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WHO technical brief for countries preparing malaria funding requests for the Global Fund (2020–2022)
Global Malaria Programme
Advance copy
WHO technical brief for countries preparing malaria funding requests for the Global Fund (2020–2022)
Global Malaria Programme
Advance copy
Advance copy© World Health Organization 2020
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CONTENTS
FOREWORD 1
1. INTRODUCTION 2
2. USE OF STRATEGIC INFORMATION TO DRIVE IMPACT 4
3. MALARIA VECTOR CONTROL INCLUDING INSECTICIDE RESISTANCE 19
4. PREVENTIVE CHEMOTHERAPIES 28
5. CASE MANAGEMENT (MALARIA DIAGNOSIS AND TREATMENT) 35
6. MALARIA ELIMINATION AND PREVENTION OF RE-ESTABLISHMENT 52
REFERENCES 57
QUICK REFERENCE TABLE 59
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FOREWORD
After many years of great progress in our fight against malaria, our trajectory is plateauing and the world will not achieve the 2020 malaria targets for morbidity and mortality reduction. With over 400 000 deaths and in excess of 200 million malaria cases each year, we must urgently evolve our approach if we are to realize the full potential of current tools and the available resources and get back on track.
The country-led “High burden high impact” (HBHI) response, launched in 2018 by WHO and the RBM Partnership to End Malaria, aims to reignite the pace of progress in the global malaria fight and is guided by four key elements (1).1
Clear evidence-informed guidance is one, critical, response element. This document summarizes all of the current WHO malaria recommendations. These remain unchanged and are the product of careful evaluation following standardized procedures as part of the WHO normative processes. WHO uses strictly defined processes to assess the strength of the recommendations and the certainty of the evidence upon which they are based. Our recommendations tend to be summary statements, which are usually accompanied by supplementary statements that draw attention to contextual and implementation considerations and key desirable and undesirable effects. This document helps to distinguish the formal recommendations from the supplementary statements. We are working to improve the development, presentation and flexibility of our recommendations. In future, we aim to produce living guidelines which will be updated more rapidly following the availability of new evidence.
A second response element focuses on the strategic use of local data. This acknowledges the great contextual diversity within which we collectively operate. A good understanding of the different types of settings within each country – or strata – is essential to identify the optimal mix of interventions, and the best means to deliver them. We are therefore working with countries to strengthen the use of local information for stratification, the definition of optimal mixes of interventions and the rational, safe and ethical prioritization of resources to maximize impact. Local data are also essential to understand the impact of the strategies deployed, providing opportunities to further refine sub-national strategies and to inform global knowledge.
This document builds on the principles articulated in the global technical strategy, elaborated in the elimination framework and the HBHI approach. In 2019, the Malaria Policy Advisory Committee (MPAC), an independent advisory group of global experts that advises WHO, endorsed the fundamental need to invest in data collection, collation and curation at the country level, and to build capacity to use these data to inform prioritization processes (2).
This document is an evolution of previous guidance and intended to support national malaria programmes in the development of robust funding proposals that are tailored to their contexts, and the evaluation of the proposals by the Global Fund’s Technical Review Panels. The first section provides an overview of the purpose of the brief. Section 2 describes the process of stratification, that guides intervention mixes for local contexts, and prioritization. Section 3 presents the evidence-based recommendations that have been developed through WHO’s standard, stringent processes. The final section comprises a quick reference table which summarizes the link between the recommendations and their potential adaptations as part of a tailored malaria intervention approaches, informed by local data.
1 HBHI four key elements: 1) political will to reduce malaria deaths; 2) strategic information to drive impact; 3) better guidance, policies and strategies; and 4) a coordinated national malaria response.
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1. INTRODUCTION
The World malaria report 2019 estimates that 405 000 deaths and 228 million cases were due to malaria in 2018 (3). The global priority is to reduce the high malaria burden, while retaining the long-term vision of malaria eradication. This document was developed by the WHO Global Malaria Programme as a summary of existing guidance and its application to the formulation of Global Fund grants. It is not intended as a substitute for the published WHO documents on which it is based but highlights the need to adapt global guidance according to national needs and evidence.
Malaria control and elimination efforts are guided by the Global technical strategy for malaria 2016–2030 (GTS) (4). Adopted by the World Health Assembly in May 2015, the strategy defines goals, milestones and targets on the path to a world free of malaria and (table 1). The goals focus attention both on the need to reduce morbidity and mortality, and to progressively eliminate malaria from countries that had malaria transmission in 2015.
Table 1: Goals, milestones and targets for the Global technical strategy for malaria 2016–2030
GOALS MILESTONES TARGETS
2020 2025 2030
1. Reduce malaria mortality rates globally compared with 2015
At least 40% At least 75% At least 90%
2. Reduce malaria case incidence globally compared with 2015
At least 40% At least 75% At least 90%
3. Eliminate malaria from countries in which malaria was transmitted in 2015
At least 10 countries
At least 20 countries
At least 35 countries
4. Prevent re-establishment of malaria in all countries that are malaria-free
Re-establishment
prevented
Re-establishment
prevented
Re-establishment
prevented
Figure 1: Global technical strategy for malaria 2016–2030 – framework, pillars and supporting elements
Pillar 3Transform malaria
surveillance into a core intervention
Pillar 1Ensure universal access to malaria prevention,
diagnosis and treatment
Pillar 2Accelerate efforts towards elimination and attainment
of malaria-free status
Global technical strategy for malaria 2016–2030
Supporting element 1. Harnessing innovation and expanding research
Supporting element 2. Strengthening the enabling environment
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Following steady reductions in malaria morbidity and mortality between 2000 and 2015, progress has stalled in recent years and the world is now off track to achieve the 2020 malaria morbidity and mortality targets. A revitalization effort, called “High burden to high impact”, was launched by WHO, the RBM partnership and countries with a high malaria burden in 2018 (1). This approach focuses attention on how to get back on track: garnering political will to reduce the toll of malaria; using strategic information to drive impact; developing better guidance, policies and strategies; and improving coordination of support for national malaria responses. Although the impetus for articulating these key activities was the need to get back on track to achieve the GTS morbidity and mortality targets, these activities apply equally well to all malaria endemic countries and to ensuring continued progress with the GTS elimination goals.
A key pillar of the GTS is enhanced surveillance and the local use of local data. This is essential for four steps involved in the development and monitoring of prioritised malaria control and elimination programmes: (i) stratification, of malaria risk and approaches to service provision; (ii) development of an optimal national strategic plan which that defines the packages of interventions needed to optimise malaria control and elimination in a country; (iii) informing rational prioritisation to maximise impact when the resources are insufficient to provide the optimal packages; (iv) monitoring the impact of the deployed intervention packages. This document is intended to support national malaria programmes in the development of robust funding proposals that deliver value for money in line with the national malaria strategic plan behind which partners can rally. This document will evolve using feedback from national programmes and their implementing partners, and ongoing work within WHO to better guide national prioritization processes in malaria control and elimination.
In 2019, WHO created a compendium of its malaria guidance (5). For the first time, this lists all WHO recommendations and associated guidance on malaria in a single resource, informing program managers, national and international stakeholders. The compendium aims to inform end-users about WHO’s global guidance but, like all global guidance, falls short of providing guidance on what every national malaria programme and their implementing partners should do in specific situations. In addition, the compendium references the relevant WHO handbooks, manuals, and other resources to guide readers on how these global recommendations can best be implemented.
The present document builds on the compendium by providing further advice on how to adapt the WHO recommendations across different contexts. The next section focuses on the central role of surveillance and is followed by sections on the preventive strategies of vector control and chemoprevention, then diagnosis and treatment. The final section looks at the ultimate ambition of elimination.
Feedback can be provided to WHO Global Malaria Programme using the following email address: [email protected]
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2. USE OF STRATEGIC INFORMATION TO DRIVE IMPACT
Malaria is a disease with complex transmission dynamics that is associated with considerable heterogeneity geographically and over time. Within any malaria endemic country, it is not unusual that the intensity of transmission and the associated burden of disease vary considerably due to climate, socioeconomic development, urbanization, health system as well other factors. Over time, parts of a country could also change from one level of endemicity to another due to changes in the determinants, especially as coverage and use of interventions impact on transmission and burden of disease. This heterogeneity requires a targeted response and the choice of interventions based on data and local (subnational) information. Value for money principles listed below (Box 1) should guide all aspects of the Global Fund funding proposal.
Box 1: The principles of value-for-money
Economy: addresses whether inputs (staff, consultants, raw materials and capital that are used to produce outputs) are purchased at appropriate quality and at the right price. In the case of malaria intervention, this will entail the collection of unit cost data for human, material and financial for all activities.
Efficiency: links inputs to outputs and measures, for example, whether quality malaria interventions are delivered at the right quantity and right timing to those populations that need them the most.
Effectiveness: how well are the outputs from an intervention achieving the desired outcome on the burden of malaria (measured as malaria infection, morbidity and all-cause mortality).
Equity: degree to which the results of the intervention are equitably distributed
Cost-effectiveness: the relationship between economic inputs and outcomes.
In the context of the fight against malaria, the strategic use of information for impact entails developing systems to generate, analyse and use reliable data to:
• identify populations at risk and the level of transmission and disease burden or malariogenic potential;
• review progress against malaria, nationally and sub-nationally, in a country to define the impact of interventions and activities that have been implemented, identify bottlenecks and set subnational targets;
• inform the best pathway to further progress in future;
• mobilize resources and maximize their impact through targeted subnational operationalization;
• identify the optimal means of delivery and address obstacles to access;
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• respond to outbreaks, epidemics and other emergencies;
• provide relevant information for certification of elimination;
• monitor whether the re-establishment of transmission has occurred and, if so, guide the response; and
• improve accountability.
Some of the main sources of strategic information include:
• routine health information systems, which may either cover multiple programmes, be specific to malaria or be limited to certain activities (e.g. laboratory services, interventions, distribution, surveillance);
• detailed epidemiological data from case-based malaria surveillance systems, which may be implemented when case numbers are low enough to match the resources needed to undertake such intensive surveillance;
• health facility surveys, which usually address whether facilities have the physical and human resources necessary to provide services (especially chemoprevention, diagnostic testing and treatment), and may include whether patients receive diagnostic testing and appropriate treatment;
• household surveys, which usually cover several health interventions, may capture health-seeking behaviour, and often target children under 5 years of age and women of reproductive age. Malaria-specific surveys are also common;
• operational or implementation research, which usually addresses specific questions of relevance to the malaria programme, may rely on household or health facility surveys, and may include studies of drug or insecticide efficacy;
• entomological surveillance, for understanding the distribution of the main malaria vectors, their behaviour and changes in their biting habits in response to the intervention; part of sentinel surveillance by national programmes and often including vector resistance to insecticides;
• data from supervision of health services (central, intermediate, health facility and health worker levels); and
• contextual data, which are not collected routinely or during operational research but are useful for further understanding and explanation of changing trends in the malaria burden (they include population censuses and climate and socioeconomic data);
• social science and qualitative research on treatment-seeking behaviour and barriers to access;
• climate data from national metrological departments and online data portals.
2.1 Steps in the use of strategic information for impactThe use of strategic information forms the basis for malaria progress reviews, stratification and intervention mix analysis, setting national strategic plans, supporting resource mobilization and prioritizing investments to increase impact. Operational activities must be linked to a robust monitoring and evaluation processes to ensure a dynamic loop of information that is necessary for continued impact. Figure 2 provides a brief description of the process and use of strategic information for malaria program reviews, national strategic plan development, resource mobilization, prioritization and implementation.
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Figure 2: An illustrative process for the collection, collation and use of strategic information for the delivery of national malaria programmes
2.2 Effective malaria surveillance systemAn effective surveillance system is fundamental to reliable strategic information. Malaria surveillance is “the continuous and systematic collection, analysis and interpretation of malaria related data, and the use of that data in the planning, implementation and evaluation of malaria programmes”. Pillar 3 of the Global technical strategy for malaria 2016-2030 is to transform malaria surveillance into a core intervention. The WHO Malaria surveillance, monitoring and evaluation: a reference manual was published in 2018 (6). The manual provides information that can be used to develop national standard operating procedures (SOPs) the following areas:
• malaria case surveillance in settings of malaria burden reduction and elimination;
• drug efficacy surveillance in elimination settings, especially in areas where each case is followed up in routine surveillance;
• entomological surveillance in settings of malaria burden reduction and elimination;
• epidemic detection, preparedness and response, especially in low- to moderate-transmission settings of burden reduction; and
• monitoring and evaluation of programmes and surveillance systems in all endemic settings.
As transmission decreases, the epidemiology of malaria is likely to change.
• The number of uncomplicated malaria cases and related fevers will decrease.
• The age distribution of cases of disease will become more evenly distributed, reflecting decreasing exposure, but with a greater proportion of adults, particularly males, when the countries near elimination.
• The numbers of severe cases and deaths will decrease, although the proportion of severe to uncomplicated disease may increase.
• The clinical presentation of severe disease, and the age group affected, may change
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• Malaria transmission will become more focal.
• In some settings, disease may become more prevalent among people in certain occupations more exposed to inoculations by local vectors, such as forest workers.
• Populations will become less immune, and the risk of epidemics and the associated case fatality rate will increase if interventions are interrupted.
• Imported cases may represent an increasing fraction of overall number of malaria cases.
• In countries with both P. falciparum and P. vivax malaria, the proportion of cases due to P. vivax may gradually increase, as generally the transmission of P. falciparum can be reduced faster with current interventions, while P. vivax infections may cause relapses due to the hypnozoite stage.
• Continued use of intervention exerts selection pressures on malaria vectors and parasites that lead to loss of efficacy of insecticides, drugs and diagnostics.
The goals and possibilities of surveillance, monitoring and evaluation also evolve during this transition (Figure 3).
• In areas of where the objective of the NMP is to reduce the burden of malaria, programme monitoring and evaluation are based mainly on aggregate numbers from routine information systems and household surveys, and actions are designed to ensure that the entire population has access to relevant services and there are no adverse disease trends.
• In areas with very low transmission where the objective of the NMP is to implement elimination activities, the distribution of malaria is more heterogeneous, and it is important to identify the population groups that are most severely affected by the disease and to target interventions appropriately. This will be facilitated by mapping areas of ongoing transmission and analysis of case distribution at community or household level. Case-based surveillance becomes critical in such settings.
• As transmission is reduced, the risk of epidemics increases; thus, cases at health facilities must be reported and analysed more frequently to ensure the early detection of a potential outbreak.
• Across all settings monitoring the efficacy and resistance of insecticides, drugs and diagnostics become essential components of the surveillance system.
• Ancillary data such as climate, population movement and logistics data on interventions, human resources and funding become integral to programme planning.
• Continuous evaluation of surveillance as an intervention becomes essential to improving quality of data.
• Increasing multidimensional data required structured databases that are available to lower level health entities and workers for monitoring and response.
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To develop effective surveillance systems, countries must focus on the following core elements:
• the people: including decision-makers both inside and outside the health service who use data from surveillance systems, the health staff who gather and/or use the data and the patients and communities whose details are registered;
• the procedures: including case definitions, reporting frequency, pathways of information flow, data quality systems, incentivizing capture and collation of good quality data, data analysis, mechanisms for reviewing performance, methods for and frequency of disseminating results, using data for making decisions about appropriate responses, supervision and planning;
• the tools: including report forms, tally sheets, registers, patient cards, database platforms with analysis dashboards, computer hardware and software, documentation and training materials;
• the structures: including the ways in which staff are organized to manage, develop and use the system.
In elimination settings, additional surveillance requirements include case notification, case and focus investigations and active case detection among high risk populations. Such intensified surveillance comes with significant costs and should be implemented when malaria elimination is in sight. Initial efforts should first be invested in increasing reporting of cases from monthly to weekly, and later to daily, using these data to better understand patterns and potential foci of transmission, analysing determinants of transmission in areas remaining with cases, identifying areas of low transmission and if cases are sufficiently few, implementing case-based surveillance, notifications and investigations.
Relevant data elements and indicators are shown in the annexes of the Malaria surveillance, monitoring and evaluation: a reference manual (6).
2.3 Structured national malaria programme database and analytical toolsTo ensure that countries use their surveillance data for operational activities and the development of policies and strategies, they need to develop structured and frequently updated databases that can be analysed to inform decision making at all levels of the programme. Such a database is not a replacement or equivalent to the HMIS but a mechanism to pull together routine and non-routine data to enhance the use of strategic information for impact. The WHO recommends the development of a single nationally owned malaria data repository. The core content of the malaria data repository is malaria related information from routine surveillance systems, intervention distributions from programmatic and logistics management systems, malariometric and intervention coverage data from household surveys, entomology, efficacy data (drugs, insecticides and diagnostics), funding, human resource, key documents and partnership inventories and climatic data. As much as possible, such repositories should be governed within the national health information systems in terms of hosting, updating, sharing and other data governance processes, but should be available to national malaria programme and partners and be available for use subnationally. Over time, the national repository will feed into, and benefit from, national health observatories. A proposed structure of national data repositories is shown in Figure 4.
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Figu
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: Pro
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2.4 Analysis for response, programmatic monitoring, review and strategic planning
Analysis and review of malaria related data sub-nationally is needed to understand the drivers of progress, the bottlenecks and to selectively apply interventions to maximise impact. Malaria programme reviews as recommended by WHO should be conducted using the best available and validated subnational data (7).
Detailed subnational analysis and stratification should be part of the malaria programme reviews to assess the status of the burden of malaria over time, the impact achieved by countries so far, the determinants of observed progress to inform future actions.
Three such actions are:
1. developing new national strategic plans with a process of optimizing the intervention strategies stipulated in the strategy to achieve the national goals;
2. prioritizing available resources, which are often not enough to achieve the full strategic goals, so that all investment lead to greatest possible impact; and
3. developing and monitoring sub-national operation plans to efficient, effective and equitable delivery of quality services.
3.4.1 Subnational malaria stratification Malaria stratification is the process of classification of geographical areas or localities according to epidemiological, health system, ecological, social and economic determinants of malaria for planning, monitoring progress and guiding interventions. The benefits of stratification include:
• tracking progress against malaria and evaluating the impact of interventions;
• identifying and targeting the best mix of interventions for national strategic planning;
• efficient prioritization and quantification of resources, implementation of interventions to optimize impact of available resources.
To provide the relevant information needed for programmatic use the stratification analysis must be done at subnational level, preferably district (or equivalent) or lower levels. In elimination settings, stratification should be done at village level at a minimum, and at the focus level where possible.
Metrics for malaria stratification, therefore, cover a broad range of malaria related areas that directly or indirectly impact on malaria transmission, uncomplicated and severe disease, and/or death. These include:
• epidemiological: Plasmodium parasite prevalence, cases, malaria and all-cause under 5 mortality rate, Pf /Pv ratio, incidence;
• entomological: mosquito vector species, their abundance and behaviour, biting rates;
• interventions: type, distribution, coverage, efficacy (drug and insecticide resistance, hrp2 deletions);
• health system readiness: accessibility, timeliness, intensity and quality of service delivery, quality of surveillance systems and data;
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• ecological: climatic factors (altitude, temperature, rainfall), environmental (vegetation, agriculture, housing, urbanization, infrastructure etc.);
• human behaviour: use of interventions, seasonal migration and other behaviour related to risk of exposure and access to treatment;
• other contextual factors: socio-economic status, occupation, conflicts, location of refugees and internally displaced persons or other humanitarian emergencies.
