The document discusses global progress towards malaria elimination. It notes that WHO plays four key roles in malaria control including setting evidence-based policies and guidelines. It then provides regional summaries of malaria elimination efforts. Several countries in multiple WHO regions have achieved elimination or are making progress towards elimination goals through strengthened control programs and surveillance. However, malaria remains endemic in many countries, particularly in Africa, and continued efforts are needed to work towards global elimination targets.

1. Malaria Elimination: Global Picture
The Science of Eradication: Malaria
Boston
8 June 2012
Robert D. Newman, MD, MPH
Director, Global Malaria Programme

2. WHO Global Malaria Programme:
four key roles
I II
Set, communicate and Keep independent score
promote the adoption of of global progress
evidence-based norms, I
standards, policies, and
II
guidelines
Chart the
course for
malaria
control
IV
& elimination III
IV
Identify threats to malaria Develop approaches
control and elimination as III
for capacity-building,
well as new opportunities systems strengthening,
for action and surveillance

3. MPAC Background
● Scale up of malaria control and major investments in research =
rapidly evolving policy environment for new tools and
technologies (and end of one-size-fits-all approach)
● Setting policy, norms and guidance on malaria control is primary
role of WHO Global Malaria Programme (GMP)
● MPAC provides independent strategic advice and technical input
to WHO for development of policies related to malaria control &
elimination
● GMP dedicated to a policy setting process that is more:
§ Timely, transparent, and accountable
● 2011 was a critical year in the redesign, launch and
implementation of a strengthened policy setting process

4. Designing and Launching MPAC
● March 2011 - GMP Advisory Group on policy setting convened to
review previous and existing processes, consider successful
models, propose draft ToR
● April-June 2011 - Draft ToR (based on SAGE) received extensive
input from over 40 external stakeholders
● August 2011 – ToR approved by WHO Director General
● September-October 2011 – Open call for nominations, 100
applications received & reviewed by independent selection panel
● November 2011 – 15 nominees appointed as MPAC members,
selected for their experience and broad expertise
● December 2011 – all MPAC related information available online
● January/February 2102 – Inaugural meeting
● April 2012 – MPAC report published in Malaria Journal

5. MPAC: organogram
Evidence Review
Groups
ERG a ERG c
ERG b Standing TEG
on
chemotherapy
WHO COs
WHO malaria policy
SAGE MPAC WHO DG recommendations and
guidelines
MoH and
NMCPs
JTEG
(with IVB)
Other WHO WHO GMP WHO ROs RBM: Secretariat,
departments Secretariat WGs and SRNs
VCAG
(Proposed,
with NTD)

6. Interface between Roll Back Malaria
Partnership (RBM) and WHO-GMP
● RBM Secretariat is hosted at WHO
● RBM Roles
§ Advocacy
§ Resource mobilization
§ Partner harmonization
● Important to optimize interface between RBM
mechanisms and WHO-GMP
§ Example: MPAC meetings are offset from RBM Board
meetings by 3 months to allow for dissemination of
new policies and input into next agenda

7. World Malaria Report 2011
• 2011
Report
released
on
13
December
2011
•
Annual
reference
on
the
status
of
global
malaria
control
&
elimina<on.
Data
to
2010
and
2011
•
Principal
data
source
is
na<onal
programs
in
106
endemic
countries
with
support
from:
WHO
Regional
offices,
ACT
Watch,
AMFm,
ALMA,
CDC,
CHAI,
Columbia
University,
DFID,
DHS/
Measure,
FIND,
GHG
UCSF,
Global
Fund,
IHME,
ISGlobal,
JHU,
PATH,
R4D,
RBM,
Tulane
University,
UNICEF,
UNSE,
USAID
•
Summarizes
key
malaria
targets
&
goals
•
Documents
trends
in
financing,
interven<on
coverage
and
malaria
cases
and
deaths
•
Updates
malaria
burden
es<mates
for
decade:
2000-­‐2010
•
NEW:
Profiles
for
each
of
the
99
countries
with
ongoing
transmission

