critical in areas with significant population movement from areas of high transmission intensity. One example of a cross-border initiative is the Lubombo Spatial Development Initiative (LSDI), initiated in 1999 among South Africa, Swaziland, and Mozambique. The LSDI has since pushed the frontiers of malaria almost completely out of Swaziland and South Africa; an area in KwaZulu-Natal that previously had a malaria prevalence of over 90 percent now reports 0.89 percent. In addition, significant reductions in malaria prevalence have been achieved in southern Mozambique.[79]Presented by Rajendra Maharaj, Trans-Zambezi RMCC Meeting, January 2008.

Another example is the Korean peninsula. Malaria was eliminated from the Korean peninsula in the 1970's but re-emerged in the Democratic People's Republic of Korea (DPR Korea) due to changing agricultural practices and energy problems.[80]Update on WHO in DPR Korea. Geneva, World Health Organization, November 2003. Malaria then spread south to the Republic of Korea. The Republic of Korea instituted early case detection and mass chemoprophylaxis for soldiers, as well as financial contributions to DPR Korea and other support facilitated by China. As a result both countries have seen dramatic reductions in incidence.[81]Han ET et al. Reemerging vivax malaria: changing patterns of annual incidence and control programs in the Republic of Korea. Korean Journal of Parasitology, December 2006, Vol. 44, No 4: 285-294.

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Other cross-border initiatives include China's Global Fund Round 6 program with Myanmar, the collaboration between Bhutan and India, and between Bhutan and China, the WHO Mekong Malaria Programme (a cooperation of all 6 Greater Mekong Subregion countries), the cooperation between Cambodia and Thailand to contain artemisinin tolerance in the border area, and the Pacific Malaria Initiative involving Papua New Guinea, Solomon Islands and Vanuatu.

Prevention of Reintroduction [82]Malaria Elimination: A Field Manual for Low and Moderate Endemic Countries. Geneva, World Health Organization, 2007.

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Preventing reintroduction of malaria, particularly cases that lead to re-establishment of local transmission, is key to sustaining elimination efforts. As mentioned earlier, Mauritius, Jamaica, Morocco, Oman, Syria, and the Russian Federation currently fall within this stage.

If an area's receptivity[83]Even if receptivity alone is zero, risk of reintroduction is zero. and vulnerability to malaria is zero, the probability of reintroduction of malaria is zero. However, risk varies across regions and can change seasonally or with other factors such as population movement and development projects (such as irrigation projects, mining, and forest clearing) that create favorable conditions for vectors and increase human-to-vector contact.

Prevention programs must therefore be geared specifically to each region. Suggested actions based on regional characteristics are detailed in the WHO publication "Malaria Elimination: A Field Manual for Low and Moderate Endemic Countries." Key findings are described in Table II.1:

Table II.1: Suggested actions for prevention of reintroduction programs


Regional characteristic Suggested actions
Areas of low receptivity and vulnerability Use early case detection, epidemiological investigation of every case and appropriate curative and preventive measures
Areas of increasing levels of receptivity and vulnerability Conduct activities recommended for areas of low receptivity and vulnerability, and consider active case detection
Areas of high vulnerability Continued use of vector control measures (IRS, LLINs, or larviciding)

Source: Malaria Elimination: A Field Manual for Low and Moderate Endemic Countries, WHO


Preventing reintroduction is the responsibility of the general health services in collaboration with other relevant sectors (e.g. agriculture, environment, industry, tourism). A country's success in maintaining zero locally acquired transmission for at least three consecutive years is required for WHO malaria-free certification.

Eradication

Eradication is the permanent reduction to zero of the global incidence of infection caused by Plasmodia as a result of deliberate efforts, so that intervention measures are no longer needed.[84]Dowdle W. The principles of disease elimination and eradication from the 1997 Dahlem Workshop. WHO Bulletin, 1998, 76 (supplement 2) Malaria will be eradicated when transmission of all four types of human malaria in every country of the world ceases.