Stratification using epidemiological metrics forms the foundation of most programmatic decisions, but countries should consider these metrics together with the others listed above for better decision making. Examples of epidemiological metrics, used often in moderate and high transmission areas are defined in Box 2, and include parasite prevalence from surveys, case incidence from routine data and mortality rate estimates. Often all-cause mortality in children under the age of five years may be more readily available than malaria-specific mortality in moderate and high transmission malaria countries. In elimination settings, case counts are the primary epidemiological metric used in combination with data on case classifications. Entomological parameters or historical epidemiological data could be used to define the malariogenic potential of an area. These metrics have strengths and limitations and their use is context dependent. Figure 5 a–d show examples of district level stratification using different types of epidemiological metrics and composite strata based on their combinations.
Box 2: Epidemiological metrics for malaria risk stratification
Parasite prevalence (PR)
Definition: Proportion of a specified population with patent malaria infection at one time
Measurement: Rapid diagnostic tests (RDTs) and / or microscopy
Data sources: household surveys, school surveys, ANC surveillance
Strengths: common and easy to measure, resonates more easily with programmes, indirect proxy of transmission
Weaknesses: infrequent surveys that are not designed for measuring parasite prevalence with high level of precision sub-nationally, relatively weak seasonal and temporal signal (except in ANC surveillance), large sample sizes required with decreasing transmission, most surveys restricted to specific age groups (u5), not as useful in measuring P. vivax prevalence due to diagnostic limitations. Surveys in a country may be implemented at different points in the high transmission season, complicating comparisons over time and leading to biased interpretations. Where microscopy is use, this may sometimes be of low quality.
Value addition: geospatial methods can be used to estimate prevalence at subnational units below the administrative level at which surveys were originally designed to be precise (8). Uncertainty in the estimates can be measured empirically. High uncertainty areas may be targeted for additional data collection. ANC surveillance data may combined with household survey prevalence data to improve the precision of PR estimates.
Clinical case counts and incidence
Definition: Number of newly diagnosed malaria cases. Case incidence refers to the number of such cases during a defined period in a specified population, usually measured as total number of clinical cases per 1000 person-years at risk.
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Measurement: Rapid diagnostic tests (RDTs) and / or microscopy
Data sources: passive and / or active surveillance of symptomatic individuals
Strengths: available from routine systems, strong temporal signal, usually covers all ages, common and easy to measure, resonates more easily with programmes, near direct measure of disease burden
Weaknesses: susceptible to quality of diagnosis and surveillance systems, strongly influenced by case definitions, health worker practices, treatment seeking and inconclusive case classifications
Value addition: in elimination settings, case counts combined with information on case classification (imported, introduced, indigenous) and entomological data can be used to quantify the malariogenic potential of an area. In burden reduction settings, geospatial methods can be used to reduce biases in surveillance systems and treatment seeking to develop subnational estimates.
Mortality (all cause and malaria specific)
Definition: All cause under 5 mortality rate is the number of children that die before their fifth birthday per 1000 live births. Estimates of malaria mortality among children under the age of 5 years would be more appropriate for the stratification process. However, accurately estimating malaria mortality, especially sub nationally, is difficult and highly uncertain.
Measurement: U5 mortality rate is defined through a model that relies on birth history information collected during household surveys, census data as well various mortality risk factors.
Data sources: household surveys such as DHS, MIS or MICs, vital registration data, routine information systems, census data and other sources (see Figure 5c).
Strengths: in moderate and high transmission settings, malaria is a significant contributor to deaths in children and to a lesser degree in pregnant women. Combining mortality, malaria prevalence and incidence estimates (see Figure 5d) can help in targeting malaria interventions designed to reduce mortality in these population subgroups. Data on malaria deaths from inpatient facilities are useful for the analysis of potential quality of care at hospitals and provide a useful signal in burden trends.
Weaknesses: given the weakness in surveillance, vital and civil registration systems in most moderate to high transmission malaria endemic countries, the main source of mortality data are household surveys, but these happen every 3 to 5 years and are therefore not helpful for routine responses. In addition, household surveys are usually powered to produce estimates at national or regional levels, yielding only imprecise estimates at district or lower levels, and therefore of limited value to inform the targeting of control efforts. Such data can be useful for malaria strategic planning, especially where malaria is a leading cause of death. In elimination settings, malaria deaths are very rare and their contribution to all-cause mortality is very small. Actual malaria death count is more informative than using all-cause mortality rate as a proxy.
Value addition: there are several statistical and geospatial methods that can be used to estimate mortality sub nationally with quantifiable measures of uncertainty. Triangulation of routine data on inpatient case fatality rates with periodic all-cause mortality estimates may provide useful insights.
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Figure 5: district a) maps of case incidence, b) P. falciparum parasite prevalence (PfPR), c) all-cause under five mortality rate and d) a composite index that combines the epidemiological metrics (See Box 2)
3.4.2 Malaria intervention mixes for policy optimization and prioritisation The impact of malaria interventions in an area is determined primarily by three factors:
• The pre-control baseline (see the Quick reference table): in general, the higher the malaria baseline in an area, the greater the fraction of the at-risk population that must be protected with control interventions to achieve a reduction in transmission to a specific threshold.
• The expected impact of specific interventions on transmission, which may vary by type of intervention and setting. For example, the effect of ITNs and IRS will be greater where the dominant malaria vector(s) is indoor-biting and indoor resting, respectively, than in places where outdoor-biting and outdoor-resting vectors predominate.
• The fraction of the at-risk population in the area that can be fully protected by effective control measures: the greater the fraction that is protected (or covered), the larger the reduction that can be expected. This will depend on available funding and efficiency of delivery channels, acceptability, compliance and other health system and human behavioural factors.
During the development of the national strategic plans and setting of goals, these factors should come into consideration, and the eventual intervention mix maps. To inform this process, countries are advised to use WHO recommendation on interventions as guide. There are instances, however, further adaptation of these recommendations is needed to fit with country context and achieve maximum impact, both during strategy development and during budgeting.
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A detailed summary of these recommendations and possible adaptations for inclusion in national strategic plans and resource prioritization is provided in the Quick reference table. An example using the targeting of LLINs (pyrethroid only and PBO) is shown in Table 2.
Table 2: WHO recommendations on LLINs (pyrethroid only and PBOs), and possible considerations countries can make to adapt the recommendations to their national context
INTERVENTION TYPE
CURRENT RECOMMENDATION FOR
INTERVENTION TARGETING
POLICY ADAPTATION CONSIDERATIONS FOR INTERVENTION TARGETING
Insecticide treated nets (ITNs)
ITNs prequalified by WHO are recommended for deployment as a core intervention in all malaria-endemic settings
Universal coverage* with effective vector control using a core intervention (ITNs or IRS) is recommended for all populations at risk of malaria in most epidemiological and ecological settings. The population at risk of malaria may increase or decrease because of changes in malariogenic potential of a given geographical area
In areas of very low receptivity, LLINs may not have substantial impact, and resource optimization should take this into account.
Such areas may include those of historically very low/no transmission such as those where climatic factors are not optimal for malaria transmission. They may also include certain urbanized areas where the environment has been modified through construction and other forms of land cover such that there is low potential for transmission.
PBO (piperonyl butoxide) ITNs
Pyrethroid-PBO nets prequalified by WHO are conditionally recommended for deployment instead of pyrethroid-only ITNs where the principal malaria vector(s) exhibit pyrethroid resistance that is: a) confirmed, b) of intermediate level, and c) conferred (at least in part) by a monooxygenase-based resistance mechanism, as determined by standard procedures
Preferred choice over pyrethroid-only nets if this will not compromise coverage
* Universal coverage is defined as access to and use of appropriate interventions by the entire population at risk of malaria. For country adaptation considerations should be made regarding the interventions that are most appropriate given the intrinsic as well current levels of risk.
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An example of a subnational intervention mix map for a national strategic plan is shown Figure 6 that is linked to the maps provided shown in Figure 5 and linked to considerations presented the Quick reference table.
Figure 6: An example of intervention mix map by district based on the epidemiological metrics shown in Box 2, as well as other indicators and policy adaptations described in the Quick reference table. CM= case management; IPTp = intermittent preventive treatment during pregnancy; IRS = indoor residual spraying; LLINS = long lasting insecticidal nets; PBO-LLINs = piperonyl butoxide LLINs; SMC = seasonal malaria chemoprevention.
National malaria reduction goals outlined in national strategic plans (NSPs) are usually developed in expectation that all resources required to achieve them will be available to the country. Usually, however, countries have far less funding than they need to achieve their NSP goals and some of the optimum mix of interventions may not be implemented or the levels of coverage required may not be achievable. This requires tailored, flexible and dynamic subnational prioritization of the limited resources to achieve the greatest impact and value for money. High levels of efficiency in service delivery are also required to ensure the expected levels of coverage commensurate to the investment in interventions is achieved.
The basis of further analysis of prioritization should the intervention mixes presented in the national strategic plan (for example Figure 6) and the policy adaptation principles described in the Quick reference table. These mixes are further analysed, using techniques such as mathematical dynamic models, to determine the affordable mixes and levels that will give you the best possible impact for available resources. Figure 7 demonstrates some of the possible scenarios that could result from optimizing of intervention mixes during NSP prioritization of resources during budgeting processes. These analyses require subnational stratification and transmission dynamic modelling. The WHO and national partners can provide support to implement these types of analyses.
Figure 7: Possible future scenarios depending on national strategic plans and resource availability
Past interventions withdrawn
Past interventions coverage reduced and not substitu-ted for equally or more efficacious ones
Past interventions and coverage maintained without further optimization
Past and new interventions and coverage prioritized within available resources to ensure maximum return on investment
Past and new interventions and coverage optimized for new NSP goals in expectation al resources will be available Time
Mal
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An example of a subnational intervention mix map for a national strategic plan is shown Figure 6 that is linked to the maps provided shown in Figure 5 and linked to considerations presented the Quick reference table.
Figure 6: An example of intervention mix map by district based on the epidemiological metrics shown in Box 2, as well as other indicators and policy adaptations described in the Quick reference table. CM= case management; IPTp = intermittent preventive treatment during pregnancy; IRS = indoor residual spraying; LLINS = long lasting insecticidal nets; PBO-LLINs = piperonyl butoxide LLINs; SMC = seasonal malaria chemoprevention.
National malaria reduction goals outlined in national strategic plans (NSPs) are usually developed in expectation that all resources required to achieve them will be available to the country. Usually, however, countries have far less funding than they need to achieve their NSP goals and some of the optimum mix of interventions may not be implemented or the levels of coverage required may not be achievable. This requires tailored, flexible and dynamic subnational prioritization of the limited resources to achieve the greatest impact and value for money. High levels of efficiency in service delivery are also required to ensure the expected levels of coverage commensurate to the investment in interventions is achieved.
The basis of further analysis of prioritization should the intervention mixes presented in the national strategic plan (for example Figure 6) and the policy adaptation principles described in the Quick reference table. These mixes are further analysed, using techniques such as mathematical dynamic models, to determine the affordable mixes and levels that will give you the best possible impact for available resources. Figure 7 demonstrates some of the possible scenarios that could result from optimizing of intervention mixes during NSP prioritization of resources during budgeting processes. These analyses require subnational stratification and transmission dynamic modelling. The WHO and national partners can provide support to implement these types of analyses.
Figure 7: Possible future scenarios depending on national strategic plans and resource availability
Table 3: Malaria strategic information components and activities for considerations in the funding requests and other funding sources
WORK AREA ELEMENTS FOR BUDGETING
Surveillance system • Standardising malaria indicators using WHO recommended standard DHIS2 module installations
• Internet connectivity• Software and hardware• Maintenance• Supervision• Technical assistance• Surveillance assessments
2.5 Subnational operational plans and monitoring and evaluationDeveloping detailed annual district operational plans, implemented and monitored by staff at the district level is key to effective intervention implementation. These district operational plans need a monitoring framework in line with the WHO recommended monitoring and evaluation approach presented in Figure 8. Strong surveillance systems and ancillary data from other sources are crucial for effective planning and implementation. Such data should, where possible, in structured databases (for example national data repositories, section 2.3). During strategic planning, a strong monitoring and evaluation framework as well as annual operational plans nested within wider ministry of health processes should be developed. This will require investment in capacity at national and subnational levels. Examples of areas countries can consider for funding are presented in Table 3.
Figure 8: Malaria monitoring and evaluation framework: from input to impact
ACT, artemisinin-based combination therapy; RDT, rapid diagnostic test; LLIN, long-lasting insecticidal net
Implementation (supply) Results (supply and demand)
Inputs Process Outputs Outcomes Impact
Financial, human,
information and other resources
mobilized to support
activities.
Budgets, staffing, health facilities, medicines and
other resources.
Reduction in, e.g. cases of severe
malaria, deaths from malaria.
Analysis of surveillance,
surveys, census and other
contextual data to measure outcomes.
Use of outputs by targeted population, e.g. people
with suspected malaria receive a diagnostic test or sleep under LLINs.
Programme, surveillance,
surveys and census data to measure
outcomes.
Services resulting from converting
inputs into outputs, e.g. RDTs,
ACTs, LLINs, surveillance, staff.
Goods and services
produced and delivered by main
implementing agency and
partners.
Action or work to convert
inputs into outputs.
Delivery of supplies, staff
training, supervision,
logistics management
systems.
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WORK AREA ELEMENTS FOR BUDGETING
National data repository • Installation of WHO recommended or similar repository modules
• Linking to HMIS• Assembly of non-routine data on structured templates and
linkages to repository• Development of relevant analysis dashboards• National and subnational installations• National and subnational training• Software and hardware• Maintenance• Technical assistance
Progress reviews • MPRs• MTRs• Impact evaluations• Annual reviews• Technical assistance
Stratification and intervention mix analysis for NSP, resource prioritization
• Assembly of data needed for stratification• Technical assistance for stratification• Technical assistance for intervention mix analysis
Subnational operation planning
• Technical assistance to develop subnational operational plans• Training in development, use and monitoring operational
plans• National and district level review meetings
Subnational monitoring and evaluation
• MIS and other relevant household surveys• Health facility readiness and epidemiological surveys• Surveillance assessments• Entomological surveillance• Efficacy studies• Priority implementation and operational research
Elimination • Malaria elimination training for districts and health facilities• Case-based surveillance• Case investigations• Focus investigations• Focus response activities• Active case detection for high-risk populations• Entomologic surveillance• Surveillance assessments• Malaria elimination audits• Cross-border meetings at district level
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3. MALARIA VECTOR CONTROL INCLUDING INSECTICIDE RESISTANCE
VECTOR CONTROL FOR MALARIA BURDEN REDUCTION AND ELIMINATION
• Universal coverage with effective vector control using a core intervention (ITNs or IRS) is recommended for all populations at risk of malaria in most epidemiological and ecological settings. The population at risk of malaria may increase or decrease as a result of changes in malariogenic potential of a given geographical area.Good practice statement
• Priority should be given to delivering either ITNs or IRS at high coverage and to a high standard, rather than introducing the second intervention as a means to compensate for deficiencies in the implementation of the first intervention.Conditional recommendation against combining the core interventions to reduce morbidity and mortality, moderate-certainty evidence
• Once high coverage with one core intervention has been achieved, programmes may consider deploying the other core intervention as an approach to prevent, manage and mitigate insecticide resistance. The ITN and IRS products selected for co-deployment must not contain the same insecticide class(es). For instance, IRS with a pyrethroid should not be deployed in the same households or areas as ITNs.Good practice statement
• Once high coverage with a core intervention has been achieved, recommended supplementary interventions with proven public health value may be deployed in specific settings and circumstances.Good practice statement
• In areas with ongoing local malaria transmission (irrespective of both the pre-intervention and current level of transmission), vector control interventions should not be scaled back. Universal coverage with effective malaria vector control of all inhabitants of such areas should be pursued and maintained.Good practice statement
• In areas where transmission has been interrupted, the scale-back of vector control should be based on a detailed analysis that includes assessment of the receptivity and vulnerability2, active disease surveillance system, and capacity for case management and vector control response.Good practice statement
2 Vulnerability means risk of malaria case importation.
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INSECTICIDE-TREATED NETS
• Pyrethroid-only LLINs prequalified by WHO are recommended for deployment as a core intervention in all malaria-endemic settings.Strong recommendation as an intervention with public health value, high-certainty evidence
• Pyrethroid-PBO nets prequalified by WHO are conditionally recommended for deployment instead of pyrethroid-only ITNs where the principal malaria vector(s) exhibit pyrethroid resistance that is: a) confirmed, b) of intermediate level, and c) conferred (at least in part) by a monooxygenase-based resistance mechanism, as determined by standard procedures.3
Conditional recommendation as an intervention with public health value, moderate-certainty evidence
• Recipients of ITNs should be advised (through appropriate communication strategies) to continue using their nets beyond the 3-year expected lifespan of the net, irrespective of the condition of the net, until a replacement net is available.Good practice statement
• Recipients of ITNs should be advised (through appropriate communication strategies) to continue using their net even if it is damaged or contains holes, irrespective of the age of the net, until a replacement net is available. Recipients of ITNs should be advised (through appropriate communication strategies) not to dispose of their nets in any water body, as the residual insecticide on the net can be toxic to aquatic organisms (especially fish).Good practice statement
• Old ITNs should only be collected where there is assurance that: i) communities are not left uncovered, i.e. new ITNs are distributed to replace old ones; and ii) there is a suitable and sustainable plan in place for safe disposal of the collected material.Good practice statement
• If ITNs and their packaging (bags and baling materials) are collected, the best option for disposal is high-temperature incineration. They should not be burned in the open air. In the absence of appropriate facilities, they should be buried away from water sources and preferably in nonpermeable soil.Good practice statement
INDOOR RESIDUAL SPRAYING
• IRS deploying a product prequalified by WHO is recommended as a core intervention in all malaria-endemic settings.4
Strong recommendation as an intervention with public health value, low-certainty evidence
LARVICIDING
• The regular application of biological or chemical insecticides to water bodies (larviciding) is recommended as a supplementary intervention in areas where high coverage with a core intervention has been achieved, where aquatic habitats of the principal malaria vector(s) are few, fixed and findable, and where its application is both feasible and cost-effective.Conditional recommendation as an intervention with public health value, low-certainty evidence
3 Given data constraints at district and province level, WHO has provided a simplified overview of areas eligible for deployment of pyrethroid-PBO nets on page 74 of the World malaria report 2019. Given the resource constraints of national malaria programmes and supply constraints for pyrethroid-PBO nets, further prioritization will be required to target any pyrethroid-PBO nets within the country. WHO recommends that within eligible areas, those with the highest malaria burden are prioritized.
4 DDT has not been prequalified; it may be used for IRS if no equally effective and efficient alternative is available, and if it is used in line with the Stockholm Convention on Persistent Organic Pollutants.
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TOPICAL REPELLENTS
• Deployment of topical repellents is not recommended as a public health intervention; however, topical repellents may be beneficial as an intervention to provide personal protection.Conditional recommendation against deployment as an intervention with public health value, low-certainty evidence
INSECTICIDE-TREATED CLOTHING
• Use of insecticide-treated clothing is not recommended as a public health intervention; however, insecticide-treated clothing may be beneficial as an intervention to provide personal protection in specific population groups.Conditional recommendation against deployment as an intervention with public health value, low-certainty evidence
SPACE SPRAYING
• Space spraying should not be undertaken for malaria control, and IRS or ITNs should be prioritized instead.Conditional recommendation against deployment, very low-certainty evidence
Vector control is a vital component of malaria control and elimination strategies. It is effective in preventing infection and reducing disease transmission. The two core interventions for malaria vector control are insecticide-treated nets (ITNs) and indoor residual spraying (IRS). In specific settings, and under special circumstances, these core interventions can be supplemented by larval source management and personal protection measures. WHO recommends that either ITNs or IRS are deployed at the highest possible coverage achievable in a given target population.