8. Past and projected international funding
for malaria control

9. Number of LLINs delivered by manufacturers
to countries in sub-Saharan Africa
294 million LLINs procured for distribution in Africa between 2008 and end 2010
More than 50% of households in sub-Saharan Africa owned at least 1 ITN as of 2011

10. Proportion of population at malaria risk
protected by IRS

11. Malaria RDT sales
Sales
to
public
and
private
sectors
Sales
by
panel
detec3on
score
(PDS)

12. Proportion of suspected malaria cases at
public health facilities receiving a parasitological test
100%
90%
80%
70% Africa
60% Americas
Eastern Mediterranean
50%
Europe
40%
South-East Asia
30% Western Pacific
20%
10%
0%
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Despite improvements, long way to go to reach
universal access to diagnostic testing, especially in
Africa (currently 45%)

13. Current classification of 193 countries and 2 territories
by the malaria programme that is implemented in the worst affected part of the country
control
9 8
8
pre-elimination
29
elimination
89
prevention of
60 reintroduction
81
certified malaria-free
supplementary list

14. Malaria Elimination: 2011

15. Progress with malaria elimination in the
WHO European Region
● Ten out of 53 countries in the European Region were
affected by malaria in 2000
● As of 2011, 102 locally acquired malaria cases were
reported in only five countries: Azerbaijan (4), Georgia
(1), Tajikistan (53), Turkey (4) and Greece (40)
● Turkmenistan was certified malaria-free by WHO in
2010 and Armenia – in 2011
● Kazakhstan was added to supplementary list of
malaria free countries in 2012

16. Progress with malaria elimination in WHO
European Region
Indigenous malaria cases in WHO EURO, 2000-2011
25000
20000
Cases number
15000
10000
5000
0
00
01
02
03
04
05
06
07
08
09
10
11
20
20
20
20
20
20
20
20
20
20
20
20
Azerbaijan Georgia Kyrgyzstan
Russian Federation Tajikistan Turkey
Turkmenistan Uzbekistan

17. Number of autochthonous cases of
malaria in EURO, 1990-2011
2011
100000
90000
80000
70000
60000
1996 50000
40000
30000
20000
10000
0
1990 1993 1996 1999 2002 2005 2008 2011

18. Autochthonous malaria, Central Asia 2011
30000
25000
20000
15000
10000
5000
0
1992 1995 1998 2001 2004 2007 2010
KAZAKHSTAN
UZBEKISTAN KYRGYZSTAN
AREAS AFFECTED BY MALARIA
TAJIKISTAN
TURKMENISTAN

19. Progress with malaria elimination in WHO
Eastern Mediterranean Region
● Twelve out of 20 countries in the Eastern Mediterranean
Region reported local malaria transmission in 2000
● During subsequent decade, six countries embarked on
nationwide elimination programmes (Islamic Republic
of Iran, Iraq, Morocco, Oman, Saudi Arabia and Syria),
resulting in 10-fold reduction in malaria cases
● Three others (Pakistan, Sudan and Yemen) developed
sub-national malaria-elimination initiatives
● The United Arab Emirates and Morocco were certified
malaria-free in 2007 and 2010, respectively

20. Elimination in Morocco
Monitoring & surveillance
Malaria has been eliminated in Morocco remain high priority
Total cases
(log scale) Map of entomological surveillance
100,000 sites in Morocco today
10,000
1,000
100
10
Local cases Permanent breeding sites for
Total cases entomological surveillance
0
1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 2010
2
0

21. Elimination in Iraq
Last Local cases in
Cases of vivax malaria Local cases in Iraq, 2008
- Iraq 1990-2008 2005-2008
Local cases Total cases
100,000
98,222 50
3 Imported cases
Local cases
40
49,836
40,000 30
1
20
20,000
9,684
10
1,860
44 2 0 1 4
1
7
0 Sulaimania was the last
0 2 2
1990 1995 2000 2005 2010 region with malaria in Iraq
2005 2006 2007 2008 2009 2010
2
1