As stated in Part I – Chapter 2: The RBM Partnership's Vision and Targets, malaria eradication is the long-term goal of the RBM Partnership. This will be achieved through the three-part strategy detailed in Part II: The Global Strategy, which includes 1) Controlling malaria, 2) Eliminating malaria, and 3) Research into new tools and approaches. While this does not mean that resources flow equally to the three parts of the strategy simultaneously, it does mean that every part is essential and needs adequate investment and attention.

Once elimination is proven possible in all countries, the international community will assess the feasibility of a global eradication campaign to assist the last countries in achieving elimination. This will be helpful to garner the financial and political support needed to sustain the campaign until malaria is officially eradicated.

International Strategy to Support Elimination and Eradication

To support its long-term goal of eradication, the RBM Partnership encourages individual countries where malaria elimination is feasible today to move toward elimination. This stance includes endorsement of the financing and support of these efforts by individual partners if so desired. Countries nearing elimination today will be an important source of evidence concerning the programmatic and scientific challenges and solutions in elimination programs, which will benefit all countries. Organizations are beginning to support these efforts. The Malaria Elimination Group (MEG), mentioned earlier, is one group supporting countries with intellectual and practical guidance to assist with the embarking on or consideration of embarking on a malaria elimination program. MEG will produce A prospectus on malaria elimination in 2009 which will contain a collection of information relevant for countries and partners interested in malaria elimination.

The RBM Partnership will increase its direct involvement in elimination and eradication work post-2010 and when most countries have achieved their coverage targets. Suggested roles are described in Part IV: The Role of the RBM Partnership, but will be defined more specifically in the future, and will be based on elimination practices and knowledge gaps that will be identified.

The high-level list of activities below details some of the elimination priorities during the short term for RBM partners.

Research for new tools. Most experts agree that elimination is not feasible in all settings with current tools and approaches. In order to maximize chances for achieving elimination across a variety of countries and settings, several gaps need to be filled. New tools, including vaccines, interventions targeting P. vivax, and those that interrupt transmission, will be needed to achieve elimination in all transmission settings. Part II - Chapter 4: The Malaria Research Agenda discusses R&D for new tools more specifically.

Research for elimination strategies and approaches. Research into multiple elimination approaches across a variety of transmission and geographical settings will be necessary to gain greater understanding of programmatic and scientific challenges and solutions. Mechanisms for sharing best practices should also be instituted, so that best practices can be used by other malarious countries embarking on elimination campaigns and by the international partners supporting those efforts.

Research should also be undertaken to help define priority areas where dramatic reductions in malaria would benefit the global community for public-good reasons (e.g. areas where historically initial onset of resistance has been seen). See Part 2 - Chapter 4: The Malaria Research Agenda for more specific information on research for elimination strategies and approaches.

Advocacy and education for elimination. Advocacy and education about elimination campaigns should be coordinated. This includes the dissemination of information regarding elimination feasibility and best practices, as well as increasing awareness of elimination strategies, challenges and country readiness. See Part IV - Chapter 2: Advocacy for more information

Technical support for elimination efforts. As knowledge of elimination is being generated, technical support will likely be of great benefit to countries in elimination campaigns. This effort would include on-the-ground support for all elements of the program (surveillance, reporting, mechanisms for case detection, etc.), as well as feasibility and cost-effectiveness studies prior to starting a program. Documentation of these experiences, along with the operational research proposed above, will be a valuable resource for countries beginning elimination campaigns in the future.

Funding for elimination efforts. Elimination will be costly. International funding support will be needed not only by some of the countries choosing to pursue elimination, but also to support the global support activities listed above: R&D, operational research, advocacy, and technical support. New financing mechanisms that support and facilitate regional and cross-border initiatives will also be needed. See Part IV - Chapter 3: Resource Mobilization and Part IV - Chapter 6: Financing for more information.