ITNs should, whenever possible, be provided in sufficient numbers to cover everyone at risk. ITNs recommended and prequalified by WHO should be procured.
IRS should be deployed with the aim of covering at least 80% of premises in target communities. IRS is effective for a number of months: usually three to six months, but occasionally up to nine months, depending on the insecticide that is used, the type of surface sprayed. Please consult the list of WHO recommended and prequalified insecticides for IRS (https://www.who.int/pq-vector-control/prequalified-lists/en/).
3.1 Implementation of ITNs• To achieve and maintain high levels of coverage, countries should apply a
combination of mass free distributions and continuous distributions through multiple channels, in particular antenatal and immunisation services. Continuous distribution channels should be functional before, during and after mass distribution campaigns to avoid any coverage gaps.
• Mass campaigns are a cost-effective way to rapidly achieve high and equitable coverage, but coverage gaps start to appear almost immediately post-campaign through net deterioration, loss of nets, population growth and movements, requiring complementary continuous distribution channels. Continuous distribution strategies are needed to avoid gaps in ITN coverage.
• Mass campaigns should distribute one ITN for every two persons at risk of malaria. However, for procurement purposes since many households have an odd number of
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members, the calculation needs to be adjusted when quantifying at the population level. A ratio of 1 ITN for every 1.8 persons in the target population should be used to estimate ITN requirements, unless data to inform a different quantification ratio are available. In places where the most recent population census is more than five years old, countries can consider including a buffer (e.g. adding 10% after the 1.8 ratio has been applied) or using data from previous ITN campaigns to justify an alternative buffer amount.
• In most contexts, ITNs tend to be less logistically demanding than other forms of malaria vector control. However, as mosquito nets are bulky, special attention must be given to storage and transport to peripheral target communities. When planning ITN campaigns, due attention should be given to the time required for procurement, storage and transport, so that ITNs can be made available, when and where needed, in sufficient numbers.
• Campaigns should normally be repeated every three years, unless available empirical evidence justifies the use of a longer or shorter interval between campaigns. In addition to these data-driven decisions, a shorter distribution interval may also be justified during humanitarian emergencies, as the resulting increase in population movement may leave populations uncovered by vector control and potentially increase their risk of infection as well as the risk of epidemics.
• ITNs should be free at the point of delivery or, in the case of private sector distribution channels, highly subsidized and should be available in the immediate proximity of target communities, without any gap in the supply chain.
• Data on insecticide resistance must be collected in the target area to inform product choice. In settings with documented pyrethroid resistance, pyrethroid-PBO nets should be considered for deployment instead of pyrethroid-only ITNs, given evidence of improved epidemiological impact.
3.2 Conditions for implementation of IRS• IRS implementation relies on the availability of operational national vector control
services with adequate human, financial and logistical resources (including skilled spray teams, storage and transport facilities, spraying equipment, etc.). As consecutive rounds of IRS are usually required to achieve and sustain the full potential of this intervention, adoption of IRS requires long-term (multi-year) political and financial commitment by national programmes, local authorities, and funding partners.
• IRS should not be planned unless full capacity for implementation, monitoring and evaluation is in place at national, provincial and district levels.
• IRS planning must be based on accurate entomological and epidemiological information: identification and bio-ecology of vectors with special reference to their feeding and resting behaviours, dynamics of transmission (rhythm and intensity), and incidence and prevalence of malaria (morbidity and overall mortality).
• Data on insecticide resistance must be collected in the target area, before and after the spraying operation. In any vector control operation using insecticides, the responsibility for ensuring the adequacy and quality of this data rests with the main implementation agency responsible for the intervention.
• Insecticide choice for IRS should follow the national policy on insecticide resistance management (see section 3.1 of the Guidelines for malaria vector control (9)).
• The procurement decision must consider all relevant data on insecticide resistance, within and near to the target area. The decision should be consistent with and checked against national resistance management policies. The process of assembling the data and choosing an insecticide must be done early in the planning process, since
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procurement delays are a common operational problem in many vector control programmes.
• The number, nature and location of premises to be sprayed, as well as access to these, must be determined through geographical reconnaissance prior to decision-making and planning.
3.3 Target areas for malaria vector control Both IRS and ITNs can be used in a range of epidemiological settings. The choice of which intervention to use should be guided by operational and financial considerations, most importantly the insecticide resistance profile of the main malaria vector(s) in the target area, while targeting should be informed by an in-depth stratification of the country. For urban areas it is recommended that microstratification is conducted to identify whether there are urban areas with ongoing malaria transmission; areas with very low transmission and not at continuing risk should not be targeted with IRS or LLINs. For example, populations at high risk, low ITN coverage and/or poor access to curative health services (often in peri-urban areas) should be prioritised over those with historically low risk and good access to diagnostic and curative services, often in more central urban areas (see also section 3.7).
4.3.1 ITNs are indicated as an intervention in most situations, especially the following:
Epidemiological factors
• in a wide range of transmission conditions where long-term protection is needed;
• in areas with a relatively long season of malaria transmission, or perennial transmission, such that more than one IRS cycle would be required;
• in areas where IRS cannot be used and only personal protection can be achieved (e.g. forest malaria or among nomadic populations).
Socioeconomic factors
• In places where IRS may face problems of acceptability.
Access and programmatic factors
• In areas where continuous ITN distribution can easily be integrated into existing health systems such as routine EPI and/or ANC;
• in areas where the specialized skills and programme infrastructure needed for IRS have not (yet) been developed, an ITN distribution campaign can rapidly achieve high levels of coverage;
• to protect hard-to-reach populations, where repeated IRS spray-cycles are not feasible (a one-time distribution of ITNs can provide relatively long-term protection, compared to the shorter-duration of protection given by one IRS spray cycle);
In every country, a variety of local situations and eco-epidemiological settings are encountered. Therefore, it may well be justifiable to use ITNs in some settings and IRS in others as part of the stratification, optimisation and prioritisation process described in section 2.
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4.3.2 IRS is best indicated in the following conditions:Epidemiological factors
• to respond to malaria epidemics or malaria cases in elimination settings, provided that insecticide and spray equipment are readily available in country or can quickly be procured and delivered; IRS may be deployed more rapidly than ITNs and is thus often the first line intervention for interrupting an epidemic;
• to control malaria in humanitarian emergencies (e.g. displaced populations and refugee settings, climatic events, etc.) where there are structures that are suitable for IRS application;
• to prevent transmission in epidemic prone areas and in areas with low seasonal transmission (e.g. highlands, fringes). Both IRS and ITNs can be used in epidemic prone areas as preventive measures.
• to cut-off well identified peaks of seasonal transmission;
• to interrupt transmission in residual foci at the end of the elimination phase;
Access and programmatic factors
• access to target communities should be possible, including during the rainy transmission season when multiple spray rounds are required;
• a pre-requisite for IRS deployment, is the availability of the programmatic capacity (planning, logistics and supervision) necessary to ensure an IRS operation of adequate quality.
IRS is contra-indicated when conditions for effective implementation are not met or where there are no structures to spray (e.g. nomadic populations, forest malaria) or where the local vectors are strongly exophilic (i.e. tend to rest outdoors, respectively).
4.3.3 Should IRS and ITNs be combined?Priority should be given to delivering either ITNs or IRS at high coverage and to a high standard, rather than introducing the second intervention as a means to compensate for deficiencies in the implementation of the first intervention. However, the deployment of both ITNs and IRS in the same geographical area may be considered for resistance prevention, mitigation or management. Given the resource constraints across malaria endemic countries, the deployment of a second core vector control intervention on top of high coverage with an existing core vector control intervention should only be considered as part of a broader prioritization analysis aimed at achieving maximum impact with the available resources. In many settings, a switch from one to the other core intervention, rather than their co-deployment, is likely to be the only financially feasible option.
1. In settings with high ITN coverage where these remain effective, IRS may have limited utility in reducing malaria morbidity and mortality. However, IRS may be implemented as part of an insecticide resistance management (IRM) strategy in areas where there are ITNs.
2. If ITNs and IRS are to be deployed together in the same geographical location, IRS should be conducted with a non-pyrethroid insecticide.
3. Evidence is needed to determine the effectiveness of combining IRS and ITNs in different eco-epidemiological settings outside Africa.
4. All programmes in any transmission setting that decide to prioritize the combined deployment of ITNs and IRS over other potential use of their financial resources should include a rigorous programme of monitoring and evaluation in order to
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confirm whether the additional inputs are having the desired impact. Countries that are already using both interventions should similarly undertake an evaluation of the effectiveness of the combination versus either ITNs or IRS alone.
3.4 Resistance managementWidespread and increasing insecticide resistance poses a threat to effective malaria vector control. Failure to prevent, mitigate and manage insecticide resistance is likely to eventually result in an increased burden of disease, potentially reversing some of the substantial gains made in controlling malaria over the last decade.
To date, there is no evidence of operational failure of vector control programmes as a direct result of pyrethroid resistance. Based on past experience, however, it is likely that operational failure will eventually occur if effective IRM strategies are not designed and implemented in line with the resistance management strategies outlined in the Global plan for insecticide resistance management in malaria vectors (GPIRM) in 2012 (10).
The GPIRM defines key technical principles for addressing insecticide resistance, as follows:
• Insecticides should be deployed with care and deliberation in order to reduce unnecessary selection pressure. Countries should consider whether they are using insecticides judiciously, carefully and with discrimination, and if there is a clear epidemiological benefit.
• Vector control programmes should avoid using a single class of insecticide everywhere and over consecutive years; instead, they should use rotations, mosaics, combinations of interventions, and mixtures (once available).
• Wherever possible, vector control programmes implementing IRS should diversify from pyrethroids in order to preserve their effectiveness. Although pyrethroids will continue to be used for ITNs in the near term, they should not generally be deployed for IRS in areas with ITNs.
• IRM principles and methods should be incorporated into all vector control programmes, not as an option, but as a core component of programme design.
• The agricultural sector should try to avoid using classes of insecticide that are widely used for public health and should collaborate with vector control authorities in an intersectoral approach.
• Routine monitoring of insecticide resistance is essential to sustain the effectiveness of vector control interventions.
• The short-term additional costs of IRM should be balanced against the long-term potential public health impact and potential costs of insecticide resistance.
More detailed guidance on how to prevent, mitigate and manage insecticide resistance in malaria vectors is provided in section 3.1 of the Guidelines for malaria vector control (9).
3.5 ITN usage• Consistent ITN usage is essential for the success of ITN interventions: ITNs are effective
when people use and maintain them properly. Regular information and advocacy campaigns are therefore needed to ensure their effective use. Evidence suggests that about 90% of the population with access to a mosquito net actually use it. In areas where ITN use is identified as being lower, WHO recommends the roll-out of behaviour-change communication programmes, including information, education and communication (IEC) campaigns.
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• Some ITN distribution campaigns have successfully used follow-up field operations to support and promote use of nets after a campaign. There is some evidence to suggest that the promotion of net repair activities (sewing in order to close holes) may be useful.
3.6 Timing and sustaining coverage
Timing in IRS operations is essential Because of the generally short duration of efficacy of most insecticides when sprayed on walls, IRS campaigns must be completed just before the onset of the transmission season. In addition, insecticide efficacy must be maintained throughout the whole transmission season. Depending on the duration of this season, the choice of insecticide and the surfaces sprayed, one or two spray cycles per year may be required. Large-scale implementation requiring more than two spray cycles per year, (e.g. in perennial transmission areas) is very difficult to achieve in most situations, because of factors such as logistics, cost and social acceptability.
In epidemic prone areas, IRS should be considered an intermittent intervention, and spray cycles should be planned based on accurate entomological, epidemiological and climate surveillance systems involving specialized vector control services. IRS can also be deployed as part of an epidemic response, or in response to cases in an elimination setting.
3.7 Budget considerations For all procurement of vector control products (ITNs and insecticides), pre-and post-shipment testing for quality control should be mandatory.
3.7.1 ITNs• In planning for procurement quantities, the aim should be to distribute enough ITNs to
achieve 100% coverage, with one net for two people. There must be a clear plan as to how this is to be achieved at household level. A good way to do this is to give nets to households at the rate of one net for every two household members, rounding up in households with odd numbers of members. The procurement ratio must be adjusted to allow for this rounding up, and this implies a procurement ratio of 550 ITNs for 1000 population, or one net for 1.8 people, in a population with a mean household size of five. Note that these figures have been adjusted in the light of practical experience following previous Global Fund rounds.
• Logistics and funds for the supply, management, storage and distribution of ITNs must be in place, such that the nets are not kept in warehouses at central level or are inaccessible to target populations. Opportunities to give a greater role to manufacturers and/or procurement agents to deliver ITNs up to destination, e.g. district level should be explored.
• Adequate and efficient planning of distribution methods (e.g. through ANC clinics, integrated with immunization campaigns, etc.) is key to ensuring that feasible targets are set and achieved. It is recommended that funds for these activities be included in the proposal. For proposals where this is not the case, there should be a clear explanation as to the source of funds for these activities.
• Education, communication materials and campaign activities to improve the use and proper maintenance of ITNs should be included in the budget.
• Funds for insecticide resistance monitoring and for proper monitoring of effective biological activity and physical durability of ITNs should be included in the budget.
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3.7.2 IRSBudgets for IRS programmes must include the following elements:
• Purchase of sufficient amounts of an effective insecticide, as well as adjunct commodities (e.g. spray pumps, protective equipment for sprayers, etc.), while avoiding unnecessary stocks that might become obsolete;
• Recruitment, training and salaries for enough sprayers and supervisors to cover target areas prior to the transmission season;
• Logistics and funds for the supply, management, storage and distribution of the insecticide so that it is not kept in warehouses at central level. Transport costs for both the insecticide and sprayers must be incorporated in the proposal;
• Education and communication materials and campaign activities to sensitize communities to the importance of IRS, particularly where activities are employed for the first time or are being widely scaled-up;
• Insecticide resistance monitoring and proper monitoring of the insecticide residual duration on sprayed surfaces;
• Where IRS is being employed for the first time, initial geographical reconnaissance studies to determine target areas and structures as well as entomological studies to ensure selection of an effective insecticide.
Only limited data is available on the relative cost-effectiveness (CE) of IRS and ITNs, and this indicates that their relative cost-effectiveness depends on various biological and programmatic contextual factors. On the whole, it may be expected that ITNs will tend to be more cost-effective in locations where there is more than six months of transmission per year.
3.8 Monitoring & evaluation• For both IRS and ITNs, specialized teams are required to conduct entomological
surveillance and vector control monitoring and evaluation activities. The entomological skills needed for this work must be maintained and strengthened if they are lacking.
• Routine entomological surveillance and monitoring of vector control must include insecticide resistance testing in multiple locations. Further entomological surveillance activities are context dependent and should be guided by the latest surveillance guidance, as provided in the WHO Malaria surveillance, monitoring & evaluation: a reference manual (6).
• Programmes should be prepared to carry out immediate entomological investigations in response to reports of any unexpected variations in impact, or any local increase in cases that is larger than would normally be expected for that season. The aim of the investigations is to establish whether this increase is likely to be due to changes in coverage of vector control interventions, or to insecticide resistance, or to a combination of these or other factors.
• ITN coverage (ownership and usage) should be reported through routine records of delivery operations and should also be estimated through standard household survey methods, such as the Malaria Indicator Survey (MIS). IRS coverage should be reported through the collation of household spray records kept by spray teams and supervisors and should also be checked or separately estimated through follow-up household surveys.
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4. PREVENTIVE CHEMOTHERAPIES
INTERMITTENT PREVENTIVE TREATMENT IN PREGNANCY
• In malaria-endemic areas in Africa, provide intermittent preventive treatment with SP to all women in their first or second pregnancy (SP-IPTp) as part of antenatal care. Dosing should start in the second trimester and doses should be given at least 1 month apart, with the objective of ensuring that at least three doses are received.Strong recommendation, high-quality evidence
INTERMITTENT PREVENTIVE TREATMENT IN INFANTS
• In areas of moderate-to-high malaria transmission of Africa, where SP is still effective, provide intermittent preventive treatment with SP to infants (< 12 months of age) (SP-IPTi) at the time of the second and third rounds of vaccination against diphtheria, tetanus and pertussis (DTP) and vaccination against measles.Strong recommendation
SEASONAL MALARIA CHEMOPREVENTION
• In areas with highly seasonal malaria transmission in the sub-Sahel region of Africa, provide seasonal malaria chemoprevention (SMC) with monthly amodiaquine + SP for all children aged < 6 years during each transmission season.Strong recommendation, high-quality evidence
The preventive chemotherapies target people who suffer the greatest burden of malaria - pregnant women and children. Strong collaboration between Malaria Programmes and Maternal, Newborn and Child Health (MNCH) services is needed to maximise the potential of these strategies.
Stronger collaborations between the programmes provide an opportunity not only to scale up malaria interventions but also to strengthen the health systems that will impact on maternal and child survival.
4.1 Intermittent preventive treatment in pregnancyAround 38 million pregnancies occur in moderate to high transmission countries in Africa each year and up to 11 million are exposed to malaria leading to 90 000 low birth weight children. Women in their first and second pregnancies have greater risk of malaria. Non-immune pregnant women are also at risk of acute and severe clinical disease, in addition to miscarriage and premature labour. All pregnancies, not only the first and second, are at high risk of malaria and its complications, even more so HIV-infected pregnant women.
4.1.1. Key policy issuesWHO recommends that all endemic countries provide a package of interventions for the prevention and management of malaria in pregnancy, consisting of (i) early diagnostic testing and effective treatment for all episodes of clinical disease and anaemia (see sections on diagnosis and treatment) and (ii) prevention of malaria either with LLINs or IRS (see section on vector control). The above strategies should be complemented by (iii) intermittent preventive treatment with sulfadoxine–pyrimethamine (IPTp-SP) in countries in sub-Saharan Africa with stable malaria transmission.
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All pregnant women at risk of P. falciparum infection in countries in sub-Saharan Africa with moderate to high malaria transmission should receive at least three doses of SP as IPT through their pregnancy, with individual doses given at least one month apart. The first does should be given as early as possible in the 2nd trimester (i.e. week 13); the last dose of IPTp-SP can be administered up to the time of delivery without safety concerns. IPT-SP should be taken as direct observation treatment (DOT) during the ANC visit (11). With the 2016 WHO recommendations on antenatal care for a positive pregnancy experience, the recommended at least eight contacts increases the number of opportunities to give at least three doses of IPTp-SP to the pregnant women (12).
4.1.2. Considerations and caveats for implementation • SP should not be administered to women receiving co-trimoxazole prophylaxis due to
a higher risk of adverse events.
• WHO recommends the administration of folic acid at a dose of 0.4 mg daily; this dose may be safely used in conjunction with SP. Folic acid at a daily dose equal or above 5 mg should not be given together with SP as this counteracts its efficacy as an antimalarial drug.