22. Elimination in Saudi Arabia
Reported malaria Strong political
cases in Saudi Arabia, 1990-2010 commitment
100,000
Total cases Local cases
10,000
1941
1,000
100
Coordination with
29
Yemen for cross-border
Southwestern Saudi
IRS activities to reduce
Arabia (including Jazan, transmission
10
Aseer & Qunfuda) is the
primary malaria focus
for P. falciparum, 1
transmitted via An. 1990
1992
1994
1996
1998
2000
2002
2004
2006
2008
2010
arabiensis

23. Progress in Republic of Iran
• Iran has had gradual
Trend of Total and Local Cases- Iran (Islamic Republic of )
25000
reduction of malaria 20000
Total Reported Cases
Local Cases
cases
15000
• Only 1847 local cases 10000
recorded in 2010
5000
(85% reduction
compared to 2000)
0
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
• Both Pf & Pv exist;
close to Pf elimination
• Transmission is focal
mainly in areas
bordering Pakistan

24. Progress with malaria elimination in WHO
Region of the Americas (PAHO)
● Local malaria transmission in 23 out of 47
countries in 2000
● Four have since progressed to the pre-
elimination phase (Argentina, El Salvador,
Paraguay and Mexico)
● Two have initiated an elimination programme
at sub-national level (Dominican Republic and
Haiti)
● Two other countries (Bahamas and Jamaica)
suffered a temporary reintroduction of
malaria transmission in 2006 that has since
been controlled

25. Progress with malaria elimination in WHO
Southeast Asia Region (SEARO)
● With exception of the Maldives, which is preventing
reintroduction following its successful elimination
efforts in the 1980s, all 11 countries affected by
malaria during last decade
● Two countries progressing with nationwide
elimination (Sri Lanka and Democratic People’s
Republic of Korea)
● Indonesia has adopted a sub-national elimination
strategy for Java and Bali
● Bhutan and Thailand, where large areas with no
malaria transmission are found, have expressed their
intention to proceed with elimination

26. Progress with malaria elimination in WHO
Western Pacific Region (WPRO)
● Malaria is still endemic in 10 of 37 countries
● Malaysia and Republic of Korea implementing
nationwide malaria elimination programmes
● Sub-national elimination on-going in Philippines,
Solomon Islands, and Vanuatu
● Cambodia, China, Viet Nam and Lao People’s
Democratic Republic have included elimination in
their national strategies.
● In 2010, China made a government commitment to
eliminate malaria

27. Progress with malaria elimination in WHO
African Region (AFRO)
● All but four of 46 countries have on-going transmission
● Lesotho, Mauritius, and the Seychelles not endemic for
malaria
● Algeria is in the elimination phase; Cape Verde entered the
pre-elimination phase in 2010
● Four countries of southern Africa (Botswana, Namibia, South
Africa and Swaziland) share a common goal of eliminating
malaria by 2015; joined by four northern neighbours (Angola,
Mozambique, Zambia and Zimbabwe) in 2009, to form sub-
regional malaria elimination initiative known as Elimination
Eight (E8)
● Another four countries in Africa (Gambia, Rwanda, Sao Tome
and Principe, and Madagascar) have secured grants to
prepare for elimination

28. Recent WHO activities on malaria elimination
● Community Based Reduction of Malaria
Transmission (with malERA)
● Eliminating Malaria: Learning from the Past and
Looking Ahead
● Malaria Elimination Case Studies Series (together
with UCSF Global Health Group)
● Elimination Scenario Planning (ESP) tool
(together with Clinton Health Access Initiative)
● Launch of Disease Surveillance for Malaria
Elimination
● Launch of T3: Test. Treat. Track.

