A recent publication in Malaria Journal introduces a free, internet-based, interactive mathematical model of malaria elimination as a tool for policy makers and program implementers. This tool is designed to assist malaria programs in determining which malaria interventions to use and how best to combine them to achieve maximum impact in a variety of settings. Based on user feedback, the mathematical models will be improved over time to enhance the tool to better inform policy planning for elimination.
A recent publication in PLoS Neglected Tropical Diseases discusses one of the challenges faced in malaria elimination: eliminating Plasmodium vivax. Although many malaria programs are focused primarily on P. falciparum, mainly due to higher mortality rates associated with it, more people worldwide live at risk from P. vivax than P. falciparum. There is consensus among malaria experts that eliminating P. vivax will be more challenging because P. vivax is harder to prevent, diagnose and treat. Additional research is greatly needed to better understand P. vivax to develop more effective interventions, in addition to sustained financing and resources to achieve and maintain elimination.
In a recent publication in the Journal of Global Infectious Diseases, authors discuss the importance of different interventions that would accelerate progress toward elimination. The authors stress that the international community possesses the necessary tools to reduce malaria morbidity and mortality; however, these tools are not being utilized efficiently. They summarize current interventions and highlight examples of countries which have experienced substantial reductions in malaria due to the scale-up of effective interventions. Increased funding and resources, collaborative regional approaches to elimination, and operational research on elimination, will be critical to the final stages of elimination.
Researchers in Bhutan - one of the 32 malaria-eliminating countries - recently conducted a spatio-temporal analysis of data collected between 1994 and 2008 to identify malaria transmission clusters and to study trends in malaria incidence over time with the goal of informing the allocation of control and elimination resources. Overall, there was a significant decrease in malaria trends, however, clusters were identified in regions where malaria transmission generally does not occur. In a low endemic setting, accurately identifying potential malaria clusters will help to control and prevent outbreaks of malaria.
A recent publication in the journal Tropical Medicine and International Health examines an outbreak of Plasmodium falciparum malaria that occurred in Jamaica between 2006 and 2009 and resulted in a dramatic increase from zero to 406 malaria cases. Ministry of Health officials mounted a massive public health response to the outbreaks including early case identification, prompt treatment, vector control, public education and intersectoral collaboration within the government. Jamaica successfully eliminated malaria in 1966, however because competent mosquito vectors still exist, the risk of reintroduction of malaria remains high. This outbreak of malaria highlights the importance of sustained capacity for surveillance and outbreak response, even after malaria has been eliminated.
In response to the enormous malaria burden in Zanzibar, from September 2003 onwards, the Ministry of Health and Social Welfare and partners scaled-up four key malaria control interventions: free treatment with artemisinin-based combination therapy, distribution of long-lasting insecticide-treated bed nets, indoor residual spraying and intermittent preventive treatment for pregnant women. By 2008, the malaria-related burden reduced by over 75% in all age groups. With Zanzibar’s success in reducing malaria, the need to maintain adequate malaria control activities becomes increasingly important to minimize the risk of resurgence.
The Board of the Global Fund to Fight AIDS, Tuberculosis and Malaria recently approved 79 grants (out of 150 submitted) for Round 10 funding, of which 19 (24%) were specifically for malaria. Proposals were submitted from four (Azerbaijan, Cape Verde, China and Iran) of the 32 malaria-eliminating countries (13%), with three approved for funding and only one (Azerbaijan) not approved.
A new article in the Malaria Journal proposes a malaria vaccine as a necessary addition to the collection of currently effective interventions for elimination and eventual eradication. Authors review the potential impact that various malaria vaccine types could have on transmission, and conclude that due to the wide epidemiological variability between endemic settings, the ideal approach to controlling malaria must depend on the specific local context. Even when partially protective vaccines become available, the integration of all available tools and resources will be critical to achieve elimination.
In a recent publication in the Malaria Journal, MEG members Bruno Moonen, Simon Hay, Oliver Sabot and David Smith present a framework to assess the feasibility of elimination to help countries weigh their options in considering malaria elimination. The framework is proposed along three axes that apply quantitative and qualitative metrics to assess the technical, operational, and financial requirements to achieve and maintain elimination. The feasibility framework was first piloted in Zanzibar in October 2009. Future adaptations of the framework will continue to refine and improve these methodologies as they are applied in other low-endemic malaria settings.
The National Malaria Programs of the Solomon Islands and Vanuatu, along with malaria researchers from institutions including the Pacific Malaria Initiative Support Center and the University of Queensland, have examined operational strategies that are required for elimination. Nine peer-reviewed journal articles on elimination have been published over the last 15 months, with topics including the spatial distribution of malaria, community participation and motivation, diagnostics, G6PD deficiency screening, and bed net acceptability and utilization. These publications and continued operational research on elimination in Melanesia further builds the evidence base on elimination and benefits other malaria-eliminating countries as they pursue a path towards elimination.
Accurate and timely diagnosis of malaria infections is critical in an elimination setting. MEG member Dennis Shanks, along with colleagues from the Pacific Malaria Initiative Support Centre at the University of Queensland and researchers from the Solomon Islands, studied the malaria epidemiology in the Temotu Province in the Solomon Islands, which is preparing for malaria elimination. Researchers compared three different diagnostic methods to evaluate the performance of each in this low endemic setting: microscopy, rapid diagnostic test, and PCR. Results revealed that a large proportion of malaria infections in the province were at low and sub-microscopic parasite densities and were not detected using all three diagnostic methods. This finding has important practical implications to developing and pursuing a malaria elimination strategy in the Temotu Province and similar low transmission settings.
As malaria interventions are scaled up in The Gambia, malaria continues to decline across the previously highly endemic country. Malaria researchers in The Gambia have examined laboratory records across 10 health facilities obtained over seven years (2003 - 2009). Their research indicates a significant downward trend in many malaria-related indicators, which allows informed discussions on the possibility of elimination. With continued support from the Global Fund and others, The Gambia will continue to decrease its burden and shrink the malaria map.