• There is currently insufficient evidence to support a general recommendation for the use of IPTp-SP outside Africa.
4.1.3 Implementation issuesAntenatal clinics provide an excellent entry point for reaching pregnant women with interventions. Communication campaigns to increase the use of ANC services (especially early in pregnancy) for malaria control and other interventions for improving pregnancy outcomes are strongly recommended.
Strengthening ANC services for the delivery of effective interventions requires infrastructure development, human resource strengthening and capacity building for reproductive health staff. It also requires uninterrupted availability of commodities and supplies for malaria control. Quality service delivery requires laboratories appropriately equipped with diagnostics for basic maternal health tests and procedures, such as haemoglobinometers and RDTs. Strong partnerships between communities and facilities should promote improved access to all reproductive health services and be expected to improve maternal and newborn health outcomes.
In addition, prompt diagnosis and effective, safe treatment for malaria and anaemia in pregnancy (suitable antimalarials, training on case management) should be made available close to home through peripheral health services.
Routine distribution of LLINs to pregnant women should occur through ANCs, supplemented by regular campaigns of free distribution to the entire population. The nets should be handed out during the very first ANC visit, together with clear instructions on their use during pregnancy, breastfeeding period and beyond to not only protect the mother but also the newborn. This requires proper procurement, planning and budgeting for the delivery, storage and distribution of nets within ANC facilities, and systems for reporting and accountability.
4.1.4 Exploiting linkages to improve the delivery of malaria specific interventions and the health outcomes of all pregnant women and their unborn children
Integrated delivery of health care entails incorporating prompt malaria diagnostic testing, effective treatment and timely referral into general health services. The development of strategies and resource allocation plans should be done in coordination with other relevant departments of the ministries of health. ANC services are now accessible to the majority of
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pregnant women, as high as 90% in some countries; therefore delivering interventions like LLINs and IPTp via ANC services could attract pregnant women to other ANC services, such as delivery assisted by skilled birth attendant.
Using malaria in pregnancy to strengthen maternal and child health services will not only reduce the burden of malaria during pregnancy but will also improve maternal and child health outcomes.
4.1.5 Issues to be considered in the development of funding proposalsA comprehensive approach is needed to reduce the burden and consequences of malaria during pregnancy. This includes a full range of interventions within ANC services to be included with adequate budget in Global Fund malaria proposals. Support for capacity building to improve quality of care, including resources for staff training and supervision, should be part of the Global Fund proposal. Specific items to be consider include:
• Medicines for IPTp (i.e. sulfadoxine- pyrimethamine): Enough doses to cover the whole pregnant population, which is calculated at about 5% of the total population times at least three doses of SP (three tablets per dose) per pregnant woman.
• Diagnostic testing: RDTs including required ancillary items (such as gloves, sharps boxes for lancets, etc.).
• Antimalarial medicines for treatment of uncomplicated and severe malaria in pregnant women, according to national guidelines. An accurate estimation should be based on the national epidemiology and burden of disease. The first choice for severe malaria treatment should be injectable artesunate, rather than injectable artemether or injectable quinine.
• Supplies for diagnosis and treatment of anaemia in all pregnant women, including routine iron and folic acid supplementation.
• Supply, management, storage and distribution of LLINs through ANCs, including training of reproductive health care workers and provision of relevant counselling and communication materials and skills.
• Logistics for timely distribution of medicines and commodities to facilities, and specifically to ANC clinics throughout the country, so that they are not kept in warehouses at central level or in stores at facility level to which ANC staff have no access.
• Education and behaviour change communication materials and campaign activities that target communities and providers to improve the use of IPTp and ANC services, including the delivery with a skilled birth attendant, for malaria and other interventions for improving pregnancy outcomes.
• Strengthening the capacity of reproductive health workers and supervisors to deliver and support MIP interventions effectively. Such capacity building should not be isolated or vertical, but must be included in comprehensive capacity building plans for reproductive health departments, budgeted for and organized jointly with the national malaria control programmes.
• Strengthening existing health information systems for monitoring and evaluation purposes, and modifying ANC registers and cards to include indicators for malaria in pregnancy, particularly IPTp-SP3 and the recording of all ANC visits.
• Operational research to ensure effective programming for MIP and continued monitoring of the prevalence of molecular markers of SP resistance.
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• Pharmacovigilance should be supported to monitor the safety of medicines used for the prevention and treatment of malaria in pregnancy.
4.2 Intermittent preventive treatment in infancy (IPTi)Intermittent preventive treatment in infancy (IPTi) is defined as the administration of a full course of an effective antimalarial treatment at specified time points to infants at risk of malaria, regardless of whether they are parasitaemic, with the objective of reducing the infant malaria burden.
WHO recommended intermittent preventive treatment for infants (IPTi) living in areas of moderate-to-high malaria transmission where SP is still effective. SP is recommended for infants < 12 months of age at the time of the second and third rounds of vaccination against diphtheria, tetanus and pertussis (DTP), and vaccination against measles (13). This builds on the routine EPI programme to deliver malaria prevention strategies.
4.2.1 Considerations and caveats for implementation• In situations where national-scale implementation may not be appropriate, IPTi may
be implemented at provincial or district scales, informed by the stratification included in NSPs.
• Programmes implementing the SP-IPTi strategy should regularly monitor and evaluate the impact on immunization services and performance.
• Pharmacovigilance systems to monitor potentially serious adverse reactions to SP should be strengthened.
• Surveillance of molecular markers of SP resistance should accompany implementation of SP-IPTi to develop further understanding of the relationship between SP resistance and IPTi-SP effectiveness.
4.2.2 Contra-indicationsSP-IPTi should not be given to infants receiving a sulfa-based medication for treatment or prophylaxis, including co-trimoxazole (trimethoprim-sulfamethoxazole), which is used as prophylaxis against opportunistic infections in HIV-infected infants.
IPTi should not be deployed in the areas already covered by SMC with amodiaquine plus sulfadoxine-pyrimethamine (AQ+SP).
4.2.3 Issues to be considered in the development of Global Fund proposalsAs with IPTp, Global Fund Malaria proposals should not focus only on funds for the procurement of SP, an inexpensive commodity, but also include other important costs. These include support for the delivery of the intervention through EPI programmes; support for capacity building of personnel to improve the quality of care, with resources for staff training and supervision. Specific items that should be included in the proposal and budget, include:
• medicines for IPTi (sulphadoxine pyrimethamine);
• logistics for distribution of medicines to facilities and specifically to EPI clinics throughout the country;
• education and communication materials, and campaign activities, to improve the use of EPI services and acceptance of IPTi;
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• strengthening the capacity of health workers to deliver IPTi through appropriate training and supervision;
• strengthening existing health information systems for monitoring and evaluation purposes, and modifying EPI and other health registers and cards to include indicators for IPTi and malaria in infancy;
• surveillance to ensure continued monitoring molecular markers of resistance to SP and of the protective effectiveness of IPTi-SP, as well as pharmacovigilance to monitor the safety of SP use in IPTi.
4.3 Seasonal malaria chemopreventionSeasonal malaria chemoprevention (SMC), is defined as the intermittent administration of full treatment courses of effective antimalarial medicines during the malaria season to prevent malarial illness. The objective of SMC is to maintain therapeutic antimalarial drug concentrations in the blood throughout the transmission season, which is the period of greatest malarial risk. SMC has been studied most frequently in areas with seasonal malaria transmission where the main burden of malaria is in children, rather than in infants, and the main risk of clinical malaria is restricted to a few months (3-4 months) each year. In these settings SMC has been shown to prevent approximately 75% of severe malaria episodes.
WHO recommends SMC with amodiaquine plus sulfadoxine-pyrimethamine (AQ+SP) given at monthly intervals during the malaria season to children aged 3–59 months in areas of highly seasonal malaria transmission (13). SMC has so far only been evaluated in the Sahel sub region in Africa. SMC has been implemented in settings where amodiaquine + sulfadoxine–pyrimethamine remains efficacious (> 90% efficacy) and has thus not been used in southern and eastern Africa, even though there are areas in those regions where the transmission pattern would suggest suitability. There is a lack of efficacy and safety data for other potential anti-malarial regimens for use in SMC.
An implementation manual for SMC developed by WHO-GMP was issued in December 2012 and an updated edition is being prepared (14).
4.3.1 Considerations and caveats for implementationThe following should be considered when determining the suitability of deploying SMC in any setting:
• malaria seasonality: SMC is recommended in highly seasonal malaria transmission settings;
• SMC is unlikely to be cost effective in settings where the clinical attack rate of malaria is less than 0.1 attack per transmission season in the target age group;
• efficacy of SP and AQ should be high (> 90% therapeutic efficacy in last available study results);
• pharmacovigilance systems are needed to monitor potentially serious adverse reactions;
• surveillance of molecular markers of SP and AQ should accompany the implementation of SMC.
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4.3.2 Contra-indicationsSMC with AQ+SP should not be given to children receiving a sulfa-based medication for treatment or prophylaxis, including co-trimoxazole (trimethoprim-sulfamethoxazole), which is used as a prophylaxis against opportunistic infections in HIV-infected children.
SMC should not be given to children with an acute febrile illness, requiring instead early diagnosis and treatment for malaria
4.3.3 Issues to be considered in the development of funding proposalsAs with IPTp and IPTi, Global Fund malaria proposals should not focus only on the funding needed for the drugs (AQ+SP), which are the relatively inexpensive components of the strategy. Provision must also be made for the delivery of this intervention through community programmes. Support for capacity building of personnel for improving quality of care, with resources for staff training and supervision, should be part of the Global Fund proposal. Specific items to be included in the proposal and budget, include:
• medicines for SMC (AQ+SP);
• logistics for distribution of medicines to facilities and communities;
• education and communication materials and campaign activities to improve acceptability and use of SMC;
• strengthening the capacity of health workers/community health workers to deliver SMC through appropriate training and supervision;
• strengthening existing health information systems for monitoring and evaluation purposes, and ensuring registers and cards are available and used to include indicators for SMC and malaria in the target age group;
• continued monitoring of molecular markers of resistance to amodiaquine and SP, and protective effectiveness of SMC, as well as pharmacovigilance to monitor the safety of AQ-SP when used as SMC.
4.4 Mass drug administration (MDA)Based on a 2015 review of evidence, the WHO Malaria Policy Advisory Committee made the following recommendations on the role of MDA for malaria (15):
• Use of MDA to interrupt transmission of falciparum malaria may be considered in areas approaching elimination, provided there is good access to treatment, effective vector control measures and surveillance and minimal risk of re-introduction of infection.
• Given the threat of multidrug resistance, MDA may be considered a component malaria elimination efforts in the Greater Mekong sub region, in areas with good access to treatment, vector control and good surveillance.
• In the case of malaria epidemics, MDA can be an initial part of the containment measures to rapidly reduce malaria morbidity and mortality, along with the urgent introduction of other control measures.
• In exceptional complex emergencies when the health system is overwhelmed and unable to serve the health needs of the population, MDA may be considered to reduce malaria morbidity and mortality.
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• Mass primaquine prophylactic treatment, requiring pre-seasonal MDA with daily administration of primaquine for two weeks without glucose-6-phosphate dehydrogenase (G6PD) testing, is not recommended for the interruption of vivax transmission.
• With diagnostic tests currently available, mass screening and treatment (MSAT) and focal screening and treatment (FSAT) are not recommended interventions to interrupt malaria transmission.
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5. CASE MANAGEMENT (MALARIA DIAGNOSIS AND TREATMENT)
5.1 Malaria treatment
TREATING UNCOMPLICATED P. FALCIPARUM MALARIA
• Treat children and adults with uncomplicated P. falciparum malaria (except pregnant women in their first trimester) with one of the following recommended artemisinin-based combination therapies (ACT):
• artemether + lumefantrine
• artesunate + amodiaquine
• artesunate + mefloquine
• dihydroartemisinin + piperaquine
• artesunate + sulfadoxine–pyrimethamine (SP)
Strong recommendation, high-quality evidence
• artesunate + pyronaridine5
Duration of ACT treatment• ACT regimens should provide 3 days’ treatment with an artemisinin derivative.
Strong recommendation, high-quality evidence
Revised dose recommendation for dihydroartemisinin + piperaquine in young children• Children < 25kg treated with dihydroartemisinin + piperaquine should receive a minimum
of 2.5 mg/kg body weight (bw) per day of dihydroartemisinin and 20 mg/kg bw per day of piperaquine daily for 3 days.Strong recommendation based on pharmacokinetic modelling
Reducing the transmissibility of treated P. falciparum infections• In low-transmission areas, give a single dose of 0.25 mg/kg bw primaquine with ACT to
patients with P. falciparum malaria (except pregnant women, infants aged < 6 months and women breastfeeding infants aged < 6 months) to reduce transmission. Testing for glucose-6-phosphate dehydrogenase (G6PD) deficiency is not required.Strong recommendation, low-quality evidence
5 Artesunate pyronaridine is included in the WHO list of prequalified medicines for malaria, the Model List of Essential Medicines and the Model List of Medicines for Children. The drug has also received a positive scientific opinion from the European Medicines Agency and undergone a review by the WHO Advisory Committee on Safety of Medicinal Products and. Although it has not yet been through a formal guideline development process, countries can consider including this medicine in their national treatment guidelines. WHO’s position on the use of this drug for the treatment of malaria can be accessed in the publication (https://www.who.int/publications-detail/use-of-artesunate-pyronaridine-for-the-treatment-of-uncomplicated-malaria) which clarifies that artesunate pyronaridine can be considered a safe and efficacious ACT for the treatment of uncomplicated malaria in adults and children weighing 5 kg and over in all malaria-endemic areas.
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TREATING UNCOMPLICATED P. FALCIPARUM MALARIA IN SPECIAL RISK GROUPS
First trimester of pregnancy• Treat pregnant women with uncomplicated P. falciparum malaria during the first trimester
with 7 days of quinine + clindamycin.Strong recommendation
Infants less than 5kg body weight• Treat infants weighing < 5 kg with uncomplicated P. falciparum malaria with ACT at the same
mg/kg bw target dose as for children weighing 5 kg.Strong recommendation
Patients co-infected with HIV• In people who have HIV/AIDS and uncomplicated P. falciparum malaria, avoid artesunate +
SP if they are being treated with co-trimoxazole, and avoid artesunate + amodiaquine if they are being treated with efavirenz or zidovudine. Good practice statement
Non-immune travellers• Treat travellers with uncomplicated P. falciparum malaria returning to non-endemic settings
with ACT.Strong recommendation, high-quality evidence
Hyperparasitaemia• People with P. falciparum hyperparasitaemia are at increased risk for treatment failure,
severe malaria and death and should be closely monitored, in addition to receiving ACT.Good practice statement
TREATING UNCOMPLICATED P. VIVAX, P. OVALE, P. MALARIAE OR P. KNOWLESI MALARIA
Blood stage infection • If the malaria species is not known with certainty, treat as for uncomplicated P. falciparum
malaria.Good practice statement
• In areas with chloroquine-susceptible infections, treat adults and children with uncomplicated P. vivax, P. ovale, P. malariae or P. knowlesi malaria with either ACT (except pregnant women in their first trimester) or chloroquine.Strong recommendation, high-quality evidence
• In areas with chloroquine-resistant infections, treat adults and children with uncomplicated P. vivax, P. ovale, P. malariae or P. knowlesi malaria (except pregnant women in their first trimester) with ACT.Strong recommendation, high-quality evidence
• Treat pregnant women in their first trimester who have chloroquine-resistant P. vivax malaria with quinine.Strong recommendation, very low-quality evidence
PREVENTING RELAPSE IN P. VIVAX OR P. OVALE MALARIA
• The G6PD status of patients should be used to guide administration of primaquine for preventing relapse.Good practice statement
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• To prevent relapse, treat P. vivax or P. ovale malaria in children and adults (except pregnant women, infants aged < 6 months, women breastfeeding infants aged < 6 months, women breastfeeding older infants unless they are known not to be G6PD deficient, and people with G6PD deficiency) with a 14-day course of primaquine (0.25-0.5 mg/kg bw daily) in all transmission settings.Strong recommendation, high-quality evidence
• In people with G6PD deficiency, consider preventing relapse by giving primaquine base at 0.75 mg/kg bw once a week for 8 weeks, with close medical supervision for potential primaquine-induced haemolysis.Conditional recommendation, very low-quality evidence
• When G6PD status is unknown and G6PD testing is not available, a decision to prescribe primaquine must be based on an assessment of the risks and benefits of adding primaquine.Good practice statement
Pregnant and breastfeeding women• In women who are pregnant or breastfeeding, consider weekly chemoprophylaxis with
chloroquine until delivery and breastfeeding are completed, then, on the basis of G6PD status, treat with primaquine to prevent future relapse.Conditional recommendation, moderate-quality evidence
TREATING SEVERE MALARIA
• Treat adults and children with severe malaria (including infants, pregnant women in all trimesters and lactating women) with intravenous or intramuscular artesunate for at least 24 h and until they can tolerate oral medication. Once a patient has received at least 24 h of parenteral therapy and can tolerate oral therapy, complete treatment with 3 days of ACT.Strong recommendation, high-quality evidence
Revised dose recommendation for parenteral artesunate in young children• Children weighing < 20 kg should receive a higher dose of artesunate (3 mg/kg bw per dose)
than larger children and adults (2.4 mg/kg bw per dose) to ensure equivalent exposure to the drug.Strong recommendation based on pharmacokinetic modelling
Parenteral alternatives where artesunate is not available• If artesunate is not available, use artemether in preference to quinine for treating children and
adults with severe malaria.Conditional recommendation, low-quality evidence
TREATING CASES OF SUSPECTED SEVERE MALARIA PENDING TRANSFER TO A HIGHER- LEVEL FACILITY (PRE-REFERRAL TREATMENT)
Pre-referral treatment options• Where complete treatment of severe malaria is not possible but injections are available, give
adults and children a single intramuscular dose of artesunate, and refer to an appropriate facility for further care. Where intramuscular artesunate is not available use intramuscular artemether or, if that is not available, use intramuscular quinine.Strong recommendation, moderate-quality evidence
• Where intramuscular injection of artesunate is not available, treat children < 6 years with a single rectal dose (10mg/kg bw) of artesunate, and refer immediately to an appropriate facility for further care. Do not use rectal artesunate in older children and adults.Strong recommendation, moderate-quality evidence
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ANTIMALARIAL DRUG QUALITY
• National drug and regulatory authorities should ensure that the antimalarial medicines provided in both the public and the private sectors are of acceptable quality, through regulation, inspection and law enforcement.Good practice statement
MONITORING THE EFFICACY OF ANTIMALARIAL DRUGS
• All malaria programmes should regularly monitor the therapeutic efficacy of antimalarial drugs using the standard WHO protocols.Good practice statement
NATIONAL ADAPTATION AND IMPLEMENTATION
• The choice of ACTs in a country or region should be based on optimal efficacy, safety and adherence.Good practice statement
• Drugs used in IPTp, SMC and IPTi should not be used as a component of first- line treatments in the same country or region.Good practice statement
• When possible, use:• fixed-dose combinations rather than co-blistered or loose, single-agent
formulations; and
• for young children and infants, paediatric formulations, with a preference for solid formulations (e.g. dispersible tablets) rather than liquid formulations.
Good practice statement
Malaria case management, encompassing prompt diagnosis and treatment with an effective antimalarial, is one of the key strategies for the control of malaria.