29. Major challenges ahead
● Political commitment
● Financial resources
● Global health architecture
● Procurement and supply chain management
● Health system capacity; human resource capacity
● Delivering quality case management in the private sector
● Antimalarial drug resistance
● Insecticide resistance
● Inadequate surveillance and controversies over burden
estimation
● Delivering results in highest burden countries

30. Challenge: Global political commitment
● Context
§ Major shift towards non-communicable diseases
§ Sense that malaria has already made significant progress, therefore
needs less support going forward
§ Fatigue (this is a long fight)
● Potential solutions
§ Consistent evidence-based policy setting (WHO Malaria Policy
Advisory Committee)
§ Careful and consistent documenting of impact
§ Link to wider health & development efforts
§ Resolutions from major organizations (e.g. UN, WHO)
§ Organizational support (e.g. ALMA)
§ Helping countries cross the finish line (malaria elimination)
● Risks
§ Advocacy sometimes out ahead of reality: a fine line

31. Continued global political commitment
● Creation of African Leaders Malaria Alliance
(ALMA): 2009
● United Nations General Assembly resolution on
malaria: April 2011
● World Health Assembly (WHA) resolution on
malaria: May 2011
● Roll Back Malaria (RBM) Partnership revised
objectives, targets, and priorities: June 2011
● malERA (2009-2011) & MESA (2012 & beyond)

32. Challenge: Financial
● Context
§ Well short of estimated 6 billion USD per year required
§ Concerning data to suggest that funds could decline by 2015
§ Global financial crisis and competing priorities with potential to
worsen the situation
§ Global Fund Continuity of Services policy does not include
malaria
● Potential solutions
§ Increased efficiency and value for money
§ Increased domestic funding for malaria
§ Innovative financing mechanisms
● Risks
§ Worsening financial crisis; continued financial challenges at
Global Fund

33. Tashkent
declara3on
WHO/
Northern
Africa
EURO
2005
WHO/EMRO
1997
The
Hispaniola
APMEN
Ini3a3ve
2009
Carter
Center
2008
Suriname
West
Africa
ini3a3ve?
Professor
Li's
2009
FEMSE
projects
2003-­‐2005-­‐2007
Mesoamerican
Ini3a3ve
for
Public
Health
2008
Southern
Cone
ini3a3ve
Arabian
Peninsula
malaria
free
2006
SADC
2007
Elimina3on
8
2009
GLOBAL
MALARIA PROGRAMME

34. Major opportunities ahead
● Malaria elimination: crossing the finish line
● Trans-border collaboration
● New uses for existing tools. Example: Seasonal Malaria
Chemoprevention (WHO policy for Sahel sub-Region as of 2012)
● New tools: malaria vaccine in 2015?
● Integrated community case management (iCCM)
● Improving efficiency and value for money. Example: a 5-year LLIN
● Universal diagnostic testing, improved case management, and
strengthened surveillance (T3: Test, Treat, Track)
● Stratification:
§ Using data for decision making
§ Determining the optimal intervention mix for different
epidemiological settings

35. Malaria Surveillance Manuals – Worldwide launch:
Namibia, 24 April 2012

36. Surveillance Manuals: Objective and Rationale
● Objective
§ To provide guidance to malaria-endemic countries on the operation of
malaria surveillance systems for malaria control and elimination
● Rationale
§ Updated malaria surveillance guidance has not been issued by WHO
since the Global Malaria Eradication Programme era
§ Scale-up of malaria interventions increases need for timely and
accurate information on malaria occurrence for program management
§ Increasing availability of malaria diagnostic tests allows for tracking
confirmed malaria cases and better targeting of resources
§ New manuals focus on program implementation and complement
other existing guidance on malaria indicators

37. Three WHO Manuals as pillars of T3
Test Treat Track

38. T3: Test. Treat. Track.
Worldwide Launch: Namibia, World Malaria Day 2012

42. Keep our eye on the prizes
● First: near zero deaths from malaria
§ Today, no one should die from
malaria for lack of a 5 dollar bednet,
a 50 cent diagnostic test, and a 1
dollar antimalarial treatment
● Ultimately: a world free of malaria