5.1.1 Malaria treatment optionsThe following points are made to complement the information presented in the box.
Uncomplicated P. falciparum malaria
Artemisinin-based combination therapies (ACTs) are the treatment recommended for all cases of uncomplicated falciparum malaria including in:
• young infants (<5 kg)
• people living with HIV/AIDS
• community case management of malaria
• pregnant women in the 2nd and 3rd trimesters (exception: use in the 1st trimester only if there are no alternative effective antimalarials)
The following six ACTs are presently recommended:
• artemether + lumefantrine
• artesunate + amodiaquine
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• artesunate + mefloquine
• artesunate + sulfadoxine-pyrimethamine
• dihydroartemisinin + piperaquine
Artesunate + pyronaridine may be considered for areas of multi-drug resistance where there are few effective alternative ACTs available.
• artesunate + pyronaridine
Management of uncomplicated malaria treatment failures occurring within 28 days of treatment with 1st line ACT should be with an alternative effective ACT: (since the efficacy and tolerability of ACTs partially depends on the efficacy of the partner medicine, it is possible to use two different ACTs as 1st and 2nd-line options).
Fixed-dose combination (FDC) formulations are strongly preferred and recommended over co-packaged or loose tablet combinations to promote patient adherence to treatment and to reduce the potential selective use of the medicines as monotherapy. Fixed-dose combination formulations are now available for all recommended ACTs, except artesunate plus SP.
Paediatric formulations, with a preference for dispersible tablets rather than liquid formulations are recommended for young children and infants.
Oral artemisinin-based monotherapy medicines
To contain the risk of development of resistance to artemisinin-based combination therapies (ACTs), WHO urges Member States to urgently cease the marketing and use of oral artemisinin-based monotherapy medicines, in both the public and private sectors, and to promote the use of ACTs instead. As part of malaria Resolution WHA60.18 (16), these recommendations were endorsed by all WHO Member States at the 60th World Health Assembly in May 2007, and WHO requests international organizations and financing bodies to cease to fund the provision and distribution of oral artemisinin-based monotherapies (this recommendation does not refer to injectable or rectal formulations, see recommendations on prereferral treatment of severe malaria section). More information on this can be obtained on the GMP website (17).
Pregnancy
The following options are recommended for the treatment of uncomplicated malaria in pregnancy:
• 1st trimester:6 quinine + clindamycin. An effective ACT should be used if quinine + clindamycin is not available. The programmatic difficulty of ensuring an individual’s adherence to this recommendation is acknowledged.
• 2nd and 3rd trimesters: any of the recommended ACTs as listed above.
Preventing relapse in P.vivax or P.ovale malaria
Where ACT (exception AS+SP) has been adopted as the first-line treatment for P. falciparum malaria, it may also be used for P. vivax malaria in combination with primaquine for radical cure.
6 ACT should be used if it is the only effective antimalarial treatment available
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Severe falciparum malaria
Treatment of severe malaria
Parenteral artesunate (IV or IM) is the medicine of choice for severe malaria in all age groups, and in all trimesters of pregnancy – severe malaria is a life-threatening condition. Compared with quinine, artesunate significantly reduces the risk of death and lowers the risk of treatment-associated side effects, including hypoglycaemia, and should be procured in preference.
Pre-referral treatment of severe malaria
The risk of death from severe malaria is greatest in the first 24 hours. Since isolated rural communities often have poor access to health facilities they are most at risk of dying from severe malaria. Pre-referral treatment options for severe malaria depend on the age of the patient and the availability of medicines. First choice pre-referral treatment is a single dose of i.m. artesunate in both children and adults.
• In areas where i.m. injections of artesunate are not available, WHO recommends that children under 6 years of age should receive a pre-referral dose of rectal artesunate (10mg/kg bw), followed by immediate referral and the complete required treatment by injectable artesunate and ACT at a health care facility. If rectal artesunate is not available, artemether or quinine, in decreasing order of preference, should be given intramuscularly prior to immediate referral. Where transfer to a health facility is delayed more than 12 hours, a further dose of rectal artesunate should be given.
• In older children (> 6 years) and adults, options for pre-referral treatment are artesunate (IM), artemether (IM) or quinine (IM). Rectal artesunate should not be used in children > 6 years of age and adults.
5.1.2 Selection and procurement of artemisinin-based antimalarial medicinesWHO recommends the procurement of the six artemisinin-based antimalarial medicines listed on the WHO Prequalification List,7 which is based on stringent and internationally agreed quality assurance criteria.
In addition to products prequalified by WHO, the Global Fund quality assurance policy also accepts antimalarial medicines which are:8
• registered by a Stringent Drug Regulatory Authority (SDRA); or
• approved by the Global Fund Expert Review Panel in cases where a WHO prequalified or SDRA-approved product cannot be made available within 90 days of receipt of the Purchase Order by the manufacturer.
Quality is one of the most important considerations in the manufacture and procurement of medicines. Artemisinin-based antimalarial medicines are particularly vulnerable to degradation by heat and humidity during transport and storage if not manufactured in the appropriate formulations and packaging and have a relatively short shelf life of 2 to 3 years.
Detailed information on each step of the procurement cycle (from estimation of requirements, through tender-related procedures and pre-/post-shipment quality control, to monitoring and evaluation) of antimalarial medicines is available in the 16 step procurement checklist in the manual on Good procurement practices for artemisinin-based antimalarial medicines (18).
7 https://extranet.who.int/prequal/content/prequalified-lists/medicines 8 https://www.theglobalfund.org/media/4756/psm_productsmalaria_list_en.pdf
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Estimating the quantities of antimalarial medicines and rapid diagnostic tests required, especially in those countries that lack a reliable logistic management information system, is a challenging task. If the pipeline is already filled and reliable stock management records are available, requirements can be estimated using the consumption method. If, however, past consumption cannot serve as a guide to the future, the morbidity method should be applied based on recent trends of reported malaria cases. Major sources of errors in estimating drug requirements may include previous budgets were too low; prescribing patterns have changed substantially; new treatments are being introduced; successful malaria control interventions have decreased drug consumption over time or changes in treatment seeking behaviour have resulted from recent changes in policies/interventions. In most situations, a combination of both methods is applicable. The estimations should be adjusted for programme delivery capacity, and take into consideration stock in hand, stock on order, anticipated losses, lead-time, product shelf-life (most malaria RDTs have a 24 month shelf-life but G6PD point of care tests are 12 months) and needs for buffer stocks. To translate the forecast into actual orders, the estimated needs should be matched against available funds.
5.1.3 Malaria treatment policyAntimalarial treatment policy is a set of recommendations and regulations regarding the availability, and the rational use of antimalarial medicines in a country. It provides guidelines for early diagnostic testing and prompt and effective treatment to be adapted as appropriate to the local context, for all levels of the health care systems.
The process of policy change
Changing antimalarial treatment policy in countries requires concerted action by all relevant stakeholders, and continuous stewardship by the Ministry of Health.
The decision on whether an existing treatment policy needs to be changed is based on results of therapeutic efficacy studies of the antimalarial drugs that are already in use, made in line with standard WHO protocols.9 In some elimination settings, integrated disease efficacy for surveillance (iDES) is used to monitor drug susceptibility. WHO’s current recommendation is to change a treatment policy when the:
• treatment failure is >10%, as assessed through monitoring of therapeutic efficacy at 28 days follow-up (42 days follow-up for piperaquine, mefloquine and pyronaridine-containing combinations).
Similarly, an antimalarial medicine should only be selected as a new treatment policy option when the medicine has an average cure rate of >95% as assessed in therapeutic efficacy studies.
The process of implementing a new treatment policy
The following areas and activities are critical to the effective implementation of a revised and/or expanding policy. They have budgetary implications and should thus be taken into account in the preparation of any proposal intending to support the implementation of an ACT based treatment policy:
1. Provision for preliminary activities for planning and development of a framework for implementation or scale-up, such as forecasting, training, and supervision.
2. Provision for procurement and distribution of supplies. To include:
9 See section 5.1.4 on Therapeutic efficacy monitoring for details on protocols. https://www.who.int/malaria/areas/drug_resistance/efficacy-monitoring-tools/en/
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• estimation of needs (medicines and diagnostic tests);10
• procurement costs for antimalarials and diagnostic tests. This should also include the cost of insurance, transportation, delivery, stock management within the country, etc.;
• medicines storage and distribution systems;
• resources for purchase of microscopes, laboratory supplies and malaria rapid diagnostic tests, point of care G6PD tests, control materials and ancillary items.
3. Provision for orientation and training of all health workers in public and/or private sector. To include:
• development and production of training materials and tools for all health workers;
• a budget for orientation, training and updating of health workers;
• funding for periodic supervision of health workers;
4. Provision for behaviour change communication strategy. To include:
• production and pre-testing of education, information (IEC), behaviour change communication (BCC) and advocacy materials;
• implementation of IEC, BCC and advocacy activities targeting various groups (communities, health workers, leaders at different levels and partners);
• activities and tools to enhance compliance with diagnostic test results and ACT treatment.
5. Quality assurance. To include:
• resources to support quality assurance systems for medicines and diagnostics – specifically:
a) resources for quality control (QC) of medicines and diagnostics (malaria and G6PD);
b) resources for post-marketing surveillance of medicines and diagnostics linked to national QC laboratories;
6. Monitoring and evaluation. To include:
• setting up a system for data collection and reporting on distribution and stock-outs of antimalarial medicines and diagnostics;
• routine therapeutic efficacy of first and second line ACTs in representative sites every other year. These should be conducted as an essential surveillance activity of a malaria control programme (See section 6.1.4 below for more information);
• surveys for pfhrp2/3 deletions if there are reports of pfhrp2 deletions in the country or in neighbouring countries (19, 20). Surveys should be according to WHO recommended protocols.
7. Pharmacovigilance. Working in conjunction with the National Regulatory Authority or other body responsible for pharmacovigilance, this should include:
• development and production of Adverse Events Reporting forms;
• cascade training of health workers (public and private sector);
• costs for investigation of reported Adverse Events;
10 See section 5.3 on supply chain management for details on quantification and procurements
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• data processing equipment, data management and communication.
5.1.4 Monitoring antimalarial drug resistanceAntimalarial drug resistance is a major public health problem, which hinders the control of malaria. A summary of worldwide data on antimalarial drug efficacy and drug resistance is available on GMP website: https://www.who.int/malaria/areas/drug_resistance/drug_efficacy_database/en/ and a visual overview is available at http://apps.who.int/malaria/maps/threats/.
WHO developed a protocol for assessing antimalarial drug resistance for all transmission areas, as well as for monitoring efficacy of antimalarial medicines against vivax malaria.
These protocols are designed to provide essential information for monitoring the therapeutic efficacy of a range of antimalarial drugs against uncomplicated falciparum malaria and to ensure a sufficient evidence base from which Ministries of Health can develop informed treatment policies and guidelines. The use of a standardized protocol allows for the comparison of results in country and among countries in the same region.
Routine monitoring of the therapeutic efficacy of artemisinin-based combination therapies (ACTs) is essential for timely changes to treatment policy and can help to detect early changes in P. falciparum sensitivity to artemisinins. WHO currently recommends monitoring the efficacy of first line and second line ACTs every two years in all sentinel sites, and changing antimalarial treatment policy when the treatment failure rate of a 28- or 42-day follow-up study (depending on the medicine) exceeds 10%. The proportion of patients who are parasitemic on day 3 is currently the best available indicator used in routine monitoring to measure P. falciparum sensitivity to artemisinins. Molecular markers for antimalarial drug resistance should be added systematically to the TES. Molecular markers are an early warning signal for the emergence of resistance, can confirm that treatment failures are due to resistance and can be an asset for policy decision and change.
Protocols and tools are available on GMP website: https://www.who.int/malaria/areas/drug_resistance/efficacy-monitoring-tools/en/
5.2 Malaria diagnostic testing
DIAGNOSIS OF MALARIA
• All cases of suspected malaria should have a parasitological test (microscopy or RDT) to confirm the diagnosis. Both microscopy and RDTs should be supported by a quality assurance programme.Good practice statement
5.2.1 BackgroundPrompt and accurate diagnosis of malaria is fundamental to effective disease management and essential to improving the overall management of febrile illnesses. WHO currently recommends:
• prompt parasitological confirmation by microscopy or RDTs in all patients suspected of malaria before treatment.11
11 Treatment solely based on clinical suspicion should only be considered when a parasitological diagnosis is not accessible.
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The ongoing implementation of this recommendation is leading to a progressive shift from presumptive treatment towards parasitological confirmation prior to treatment. This is a major paradigm change, particularly in areas of high malaria transmission for children under five years of age. It has required an increase in the procurement and use of rapid diagnostic tests, as well as a continued need for strengthening of laboratory and microscopy services.
In line with the above, estimation of the requirements and costs (direct and indirect) of malaria diagnostic tests should be factored into the cost of case management, and should include: the training of health workers; consumer education; supervision; quality assurance services, surveillance for pfhrp2/3 deletions where applicable, and cost of other consumables – slides, reagents, lancet, gloves etc.
Clinical diagnosis of malaria has poor accuracy and leads to over-diagnosis, with resultant inappropriate management of non-malarial febrile illness and wastage of antimalarial medicines. As such, evidence of the presence of malaria parasites prior to treatment with antimalarial medicines is fundamental and WHO recommends parasitological confirmation of malaria through quality-assured diagnostic testing in all settings before treatment is started. Prompt diagnostic confirmation of malaria can be achieved through good quality microscopy or quality-assured RDTs, depending on the setting / area of intended use.
5.2.2 MicroscopyAn acceptable microscopy service is one that is cost-effective, provides results that are consistently accurate and timely enough to have a direct impact on treatment. This requires a comprehensive and active quality assurance (QA) programme. The primary aim of malaria microscopy QA programmes is to ensure that microscopy services employ competent and motivated staff, who are supported by effective training and supervision and by a logistics system that provides and maintains an adequate supply of reagents and equipment and maintains high level of competency and performance. QA programmes must be sustainable, compatible with the needs of each country, and able to fit into the structure of existing laboratory services. A QA programme should: appropriately recognize performance and accredit competence; identify laboratories and microscopists with problems resulting in poor performance and implement corrective measures; and establish regional or national benchmarks for quality of diagnostic testing and central reporting of indicators including accuracy, equipment and reagent performance, stock control and workload. Without an efficient QA programme, resources spent on diagnostic services are likely to be wasted and clinicians will have no confidence in the results.
At a minimum, a malaria microscopy QA programme should include the following:
• a central coordinator(s) to oversee QA;
• a reference (core) group of microscopists at the head of a hierarchical structure, supported by an external QA programme and with demonstrable expertise in overseeing programme training and validation standards;
• good initial training with competency standards that must be met by trainees prior to operating in a clinical setting;
• clear standard operating procedures (SOPs) at all levels of the system;
• regular retraining and assessment/grading of competency, supported by a well validated reference slide set (slide bank);
• a sustainable cross-checking (validation) system that detects gross inadequacies without overwhelming validators higher up the structure, with good feed-back of results and a system to address inadequate performance;
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• good outreach training and supportive supervision at all levels;
• good logistical management, including supply of consumables and spare parts for maintenance of microscopes;
• an adequate budget as an essential part of funding for malaria case management.
5.2.3 Rapid diagnostic tests (RDTs)It is the responsibility of each national malaria control programme to select well performing RDTs that are adequate for the intended setting. To guide the selection and procurement of RDTs a WHO Information note on recommended selection criteria for procurement of malaria rapid diagnostic tests (RDTs) is available on the website (21). Since January 2019, WHO requires that malaria RDTs intended for the following purposes should be WHO-prequalified:
1. malaria RDTs that diagnose P. falciparum-only through detection of histidine rich protein 2 (HRP2);
2. malaria RDTs that diagnose and distinguish between P. falciparum (through detection of HRP2) and non falciparum malaria and/or P. falciparum (through detection of HRP2) and P. vivax.
The list of all currently prequalified malaria RDTs and those in the pipeline is available on the WHO prequalification website.12
Concerning all other types of malaria RDTs, including Pan-only detecting RDTs and RDTs specifically targeting non-HRP2 antigens, i.e. Pf-LDH for the detection of P. falciparum, WHO procurement requirements are the following, until further notice:
• a valid ISO 13485:2003,
• application for WHO prequalification submitted, and
• acceptable performance indicators in product testing, as per WHO assessment, based on the results of WHO malaria RDT product testing, as indicated below:
• for the detection of P. falciparum in all transmission settings, the panel detection score against P. falciparum samples should be at least 75% at 200 parasites/μL;
• for the detection of P. vivax in all transmission settings, the panel detection score against P. vivax samples should be at least 75% at 200 parasites/μL;
• the false positive rate should be less than 10%;
• the invalid rate should be less than 5%.
In addition to the above criteria, national health authorities should take the following factors into consideration when selecting appropriate malaria RDTs for procurement:
• stability requirements at temperatures of intended storage, transport and use;
• ease of use and training requirements for health workers;
• supplier production capacity and lead times;
• delivery schedules, box size and shelf life;
12 https://www.who.int/diagnostics_laboratory/evaluations/190121_prequalified_product_list.pdf
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• product registration requirements of the national regulatory authorities.
Once all these factors have been considered, other parameters should also be evaluated, such as completeness of the kits (e.g. inclusion of lancets and alcohol swabs), programmatic needs, and price. It must be stressed that price alone should not be the determining factor for the procurement of RDTs.
Any plans to change the type of RDT in routine use should take into consideration all corresponding training and programmatic requirements.
5.2.4 Point of care G6PD tests Both qualitative and quantitative point of care G6PD tests have recently been commercialized. No products currently have WHO prequalification but one is in the pipeline and others are expected to be submitted in 2020.
Qualitative tests can distinguish between deficient and non-deficient cases (<30% of normal G6PD activity and > 30% of normal G6PD activity) but cannot discriminate those with intermediate G6PD enzyme activity (heterozygous women).
In 2015, a WHO technical consultation concluded that the CareStart G6PD RDT (Access Bio Inc) performed comparably with the fluorescent spot tests (the recommended screening test for several decades). However, the performance was based largely on studies conducted by trained laboratory technicians and the absence of a control line, as well as somewhat subjective read out (colour change), would need to be cautiously monitored in programmatic settings.
Following the Expert Review Panel for Diagnostics (ERPD) assessment the CareStart G6PD RDT was granted ERPD Risk Category 3,meaning they may be considered for time- limited procurement only if there is no other option and if the risk of not diagnosing and/or making treatment decisions is higher than the risk of using the product. In April 2019, the SD Biosensor quantitative G6PD test was granted Risk Category 2 approval, meaning they may be considered for time-limited procurement. Both products have commercially available control materials that can be purchased separately.
G6PD point of care tests currently have shelf lifes of 12 months (compared to 24 months for malaria RDTs) and can be stored and transported up to 30°C maximum (compared to 40°C for most malaria RDTs). These differences in storage/transport requirements and shelf life need to be carefully managed to avoid stock outs and reduced performance.
5.2.5 RDT lot testing programmeThe performance of individual malaria RDTs is likely to vary between lots over time. It is therefore recommended that all lots of RDT procured be checked for quality prior to large-scale deployment in the field, and that a process of monitoring RDT performance in the field should be put in place. This should be applied to all RDTs. WHO lot testing services are available free of charge and results are provided within seven days of RDTs being received at the testing laboratory. Full information on WHO procedures for RDT lot testing request and shipping is available on the website.13
13 https://www.who.int/malaria/areas/diagnosis/rapid-diagnostic-tests/evaluation-lot-testing/en/
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5.2.6 P. falciparum histidine-rich protein 2/3 gene deletionsMost of the currently available commercial RDT kits work by detecting a specific protein expressed only by P. falciparum, called HRP2, in the blood of people infected with falciparum malaria. The antibodies on the test strip recognize the PfHRP2 antigen but may cross-react with HRP3, another antigen produced by the HRP gene family, pfhrp3, with strong similarity of the amino acid sequence. The general preference for PfHRP2-based RDTs is due largely to their higher sensitivity and heat-stability than RDTs that detect other malaria antigens, such as plasmodium lactate dehydrogenase (pLDH) – pan (all species) or P. falciparum-specific – or aldolase.
If P. falciparum parasites have pfhrp2 gene deletions, RDTs targeting only HRP2 antigens may give a false negative result. In light of recent confirmation of high prevalence of HRP2 deletions in P. falciparum parasites in Eritrea and reports of lower prevalence in several African countries, WHO has provided guidance to RDT manufacturers, procurers, implementers and users on procedures for confirming (or excluding) pfhrp2/pfhrp3 gene deletions and on investigating other causes of suspected false-negative RDT results (19)..
Countries with reports of confirmed pfhrp2 deletions, and countries that neighbour these countries, should conduct surveys to determine if pfhrp2/pfhrp3 gene deletions account for ≥ 5% of false negative RDT results. If so, then, alternative RDTs detecting non-HRP2 antigens should be procured, with development of new algorithms and job aids, and re-training of health care providers in the use of the new RDTs. Therefore, all investigations must be carried out systematically and accurately following WHO protocols. A WHO global response plan describes the range of activities that are required to address the threat of pfhrp2/3 deletions (22).
5.3 Plan of activities for budgeting purposesTo allow for adequate budgeting, it is essential to make a comprehensive list of activities and commodities for which funding is required. Below is an example of such a list.14 This is not exhaustive and should be modified and customized per the country’s specific needs:
1. Completion of preliminary activities – such as quantification and training, and introduction and procurement planning of medicines and/or diagnostics supply.
2. Orientation and training of all health workers in public and private sector on the use of medicines and rapid diagnostic tests. These activities should be planned in conjunction with MoH staff responsible for an integrated approach to the management of febrile patients, and include:
• development and production of training materials for all health workers;
• a budget for orientation and training of health workers;
• resources for periodic supervision of health workers.
3. Elaboration of behaviour change communication strategy:
• development, field-testing and production of IEC and advocacy materials;
• education and communication activities targeting various groups (e.g. communities, health workers).
14 See table “Components of a budget for strengthening malaria diagnosis”, in Universal access to malaria diagnostics testing: an operational manual: https://apps.who.int/iris/bitstream/handle/10665/44657/9789241502092_eng.pdf#page=52
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4. Procurement and distribution of malaria medicines and diagnostics:
• Quantification: Estimation of needs and forecast of demand for medicines and rapid diagnostic tests as well as required ancillary items.
• Procurement running costs for medicines and diagnostic tests should not only consider cost of goods prices but also the costs of freight, insurance, programme support, port clearance and customs procedures, in-country distribution and storage. Costs of tender-related procedures (preparation of tender documents, tender invitation and bid evaluation by sufficient staff with appropriate expertise) must also be included.
• Transport and storage: All necessary equipment (including for distribution, storage, and RDT waste management) need to be taken into account, together with maintenance costs.
5. The implementation and ongoing running of sound quality assurance systems for medicines as well as diagnostics (pre-/post-shipment quality control systems for medicines and pre-/post-shipment lot testing for RDTs). Quality assurance materials and services for microscopy and RDTs.
6. Development and implementation of sound monitoring systems:
• to collect and evaluate data concerning in-country distribution and stock-outs on medicines and RDTs (from all levels of the health care system);
• therapeutic efficacy and resistance monitoring;
• pharmacovigilance (development and production of adverse events reporting forms, cascade training of health workers (public and private sector), costs for investigation of reported cases, data processing equipment, data management and communication).
5.4 Delivery of malaria treatment Progress towards the Sustainable Development Goal target 3.8 on Universal Health Coverage (UHC) and target 3.3 on communicable diseases, requires countries to move towards ensuring that all people and communities have access to health services and commodities that are high quality, safe and acceptable.
Universal health coverage is a commitment for universal access to a strong and resilient people-centred health system. Implicit in the definition of UHC is that the services are of high quality, meaning that more people, especially the poorest and most vulnerable, are diagnosed correctly and receive the interventions they need.
Primary health care is the foundation of UHC. Primary health care (PHC) is the most equitable, efficient, cost-effective and sustainable platform for delivering malaria services. It is intended to provide most of the services that people need, supplemented by emergency care, hospital-based treatment and crisis management of epidemics, when required.
Governments are the stewards of health systems, orchestrating services so that they are financially viable and designed to suit the local context, user needs and preferences. Delivery will vary according to factors such as health-seeking behaviour, the accessibility and functioning of the public and private health infrastructure, availability of the private retail sector and the potential of community cadres. The different service delivery points should be mapped alongside information on changing epidemiological and demographic trends, and social and cultural contexts, to help identify the optimal delivery channels.
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5.4.1 Community delivery Malaria imposes its greatest burden in remote rural areas of endemic countries where health services are weakest, and most people do not have ready access to quality malaria diagnostic testing and treatment. WHO recommends that diagnostic testing and effective treatment should be made available at all levels of service delivery, including at community level. Once ACTs are adopted by a country as first line treatment, mechanisms to facilitate access to malaria RDTs and ACTs – including, where appropriate, making them available at the community level – should rapidly be put in place.
To facilitate access to essential treatment at the community level, countries should consider the potential of integrated community case management (iCCM) as a component of Primary Health Care. iCCM can act as an extension of health facility service delivery points and may be incorporated into the overall malaria and child health strategic and implementation plans.
WHO recommends that community case management of malaria be delivered as part of iCCM, which also includes the treatment of pneumonia and diarrhoea in children under five years of age. While the Global Fund does not currently allow for funding of antibiotics or ORS and zinc, the funding of most community case management services (including the training, supervision, and supply chain systems for community delivery of case management through an iCCM platform) may be supported by Global Fund Grants.
Implementation of the full iCCM package is associated with an increase in rational use of antimalarials, and countries are strongly encouraged to secure funds for the procurement of all commodities needed for iCCM, including antibiotics, ORS and zinc.
Implementation requirements
In countries that do not have any experience of community-based malaria case management, it is recommended that implementation be undertaken in a phased manner to allow the country to build up experiences and document best practices. Reference can be made to the iCCM Benchmarks Matrix, which lays out the necessary steps to take across the various critical programme components of iCCM. Opportunities to learn from experience in neighbouring countries that have deployed iCCM should also be considered.
To scale up malaria case management as part of an iCCM strategy, the following steps need to be taken and should have clear and specific budget lines:
• sensitization of all stakeholders at national, sub-national, district and community levels;
• development of integrated training materials based on the WHO Caring for Sick Child in the Community manual for community-based providers;
• development of a community engagement strategy, including the community’s engagement in planning, implementing and uptake of quality iCCM services;
• development of behaviour change communication strategies and materials to create demand and increased care seeking for sick children;
• training of selected community-based providers on iCCM, including malaria case management, diagnostics and medicine handling, and reporting;
• procurement and distribution of age-based pre-packed treatment courses of ACT ;
• procurement and distribution of quality-assured RDTs;
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• development of a supportive supervision strategy to ensure retention of community health worker case management skills, quality of reporting, availability of commodities at community level and linking of health facilities to communities and their community-based providers;
• mechanisms for motivation and retention of community-based providers;
• development of a monitoring and health information system with simple recording tools harmonized with health facility tools to collect data from community activities. This is essential to guide action at the local level, ensure accountability and sustained improvement of iCCM programming;
• data flow from community-based providers, integrated in the health facility management information system;
• improvement in the quality of care at first level and inpatient referral facilities for management of children referred from the community.
Challenges related to deployment of ACTs and RDTs at community level
Many countries have implemented iCCM at scale or are in the process of scaling up iCCM. Major challenges in scale-up include:
• weaknesses in sustainable financing and integration of iCCM into the national health system;
• lack of a programme/institution in charge of iCCM coordination;
• a coherent remuneration and motivation strategy for community-based providers;
• poor supervision due to shortage of staff at health facilities, weak links between community-based providers and health facilities, and limited dedicated funds for supervision;
• non-integrated iCCM supply chain, poor data on iCCM commodity consumption, and inadequate funding for pneumonia and diarrhoea commodities;
• parallel community information systems supported by partners;
• absence of a community engagement strategy.
These challenges may require operational research at country level to address the issues, and countries are encouraged to include the resources for this in their funding requests.
5.4.2 Working through the private sector In many countries the private sector is the first source of care for malaria for considerable portions of the population. Private providers may include pharmacies, authorised and informal drug shops, and other medicine sellers, in addition to private health facilities. As much as possible, countries should engage with the different parts of the private sector to ensure the provision of quality care for malaria, including diagnostic testing and ACTs, as part of national efforts to reduce the burden of malaria. The following priority activities should be considered:
• Promotion: Governments, NMCPs and other key stakeholders should invest in demand generation among the population for better quality care in the private health sector, with behaviour change and communication activities promoting malaria diagnostic testing and compliance with the results as part of “T3: test, treat and track”.
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• Quality of care: The confidence in the quality of care delivered by private sector providers can be enhanced through: 1) accreditation systems for drug shops; 2) training in malarial and non-malarial fever case management, and professional development schemes for private health care providers; 3) supervision of private health care providers, ideally by existing government health care workers; and 4) increasing the availability and affordability of quality diagnostics and medicines.
• Policy and regulations: Country policies and regulations should be reviewed and revised to ensure consistency on where mRDTs can be sold and who can perform them, and where antimalarials can be accessed and who can prescribe and/or sell them. This should take into account client care-seeking practices and supporting the extension of quality malaria testing to ensure the rational use of malaria medicines. Guidance should be developed and behaviour change promoted – by health workers, community-based providers, private providers, as well as the communities they serve – to ensure that health care providers and patients know what should happen in the event of a negative malaria test result.
• Market information: The lack of detailed current information on private sector antimalarial and RDT market dynamics, especially outside the large urban areas, should be addressed and results disseminated among all stakeholders. As countries differ, each needs to undertake an in-depth market review, with periodic updates to monitor progress and inform future actions.
• Surveillance: Simple systems should be developed to allow the private sector to be fully integrated into national malaria surveillance systems, and providers should be supported to report complete, accurate and timely data through training, supervision and appropriate incentives.
• Pricing and incentives: Countries should ensure that quality-assured products crowd out poor-quality and inappropriate products through pricing and other measures that make them preferred by patients and providers. The cost to the caregiver/patient of the testing and treatment package should be affordable and promote appropriate case management. Taxes and tariff systems for finished products should be aligned so that diagnostics are not disadvantaged compared to quality ACTs or other pharmaceutical products.
• Coordination: As different stakeholders are not always aligned on how to involve the private sector in delivering quality case management, it is necessary to bring all groups together to work out ways to overcome this constraint, under the stewardship of government.
Countries should develop and explore innovative models for organizing and engaging the private sector to expand access to subsidized ACTs and RDTs. The public sector should provide overall stewardship to private providers, including training on use of RDTs, patient counselling, drug handling, dispensing and referral of severe cases. The public sector should subsequently monitor private providers to ensure they maintain quality of care standards and reliable record-keeping. A multi-agency, multi-country project aiming to increase malaria rapid diagnostic testing outlines a step by step approach for engagement through implementation.15
15 https://www.psi.org/wp-content/uploads/2019/06/PSI-Private-Sector-RDT-Roadmap.pdf
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6. MALARIA ELIMINATION AND PREVENTION OF RE-ESTABLISHMENT
6.1 IntroductionMalaria elimination is the ‘interruption of local transmission (reduction to zero incidence of indigenous cases) of a specified malaria parasite in a defined geographical area because of deliberate activities’. Continued measures to prevent re-establishment of transmission are required. The certification of malaria elimination in a country will require that indigenous transmission is interrupted for all human malaria parasites.
The GTS calls for all malaria-endemic countries to accelerate efforts towards elimination and attainment of malaria-free status. The actions that programmes along the continuum of malaria transmission, from very high to very low, can take to move towards elimination are highlighted in the WHO Framework for malaria elimination (23). The distinct categories of ‘control,’ ‘elimination’ and ‘pre-elimination’ are no longer used, and the Framework recommends that all countries move towards elimination through successive steps of iterative planning with anticipation of transitions and evolving approaches. In addition, the Framework stresses the importance of adapting and tailoring interventions to subnational areas in the same country, based on stratification.
Elimination can be considered achieved when there are zero indigenous cases over a period of three years, and a robust surveillance and response system is in place to prove it. However even after elimination has been achieved, continued intervention measures are required for as long as the area remains receptive to transmission and exposed to importation of parasites16. Countries must develop strategic plans to prevent re-establishment of transmission, the second requirement for certification after achieving three years of zero indigenous cases.
6.2 Progressing towards malaria elimination To reduce the disease burden and progress to elimination as soon as possible, countries should seek to promote universal coverage with an appropriate mix of malaria interventions in populations at risk.
Countries should stratify subnational areas, according to the burden and characteristics of malaria, to identify the appropriate mix and intensity of interventions. By stratifying subnationally, countries can accelerate subnational elimination of malaria by targeting appropriate interventions according to the burden of disease, set subnational elimination targets and monitor progress.
6.3 Main elements of a malaria elimination strategyMost countries introduce malaria elimination in a geographically phased manner, expanding the programme area over time. The Framework describes the principles, practice, tools and approaches, as well as monitoring and evaluation requirements, for malaria elimination.
16 Receptivity is the degree to which an ecosystem in a given area at a given time allows for the transmission of Plasmodium spp. from a human through a vector mosquito to another human. Note: This concept reflects vectorial capacity, susceptibility of the human population to malaria infection, and the strength of the health system, including malaria interventions. Receptivity depends on vector susceptibility to particular species of Plasmodium and is influenced by ecological and climatic factors. Importation of parasites is of particular concern in countries that neighbour highly endemic areas, or otherwise experience high rates of population exchange with such areas.
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6.3.1 National strategy, coordination and advocacyCountries need highly competent and dedicated staff at national and subnational levels with expertise in malaria prevention and control activities. Countries need a national strategic elimination plan that is aligned with WHO guidance, up to date, costed and implemented. The plan should include the stratification scheme (described below) and a monitoring and evaluation plan to ensure that activities and impact are occurring as planned.
Community engagement should be considered from the outset of an elimination programme and be specifically addressed as part of the national strategic plan (25). Countries should develop specific structures to promote community engagement in developing and evaluating the elimination programme and its impact in their locality.
WHO recommends that countries have independent national elimination advisory committees in place to help monitor progress, address elimination bottlenecks, provide an objective review of case classifications when approaching zero indigenous cases, oversee subnational elimination and assist with coordination of the certification process. Suggested terms of reference are available in the Framework for malaria elimination.
6.3.2 Stratification: the starting pointAccurate stratification of malaria transmission intensity is essential for effective targeting of interventions. Stratification involves classification of geographical units according to their current transmission intensity and characteristics of malaria, and, once transmission intensity has been reduced, according to their receptivity to malaria and risk for importation of malaria cases. As countries progress towards elimination, finer-scale mapping is required, and stratification should be more specific, ideally at the level of localities or health facility catchment areas, and ultimately at the level of transmission foci.
Malaria surveillance, case management, vector control and chemoprevention strategies must be targeted appropriately based on the stratification scheme. The appropriate targeting will be based on the number of malaria cases and their classification, underlying receptivity and risk of importation, and the health system capacity to undertake activities. For example, a district with more than 1000 local malaria cases per year would need between 5-10 investigation teams before they could begin case and focus investigations, but districts with only 100 local malaria cases per year could consider starting case and focus investigations with 1-2 investigation teams. Vector control should be targeted to all areas of active transmission as well as those areas that have eliminated but remain receptive to transmission and have a risk of malaria importation. Mass drug administration can be used to reduce P. falciparum transmission in areas where there is good access to case management, effective implementation of vector control and surveillance and minimal risk of parasite importation.
6.3.2 Passive surveillance and case managementThe backbone of a successful elimination programme is the passive surveillance system in which suspected malaria cases are identified, tested using microscopy or rapid diagnostic tests, treated according to WHO guidelines and notified to the surveillance system for further investigation. Without a strong passive surveillance system, it is not possible to implement more intensive surveillance strategies such as case and focus investigations.
Passive surveillance systems must be fully operational throughout the country, even in areas not receptive to transmission but where imported malaria cases may be diagnosed. Private, military, social security and police clinics with the potential to receive suspected malaria cases must also fully participate in the malaria surveillance system.
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Critical milestones for monitoring progress in implementing elimination-ready passive surveillance and case management include:
• malaria is a notifiable disease nationwide;
• all cases of malaria in the public as well as the private sectors are confirmed by quality-assured microscopy or WHO-prequalified rapid diagnostic tests;
• all confirmed cases of malaria have their treatment supervised to ensure compliance, and are followed-up to day 28 (or 42, depending on the half-life of the antimalarial treatment) to ensure compliance and cure;
• full engagement of the private sector including reporting, and phasing out the sale of antimalarial medicines;
• nationwide microscopy and antimalarial drugs quality assurance system covers both the public and private sector;
• a single low-dose of primaquine is used to reduce transmission from cases of P. falciparum (see section 6.1);
• national policy for radical treatment with primaquine for P. vivax is fully implemented.
6.3.3 Active surveillance Active case detection can play an important role by targeting high risk populations who may not receive a timely diagnosis of malaria through passive case detection. Countries should identify their actual or potential high-risk groups and supplement passive case detection with active case detection when necessary.
6.3.4 Enhancing and optimizing vector controlVector control strategies, such as use of insecticide-treated mosquito nets (ITNs/LLINs) and indoor residual spraying (IRS), supplemented by larval source management when appropriate, are critical for reducing malaria transmission. Entomological surveillance should be able to characterize receptivity to guide stratification and selection of interventions, determine the seasonality of transmission for optimal timing of interventions, and monitor the susceptibility of vectors to insecticides used in vector control.
In many countries, continued implementation of core vector control interventions will be required even as transmission is markedly reduced: a large proportion of the reduction in receptivity is due to vector control. Once elimination has been achieved, vector control may be “focalized” rather than scaled back, i.e. the intervention should be made available for defined at-risk populations to prevent re-establishment or resumption of local transmission.
6.3.5 Population-wide parasite clearanceMass drug administration is currently recommended for consideration in areas approaching elimination of P. falciparum where there is good access to treatment, surveillance and vector control, and limited parasite importation. Decisions to deploy mass drug administration should only be made after careful assessment of these factors and the potential benefits and costs. The WHO Manual on mass drug administration can provide more details on how to operationalize mass drug administration campaigns (24).
7.3.6 Surveillance to target individual cases and foci of transmissionSurveillance systems should identify the areas and population groups most affected by malaria, assess the impact of interventions and progress towards elimination, actively identify
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and treat cases to prevent onward transmission, investigate cases to determine their likely location of infection and monitor the malaria-free status of areas that have eliminated transmission.
When countries approach elimination, all cases need to be investigated immediately to first determine whether they are imported (infected in another country) or local (infected within the country, including both introduced and indigenous cases). The main purpose of the case investigation is to gather enough information to determine where the patient was during the likely period of infection, which for P. falciparum is 9-14 days before symptom onset, and for primary infections with P. vivax is 12-17 days before symptom onset. The case investigation also gathers information on characteristics of the case that can be used to identify high-risk groups. Most case investigations should be conducted at the household level to ensure there is enough time for a thorough investigation, but when cases are clearly imported, it is possible to conduct case investigations at the health facility.
Once a case has been classified as local or imported, additional investigations may be needed to determine whether a local case is further classified as indigenous or introduced. The distinction between indigenous and introduced is rarely useful until countries are within 1-2 years of reaching 0 indigenous cases, generally when the number of local cases is <20 per year. Additional investigations to help distinguish indigenous from introduced cases when there is no history of travel includes record reviews of health facilities in the area to identify imported cases, reactive case detection around the index case and, in some cases, entomological surveillance to determine whether the area is receptive.
Focus investigations are conducted in the likely location of infection when the number of cases is very low and additional information is needed to respond appropriately. The purpose of the focus investigations is to identify the factors contributing to transmission and address them systematically through development of a focus microplan. Focus investigations can begin with the case investigation, if the likely location of infection is determined to be the homestead, and do not have to be considered a separate step. However, if it appears that transmission occurred outside the homestead, focus investigations need to take place at the likely location of infection, whether that is in a forest or another part of the district. Focus investigations may include: desk review of existing data on the focus; active detection of malaria cases in the area around the index malaria case (known as ‘reactive case detection’) to determine the extent of transmission; entomologic investigations to identify putative vector species, their abundance and insecticide susceptibility and, if larval source management is a potential intervention, identification of larval breeding sites; and key informant interviews to understand changes in environment, weather, healthcare seeking or changes in other factors that could affect malaria transmission.
7.3.7 Prevention of re-establishmentAs an area or a country approaches elimination, plans for prevention of re-establishment should be initiated. Preventing the re-establishment of malaria transmission requires proper management of receptivity (the ability of an ecosystem to allow transmission of malaria) and risk of malaria parasite importation.
Management of receptivity requires vector control, and areas that are receptive with risk of parasite importation may need to continue vector control even after elimination. In order to manage the risk for re-establishment of malaria transmission effectively, a high-performing surveillance system should be maintained to ensure early detection, mandatory notification, prompt treatment and thorough investigation of all malaria cases.
Once malaria elimination has been achieved, the malaria programme should be integrated into public health programmes in order to maintain the necessary technical expertise, even if the responsible staff no longer work solely on malaria. After elimination, response to malaria cases should be integrated into the country’s outbreak response system.
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Political and financial commitment for malaria must be sustained at national and subnational levels even after elimination to prevent re-establishment.
Prevention of re-establishment can be enhanced through cross-border collaboration with neighbouring countries that have a higher burden of malaria. Face-to-face meetings between districts or health facilities on either side of the border and simple social media platforms can help facilitate communication and collaboration.
6.3.8 Preparing for certification of malaria-free statusCertification of malaria elimination is granted by WHO to a country after it has been proven beyond reasonable doubt that human malaria transmission has been interrupted in the country, resulting in zero indigenous malaria cases for at least the past 3 consecutive years, and a programme for the prevention of re-establishment is in place. Certification of malaria elimination is a voluntary process initiated at a country’s request. The certification process provides an expert, objective and independent review and evaluation of a country’s declaration of malaria elimination and programme to prevent re-establishment of transmission. Preparation for certification begins before countries interrupt malaria transmission through development of national strategic elimination plans, effective implementation of planned activities, monitoring of progress and evaluation of impact. Documentation of efforts must begin during this time. Regular programme audits and intervention assessments, including surveillance assessments, should be conducted to determine whether key components of the elimination programme are being implemented effectively and whether documentation of activities and impact is occurring appropriately.
Countries approaching elimination should begin preparing for certification, which requires maintenance of records and documents to support a country’s claim of having eliminated malaria.
6.3 Tools to assist in auditing elimination programmes and planning for certification
A number of documents exist to help orient countries to the appropriate strategies and activities for elimination, including the Framework for malaria elimination and the Malaria surveillance, monitoring and evaluation: a reference manual. In addition, WHO has prepared the Malaria Elimination Audit Tool (MEAT) which countries can use as a checklist to prepare national strategic plans, for self-audit of programme status and for preparation of documentation needed for certification. The MEAT is currently being finalized but is available from the Global Malaria Programme by request ([email protected]).
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REFERENCES
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2. WHO | Statement by the Malaria Policy Advisory Committee on reconsidering the formulation of malaria policy guidance [Internet]. WHO. Available from: https://www.who.int/malaria/mpac/statements/malaria-policy-guidance/en/
3. World malaria report 2019. Geneva: World Health Organization; 2019 (https://apps.who.int/iris/bitstream/handle/10665/330011/9789241565721-eng.pdf)
4. Global Technical Strategy for Malaria 2016–2030. Geneva: World Health Organization; 2015 (http://apps.who.int/iris/bitstream/10665/176712/1/9789241564991_eng.pdf)
5. Compendium of WHO malaria guidance: prevention, diagnosis, treatment, surveillance and elimination. Geneva: World Health Organization; 2019 (https://apps.who.int/iris/bitstream/handle/10665/312082/WHO-CDS-GMP-2019.03-eng.pdf)
6. Malaria surveillance, monitoring & evaluation: a reference manual. Geneva: World Health Organization; 2018 (http://apps.who.int/iris/bitstream/handle/10665/272284/9789241565578-eng.pdf)
7. Malaria programme reviews: a manual for reviewing the performance of malaria control and elimination programmes (details to be provided later).
8. Daniel J Weiss, Tim C D Lucas, Michele Nguyen, Anita K Nandi et al. (2019). Mapping the global prevalence, incidence, and mortality of Plasmodium falciparum, 2000–17: a spatial and temporal modelling study, The Lancet in press.
9. Guidelines for malaria vector control. Geneva: World Health Organization; 2019 (https://apps.who.int/iris/bitstream/handle/10665/310862/9789241550499-eng.pdf).
10. Global plan for insecticide resistance management in malaria vectors. Geneva: World Health Organization; 2012 (https://www.who.int/iris/bitstream/10665/44846/1/9789241564472_eng.pdf)
11. WHO | Intermittent preventive treatment in pregnancy (IPTp) [Internet]. WHO. Available from: http://www.who.int/malaria/areas/preventive_therapies/pregnancy/en/
12. WHO recommendations on antenatal care for a positive pregnancy experience. Geneva: World Health Organization; 2016 (http://apps.who.int/iris/bitstream/10665/250796/1/9789241549912-eng.pdf)
13. Guidelines for the treatment of malaria. Third edition. Geneva: World Health Organization; 2015 (https://apps.who.int/iris/bitstream/handle/10665/162441/9789241549127_eng.pdf#page=103)
14. Seasonal malaria chemoprevention with sulfadoxine-pyrimethamine plus amodiaquine in children: A field guide. Geneva: World Health Organization; 2013 (http://apps.who.int/iris/bitstream/10665/85726/1/9789241504737_eng.pdf)
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15. WHO Malaria Policy Advisory Committee and Secretariat. Malaria Policy Advisory Committee to the WHO: conclusions and recommendations of eighth biannual meeting (September 2015). Malar J (2016) 15:117 (DOI 10.1186/s12936-016-1169-x)
16. Resolution WHA60.18. Malaria, including proposal for establishment of World Malaria Day. In Sixtieth World Health Assembly, Geneva, 14–23 May 2007. Resolutions and decisions, annexes. Geneva: World Health Organization; 2007. (http://apps.who.int/gb/ebwha/pdf_files/WHASSA_WHA60-Rec1/E/WHASS1_WHA60REC1-en.pdf#page=65)
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19. False-negative RDT results and P. falciparum histidine-rich protein 2/3 gene deletions. Geneva: World Health Organization; 2017 (https://apps.who.int/iris/bitstream/handle/10665/258972/WHO-HTM-GMP-2017.18-eng.pdf)
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21. Information note on recommended selection criteria for procurement of malaria rapid diagnostic tests (RDTs) Geneva: World Health Organization; 2018 (http://apps.who.int/iris/bitstream/10665/259870/1/WHO-CDS-GMP-2018.01-eng.pdf)
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23. A framework for malaria elimination. Geneva: World Health Organization; 2017 (http://apps.who.int/iris/bitstream/10665/254761/1/9789241511988-eng.pdf)
24. Mass drug administration, mass screening and treatment and focal screening and treatment for malaria. Geneva: World Health Organization; 2015 (http://apps.who.int/iris/bitstream/10665/259367/1/9789241513104-eng.pdf)
25. WHO | Integrated community case management of malaria [Internet]. WHO. Available from: http://www.who.int/malaria/areas/community_case_management/overview/en/
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QUI
CK
REFE
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E TA
BLE
Cur
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WH
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com
men
datio
ns o
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for c
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Cas
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and
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tive
mal
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cas
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iagn
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treat
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in a
ll ar
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incl
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ose
with
out l
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mal
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tra
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type
of
para
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age
of p
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with
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atm
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of P
f).
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and
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may
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d re
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sub
natio
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anal
ysis
to d
esig
n th
e m
ost
appr
opria
te a
ppro
ache
s.
Refe
r to
sect
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5.1 f
or d
etai
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m
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ent
One
of t
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ain
cons
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ns
for t
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to
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are
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ofte
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out
side
of 5
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publ
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ser
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pro
vide
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Com
mun
ity h
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wor
kers
to tr
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can
be
esta
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any
m
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bigg
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are
as w
here
bur
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ly in
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of fi
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) is
rela
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y hi
gh. F
or
exam
ple,
are
as w
here
infe
ctio
n m
ay
be p
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nt in
mor
e th
an 10
% of
the
child
ren
and
whe
re a
ll ca
use
U5
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talit
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high
.
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use
iCC
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des
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se a
cces
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porta
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hild
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nder
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Info
rmat
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need
ed to
pla
n iC
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tion
incl
ude:
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prim
ary
care
hea
lth
(PH
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ties;
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nctio
nal c
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ked
to P
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• su
bnat
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• su
bnat
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inci
denc
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mor
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age
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alar
ia a
nd
othe
r iCC
M d
iseas
es
• su
bnat
iona
l tre
atm
ent s
eeki
ng
beha
viou
r for
chi
ldre
n un
der U
5
• co
st o
f iCC
M d
eliv
ery
(com
mod
ities
, lo
gist
ics,
ince
ntiv
es, t
rain
ing
etc)
• Fo
r pla
nnin
g in
terv
entio
ns to
im
prov
e m
alar
ia c
ase
man
agem
ent
in th
e pr
ivat
e se
ctor
som
e of
the
info
rmat
ion
requ
ired
are:
• di
strib
utio
n an
d ty
pe o
f dru
g ou
tlets
(a
utho
rised
and
not
) hea
lth fa
cilit
ies
• di
strib
utio
n of
trea
tmen
t see
king
in
this
sect
or
Scal
e up
of i
CCM
sho
uld
be
cons
ider
ed a
s a
way
of e
xpan
ding
ac
cess
to c
are
and
requ
ires
func
tioni
ng P
HC
faci
litie
s
They
sho
uld
be s
trate
gica
lly lo
cate
d in
pla
ces
with
hig
hest
bur
den
of
rele
vant
chi
ldho
od il
lnes
s
iCC
M p
rogr
ams
shou
ld b
e in
tegr
ated
w
ith th
e pu
blic
hea
lth s
yste
m,
incl
udin
g lo
gist
ics
and
info
rmat
ion
syst
ems
Inte
rven
tions
to im
prov
e ac
cess
to
mal
aria
cas
e m
anag
emen
t in
the
priv
ate
sect
or m
ust b
e de
signe
d in
su
ch a
way
that
they
add
val
ue to
pu
blic
hea
lth s
ervi
ces
and
conf
er
prot
ectio
n to
vul
nera
ble
hous
ehol
ds
that
bea
r the
bru
nt o
f cat
astro
phic
ex
pend
iture
60
INTE
RVEN
TIO
N TY
PEC
URRE
NT
REC
OM
MEN
DAT
ION
POLI
CY
ADAP
TATI
ON
CO
NSID
ERAT
IONS
FO
R IN
TERV
ENTI
ON
TARG
ETIN
G
ANAL
YTIC
AL C
ONS
IDER
ATIO
NS A
ND
RATI
ONA
LEKE
Y D
ATA
AND
ARE
AS F
OR
MO
NITO
RING
STRA
TEG
IC C
ONS
IDER
ATIO
NS
Cas
e m
anag
emen
t (c
ont.)
In e
limin
atio
n se
tting
s al
l cas
es m
ust
be p
rom
ptly
det
ecte
d, n
otifi
ed a
nd
inve
stig
ated
. Com
mun
ity h
ealth
w
orke
rs m
ay s
omet
imes
be
used
no
t jus
t a m
echa
nism
of i
mpr
ovin
g ac
cess
to c
are
whe
re p
opul
atio
n ar
e fa
r fro
m h
ealth
faci
litie
s bu
t as
an
appr
oach
to in
crea
sing
the
inte
nsity
of
det
ectio
n an
d su
rvei
llanc
e.
Anal
ysis
of s
ubna
tiona
l var
iatio
ns
in tr
eatm
ent s
eeki
ng in
the
priv
ate
sect
or a
s w
ell c
ost a
nd q
ualit
y of
suc
h tre
atm
ents
as
rela
ted
to m
alar
ia
are
nece
ssar
y to
dev
elop
stra
tegi
es
to in
crea
se a
cces
s to
mal
aria
cas
e m
anag
emen
t in
the
priv
ate
sect
or
• su
bnat
iona
l pre
vale
nce
and
inci
denc
e, b
y ag
e, o
f mal
aria
• C
ost a
nd q
ualit
y of
car
e in
pub
lic
and
priv
ate
sect
ors
• th
e le
vel o
f out
of p
ocke
t ex
pend
iture
by
soci
oeco
nom
ic
stat
us
• ex
istin
g re
gula
tory
mec
hani
sms,
incl
udin
g en
forc
ing
com
plia
nce
with
na
tiona
l gui
delin
es fo
r tre
atm
ent
and
repo
rtin
g
Inse
ctic
ide
trea
ted
nets
(I
TNs)
Pyre
thro
id-o
nly
LLIN
s pr
equa
lified
by
WH
O
are
reco
mm
ende
d fo
r dep
loym
ent a
s a
core
inte
rven
tion
in
all m
alar
ia-e
ndem
ic
setti
ngs.
Uni
vers
al c
over
age*
with
eff
ectiv
e ve
ctor
con
trol u
sing
a co
re in
terv
entio
n (IT
Ns
or
IRS)
is re
com
men
ded
for a
ll po
pula
tions
at r
isk o
f mal
aria
in
mos
t epi
dem
iolo
gica
l an
d ec
olog
ical
set
tings
. The
po
pula
tion
at ri
sk o
f mal
aria
m
ay in
crea
se o
r dec
reas
e be
caus
e of
cha
nges
in
mal
ario
geni
c po
tent
ial o
f a g
iven
ge
ogra
phic
al a
rea
In a
reas
of v
ery
low
rece
ptiv
ity,
LLIN
s m
ay n
ot h
ave
subs
tant
ial
impa
ct, a
nd re
sour
ce
optim
izat
ion
shou
ld ta
ke th
is in
to
acco
unt.
It is
diffi
cult
to m
easu
re re
cept
ivity
. G
ood
ento
mol
ogic
al d
ata,
pai
red
with
goo
d ep
idem
iolo
gica
l dat
a ca
n pr
ovid
e re
liabl
e in
form
atio
n on
re
cept
ivity
.
Man
y m
oder
ate
and
high
bur
den
coun
trie
s do
not
hav
e re
liabl
e en
tom
olog
ical
dat
a. H
owev
er, s
ever
al
may
hav
e go
od p
re-i
nter
vent
ion
data
on
prev
alen
ce o
f mal
aria
in
fect
ion,
whi
ch w
hen
mod
elle
d su
b-na
tiona
lly, i
s a
reas
onab
le p
roxy
of
rece
ptiv
ity.
In b
urde
n re
duct
ion
setti
ngs,
para
site
prev
alen
ce b
efor
e pe
riod
of m
ajor
sca
le u
p of
inte
rven
tions
co
uld
reas
onab
ly b
e co
nsid
ered
as
mea
sure
of r
ecep
tivity
. Pre
vale
nce
Info
rmat
ion
on p
re-i
nter
vent
ion
para
site
prev
alen
ce a
s pr
oxy
for
rece
ptiv
ity
Inve
stm
ents
in g
eosp
atia
l en
viro
nmen
tal,
epid
emio
logi
cal a
nd
ento
mol
ogic
al s
urve
illan
ce to
mic
ro-
stra
tify
in u
rban
are
as.
Info
rmat
ion
on in
sect
icid
e re
sista
nce
to d
eter
min
e se
lect
ion
of a
ppro
pria
te
net t
ype
Info
rmat
ion
on a
ccep
tabi
lity
of
ITN
s cr
itica
l to
deve
lopi
ng s
ocia
l be
havi
oral
cha
nge
com
mun
icat
ion
to im
prov
e us
e or
exp
lore
sub
stitu
tion
with
oth
er v
ecto
r con
trol i
nter
vent
ions
Anal
ysis
of e
pide
mio
logi
cal t
rend
s an
d in
terv
entio
ns c
over
age
can
help
w
ith a
naly
sis o
f pot
entia
l im
pact
of
targ
etin
g or
with
draw
ing
LLIN
s an
d or
oth
er in
terv
entio
ns in
an
area
.
In v
ery
low
rece
ptiv
ity a
nd u
rban
ar
eas
whe
re L
LIN
s m
ay n
ot b
e ta
rget
ed o
r are
with
draw
n, h
igh
leve
ls of
acc
ess
to c
ase
man
agem
ent
and
high
-qua
lity
surv
eilla
nce
syst
ems
shou
ld b
e in
pla
ce
Unl
ess
for p
urpo
ses
of re
sista
nce
miti
gatio
n, L
LIN
and
IRS
shou
ld n
ot
be ta
rget
ed to
the
sam
e po
pula
tions
. Th
e ex
cept
ion
may
be
in s
peci
fic
setti
ngs
whe
re in
the
sam
e ar
ea,
ther
e ar
e sp
ecia
l pop
ulat
ion
grou
ps
(like
fore
st w
orke
rs) w
ho m
ay b
enefi
t
WH
O T
ECH
NIC
AL B
RIEF
FO
R C
OUN
TRIE
S PR
EPAR
ING
MAL
ARIA
FUN
DIN
G R
EQUE
STS
FOR
THE
GLO
BAL
FUND
(202
0–20
22)
61
INTE
RVEN
TIO
N TY
PEC
URRE
NT
REC
OM
MEN
DAT
ION
POLI
CY
ADAP
TATI
ON
CO
NSID
ERAT
IONS
FO
R IN
TERV
ENTI
ON
TARG
ETIN
G
ANAL
YTIC
AL C
ONS
IDER
ATIO
NS A
ND
RATI
ONA
LEKE
Y D
ATA
AND
ARE
AS F
OR
MO
NITO
RING
STRA
TEG
IC C
ONS
IDER
ATIO
NS
Inse
ctic
ide
trea
ted
nets
(I
TNs)
(con
t.)
Such
are
as m
ay in
clud
e th
ose
of h
istor
ical
ly v
ery
low
/no
trans
miss
ion
such
as
thos
e w
here
clim
atic
fact
ors
are
not
optim
al fo
r mal
aria
tran
smiss
ion.
Th
ey m
ay a
lso in
clud
e ce
rtain
ur
bani
zed
area
s w
here
the
envi
ronm
ent h
as b
een
mod
ified
th
roug
h co
nstr
uctio
n an
d ot
her f
orm
s of
land
cov
er s
uch
that
ther
e is
low
pot
entia
l for
tra
nsm
issio
n.
of <
1% (o
r inc
iden
ce o
f <1 p
er
1000
pop
ulat
ion
at ri
sk) m
ay b
e co
nsid
ered
a th
resh
old
by w
hich
LL
INs
may
not
hav
e m
ajor
impa
ct.
In u
rban
are
as, m
alar
ia tr
ansm
issio
n is
likel
y to
be
high
ly c
lust
ered
and
m
icro
stra
tifica
tion
is re
quire
d to
iden
tify
clus
ters
of o
ngoi
ng
trans
miss
ion
to b
ette
r tar
get v
ecto
r co
ntro
l, in
clud
ing
LLIN
s in
stea
d of
ai
min
g fo
r uni
vers
al c
over
age
of a
ll po
pula
tions
.
A co
mbi
natio
n of
acc
epta
bilit
y of
the
inte
rven
tion,
as
wel
l as
infra
stru
ctur
e,
dem
ogra
phic
, epi
dem
iolo
gica
l, en
tom
olog
ical
and
env
ironm
enta
l da
ta c
an h
elp
with
mic
rost
ratifi
catio
n to
effe
ctiv
ely
targ
et in
terv
entio
ns.
In a
ll se
tting
s, en
tom
olog
ical
in
form
atio
n on
vec
tor s
peci
es, d
ensit
y an
d bi
onom
ics,
whe
re a
vaila
ble,
are
he
lpfu
l in
asse
ssin
g th
e ris
ks o
f not
ta
rget
ing
bed
nets
in a
n ar
ea.
Estim
ates
of p
opul
atio
ns a
t risk
as
wel
l as
data
on
rece
nt (l
ast 4
yea
rs)
dist
ribut
ion
of L
LIN
s re
quire
d fo
r qu
antifi
catio
n of
nee
d
Acce
ss a
nd u
se d
ata
by a
ge a
nd
popu
latio
n gr
oup
will
hel
p w
ith
optim
izin
g de
liver
y ch
anne
ls,
espe
cial
ly w
hen
com
bine
d w
ith
burd
en d
ata
from
thes
e po
pula
tion
grou
ps
Stat
istic
al, g
eosp
atia
l and
m
athe
mat
ical
mod
elin
g te
chni
ques
ad
d va
lue
to th
e pr
oces
s of
st
ratifi
catio
n an
d in
terv
entio
n ta
rget
ing
from
LLI
Ns
and
whe
re IR
S m
ay b
e m
ost u
se in
thei
r vill
age
of re
siden
ce.
PBO
(pip
eron
yl
buto
xide
) ITN
sPy
reth
roid
-PBO
net
s pr
equa
lified
by
WH
O
are
cond
ition
ally
re
com
men
ded
for
depl
oym
ent i
nste
ad
of p
yret
hroi
d-on
ly
ITN
s w
here
the
prin
cipa
l mal
aria
ve
ctor
(s) e
xhib
it py
reth
roid
resis
tanc
e th
at is
: a) c
onfir
med
,
Pref
erre
d ch
oice
ove
r py
reth
roid
-onl
y ne
ts if
this
will
no
t com
prom
ise c
over
age
If co
untr
ies
do n
ot h
ave
data
on
MFO
, a
prag
mat
ic a
ppro
ach
to m
axim
ise
impa
ct m
ight
be
to d
eplo
y PB
O n
ets
in a
reas
of i
nter
med
iate
resis
tanc
e w
ith th
e hi
ghes
t mal
aria
bur
den
Whe
re re
sista
nce
leve
ls ar
e hi
gh
ever
ywhe
re, a
nd re
sour
ces
are
limite
d ar
eas
of h
ighe
st b
urde
n m
ay
be c
onsid
ered
for P
BO ta
rget
ing.
Resis
tanc
e da
ta w
ith a
nd w
ithou
t M
FO fo
rms
Burd
en o
f mal
aria
(pre
vale
nce,
in
cide
nce)
as
wel
l as
all-
caus
e un
der
five
mor
talit
y ra
tes.
Thes
e ca
n ei
ther
be
look
ed a
t sep
arat
ely
or c
ombi
ned
into
a c
ompo
site
inde
x of
bur
den
Ther
e is
no s
peci
fic th
resh
old
for
clas
sifyi
ng a
reas
as
‘hig
hest
’ bur
den,
an
d th
e cu
t off
may
var
y by
cou
ntry
.
Cur
rent
ly, P
BO L
LIN
s ar
e m
ore
expe
nsiv
e th
an p
yret
hroi
d on
ly L
LIN
s.
Alth
ough
it is
ant
icip
ated
the
pric
e of
PB
O L
LIN
will
com
e do
wn
as d
eman
d in
crea
ses.
62
INTE
RVEN
TIO
N TY
PEC
URRE
NT
REC
OM
MEN
DAT
ION
POLI
CY
ADAP
TATI
ON
CO
NSID
ERAT
IONS
FO
R IN
TERV
ENTI
ON
TARG
ETIN
G
ANAL
YTIC
AL C
ONS
IDER
ATIO
NS A
ND
RATI
ONA
LEKE
Y D
ATA
AND
ARE
AS F
OR
MO
NITO
RING
STRA
TEG
IC C
ONS
IDER
ATIO
NS
PBO
(pip
eron
yl
buto
xide
) ITN
s (c
ont.)
b) o
f int
erm
edia
te
leve
l, an
d c)
co
nfer
red
(at
leas
t in
part
) by
a m
onoo
xyge
nase
-ba
sed
resis
tanc
e m
echa
nism
, as
dete
rmin
ed b
y st
anda
rd p
roce
dure
s
IRS
(indo
or
resi
dual
sp
rayi
ng)
The
depl
oym
ent
of a
n in
sect
icid
e pr
oduc
t pre
qual
ified
by
WH
O a
nd is
re
com
men
ded
as a
co
re in
terv
entio
n in
al
l mal
aria
-end
emic
se
tting
s
Exce
pt fo
r pur
pose
s of
miti
gatin
g py
reth
roid
resis
tanc
e, IR
S an
d LL
INs
shou
ld n
ot b
e ta
rget
ed
toge
ther
at t
he s
ame
popu
latio
n at
risk
.
IRS
are
very
effe
ctiv
e ag
ains
t in
door
rest
ing
vect
ors,
and
info
rmat
ion
on v
ecto
r beh
avio
r is
key
to d
eter
min
ing
whe
re to
us
e IR
S
In h
igh
trans
miss
ion
setti
ngs,
IRS
shou
ld b
e ta
rget
ed in
hi
ghes
t bur
den
area
s. In
m
ost e
limin
atio
n se
tting
s, w
here
tran
smiss
ion
is fo
cal,
IRS
rem
ains
the
core
vec
tor
cont
rol i
nter
vent
ion
to re
duce
tra
nsm
issio
n.
For p
urpo
ses
of b
urde
n re
duct
ion,
ju
st li
ke L
LIN
s, IR
S m
ay n
ot b
e co
st-e
ffect
ive
in a
reas
of v
ery
low
re
cept
ivity
. The
sam
e m
easu
res
of
rece
ptiv
ity a
pplie
d in
targ
etin
g LL
INs
can
be u
sed
for I
RS.
In m
oder
ate
and
high
mal
aria
bu
rden
cou
ntrie
s, ar
eas
of h
igh
burd
en (e
ither
from
tran
smiss
ion
pers
pect
ive
or c
ompo
site
of
trans
miss
ion,
inci
denc
e an
d m
orta
lity)
m
ay b
e th
ose
cons
ider
ed fo
r IRS
sc
ale
up.
IRS
has
may
also
be
cons
ider
ed
in e
pide
mic
pro
ne a
reas
for b
oth
prev
entio
n an
d co
ntai
nmen
t of
epid
emic
s.
In e
limin
atio
n se
tting
s, co
untr
ies
may
co
nsid
er m
aint
aini
ng IR
S in
resid
ual
non-
activ
e an
d ac
tive
foci
dep
endi
ng
on th
e co
untr
y co
ntex
t and
risk
of
rebo
und
if IR
S is
with
draw
n.
Sim
ilar d
ata
requ
ired
for L
LIN
ta
rget
ing
are
also
nee
ded
here
In a
dditi
on, r
esist
ance
dat
a on
va
rious
inse
ctic
ides
use
d fo
r res
idua
l sp
rayi
ng is
nee
ded
to s
elec
t the
righ
t in
sect
icid
es.
Giv
en th
e co
st a
nd c
ompl
exity
of
impl
emen
ting
IRS
in h
igh
burd
en
setti
ngs
the
follo
win
g co
nsid
erat
ion
shou
ld b
e m
ade
befo
re d
ecid
ing
on
its s
cale
up:
• O
vera
ll co
st a
nd s
usta
inab
ility
• Fi
nanc
ing
impl
icat
ions
for
achi
evin
g ta
rget
s fo
r oth
er p
rimar
y in
terv
entio
ns
• C
apac
ity to
man
age
inse
ctic
ide
resis
tanc
e an
d co
st
• C
omm
unity
acc
epta
bilit
y
• A
clea
r tra
nsiti
on p
lan,
incl
udin
g as
sess
men
t of p
oten
tial r
ebou
nd, i
f a
deci
sion
is m
ade
to s
cale
bac
k IR
S
WH
O T
ECH
NIC
AL B
RIEF
FO
R C
OUN
TRIE
S PR
EPAR
ING
MAL
ARIA
FUN
DIN
G R
EQUE
STS
FOR
THE
GLO
BAL
FUND
(202
0–20
22)
63
INTE
RVEN
TIO
N TY
PEC
URRE
NT
REC
OM
MEN
DAT
ION
POLI
CY
ADAP
TATI
ON
CO
NSID
ERAT
IONS
FO
R IN
TERV
ENTI
ON
TARG
ETIN
G
ANAL
YTIC
AL C
ONS
IDER
ATIO
NS A
ND
RATI
ONA
LEKE
Y D
ATA
AND
ARE
AS F
OR
MO
NITO
RING
STRA
TEG
IC C
ONS
IDER
ATIO
NS
Larv
icid
ing
The
regu
lar
appl
icat
ion
of
biol
ogic
al o
r ch
emic
al in
sect
icid
es
to w
ater
bod
ies
(larv
icid
ing)
is
reco
mm
ende
d as
a
supp
lem
enta
ry
inte
rven
tion
in
area
s w
here
hig
h co
vera
ge w
ith a
co
re in
terv
entio
n ha
s be
en a
chie
ved,
w
here
aqu
atic
ha
bita
ts o
f the
pr
inci
pal m
alar
ia
vect
or(s
) are
few
, fix
ed a
nd fi
ndab
le,
and
whe
re it
s ap
plic
atio
n is
both
fe
asib
le a
nd c
ost-
effec
tive.
It is
a fo
rm o
f lar
val s
ourc
e m
anag
emen
t (LS
M).
In m
any
mal
aria
end
emic
co
untr
ies,
part
icul
arly
in
mod
erat
e an
d hi
gh tr
ansm
issio
n ar
eas
whe
re c
ondi
tions
for
trans
miss
ion
exist
thro
ugho
ut
the
year
and
whe
re p
oten
tial
bree
ding
site
s ar
e nu
mer
ous
and
trans
ient
, lar
vici
ding
is u
nlike
ly to
be
effe
ctiv
e an
d co
uld
cons
ume
a lo
t of r
esou
rces
to a
chie
ve h
igh
cove
rage
.
As s
uch,
it is
mor
e re
ason
able
to
targ
et u
rban
are
as, g
iven
the
confi
ned
natu
re o
f suc
h sp
aces
an
d le
nd th
emse
lves
to e
asie
r ge
ospa
tial a
nd la
rval
hab
itat
surv
eilla
nce.
Larv
icid
ing
may
also
be
used
to
com
plem
ent e
ffort
s to
miti
gate
tra
nsm
issio
n du
ring
larg
e in
frast
ruct
ure
deve
lopm
ent
activ
ities
, suc
h as
, roa
ds, d
ams
etc.
Geo
spat
ial s
urve
illan
ce o
f pot
entia
l br
eedi
ng s
ites
Goo
d en
tom
olog
ical
sur
veill
ance
Rem
otel
y se
nsed
dat
a on
bui
lt en
viro
nmen
t and
pot
entia
l bre
edin
g sit
es a
nd th
eir s
easo
nal v
aria
tions
Ento
mol
ogic
al d
ata
on ty
pes
of
mos
quito
spe
cies
and
thei
r rol
e in
m
alar
ia tr
ansm
issio
n
Whe
reve
r lar
vici
ding
is d
eplo
yed
to a
dd to
the
limite
d ev
iden
ce
avai
labl
e on
its
effec
tiven
ess,
a go
od m
onito
ring
and
eval
uatio
n fra
mew
ork
shou
ld b
e pu
t in
plac
e to
as
sess
impa
ct.
Lar
vici
ding
for m
alar
ia c
ontro
l cou
ld
idea
lly b
e do
ne th
roug
h w
ider
effo
rts
to c
ontro
l vec
tor b
orne
dise
ases
Dep
loym
ent o
f lar
vici
ding
(and
LSM
m
ore
gene
rally
) wou
ld b
enefi
t fro
m
rigor
ous
eval
uatio
n to
doc
umen
t ep
idem
iolo
gica
l im
pact
, so
as to
in
form
upd
ates
to W
HO
pol
icy
guid
ance
in th
is ar
ea o
f wea
k ev
iden
ce.
Larv
icid
ing
for m
alar
ia c
ontro
l cou
ld
idea
lly b
e do
ne th
roug
h w
ider
effo
rts
to c
ontro
l vec
tor b
orne
dise
ases
Oth
er la
rval
sou
rce
man
agem
ent
com
bine
d w
ith la
rvic
idin
g co
uld
be
a m
ore
effec
tive
appr
oach
. The
se
incl
ude:
• ha
bita
t mod
ifica
tion:
a p
erm
anen
t al
tera
tion
to th
e en
viro
nmen
t, e.
g. la
nd re
clam
atio
n;
• ha
bita
t man
ipul
atio
n: a
recu
rren
t ac
tivity
, e.g
. flus
hing
of s
tream
s;
• bi
olog
ical
con
trol:
the
intro
duct
ion
of n
atur
al p
reda
tors
into
wat
er
bodi
es.
64
INTE
RVEN
TIO
N TY
PEC
URRE
NT
REC
OM
MEN
DAT
ION
POLI
CY
ADAP
TATI
ON
CO
NSID
ERAT
IONS
FO
R IN
TERV
ENTI
ON
TARG
ETIN
G
ANAL
YTIC
AL C
ONS
IDER
ATIO
NS A
ND
RATI
ONA
LEKE
Y D
ATA
AND
ARE
AS F
OR
MO
NITO
RING
STRA
TEG
IC C
ONS
IDER
ATIO
NS
SMC
(sea
sona
l m
alar
ia c
hem
o-pr
even
tion)
In a
reas
with
hig
hly
seas
onal
mal
aria
tra
nsm
issio
n in
the
sub-
Sahe
l reg
ion
of A
fric
a, p
rovi
de
seas
onal
mal
aria
ch
emop
reve
ntio
n (S
MC
) with
mon
thly
am
odia
quin
e +
SP
for a
ll ch
ildre
n ag
ed
< 6
year
s du
ring
each
tran
smiss
ion
seas
on.
SMC
is c
urre
ntly
impl
emen
ted
in a
reas
with
sig
nific
ant
mal
aria
sea
sona
lity
in th
e Sa
hel (
betw
een
the
Saha
ra to
th
e no
rth
and
the
Suda
nese
Sa
vann
a to
the
sout
h) a
nd in
the
sava
nnah
are
as o
f Cen
tral a
nd
Wes
t Afr
ican
cou
ntrie
s w
here
m
ore
than
60%
of t
he a
nnua
l in
cide
nce
of m
alar
ia o
ccur
s w
ithin
4 m
onth
s an
d w
here
SP
and
AQ re
tain
thei
r ant
imal
aria
l effi
cacy
. SM
C is
unl
ikely
to b
e co
st-e
ffect
ive
at a
n in
cide
nce
rate
bel
ow 0
.1 ep
isode
s pe
r chi
ld
per s
easo
n.
Whe
re ro
utin
e da
ta a
re u
sed,
car
e sh
ould
be
take
n th
at th
ese
are
adju
sted
for t
estin
g, re
port
ing
and
treat
men
t see
king
rate
so
that
an
estim
ate
clos
e to
the
true
pop
ulat
ion
inci
denc
e ca
n be
qua
ntifi
ed.
Furt
herm
ore,
cau
tion
is re
quire
d w
hen
usin
g re
cent
dat
a w
hich
may
in
clud
e th
e im
pact
of S
MC
as
thes
e m
ay e
xclu
de a
reas
whe
re in
cide
nce
has
redu
ced
due
to S
MC
To d
efine
tran
smiss
ion
thre
shol
ds
for S
MC
whe
re in
cide
nce
data
is
unre
liabl
e or
una
vaila
ble,
par
asite
pr
eval
ence
cou
ld b
e us
ed in
stea
d fo
r mos
t sub
Sah
aran
Afr
ica
coun
trie
s. A
thre
shol
d of
>5%
par
asite
pr
eval
ence
in th
e U
5 ag
e gr
oup
may
be
con
sider
ed. S
uch
info
rmat
ion
is av
aila
ble
from
hou
seho
ld s
urve
ys o
r pa
rasit
e pr
eval
ence
map
s m
odel
ed
used
sta
tistic
al m
etho
ds.
Whe
re s
urve
illan
ce d
ata
is un
relia
ble
to q
uant
ify s
easo
nalit
y in
inci
denc
e,
60%
of ra
infa
ll in
4 c
onse
cutiv
e m
onth
s is
a re
ason
able
sub
stitu
te.
Rain
fall
seas
onal
ity d
ata
may
be
ava
ilabl
e fro
m n
atio
nal
met
ereo
logi
cal d
epar
tmen
ts, b
ut
thes
e ar
e of
ten
from
few
wea
ther
st
atio
ns th
at d
o no
t allo
w fo
r es
timat
ion
of s
easo
nalit
y in
eac
h su
bnat
iona
l uni
t. C
ombi
ning
thes
e da
ta w
ith s
atel
lite
deriv
ed ra
infa
ll da
ta a
vaila
ble
onlin
e sh
ould
be
cons
ider
ed.
Rout
ine
case
dat
a to
qua
ntify
in
cide
nce
Dat
a on
test
ing,
repo
rtin
g an
d tre
atm
ent s
eeki
ng ra
tes
to a
djus
t ro
utin
e ca
se d
ata
Subn
atio
nal m
odel
ed e
stim
ates
of
para
site
prev
alen
ce
Met
eoro
logi
cal a
nd o
nlin
e m
onth
ly
rain
fall
data
Info
rmat
ion
on p
ast S
MC
sca
le u
p an
d ot
her i
nter
vent
ions
that
may
ha
ve im
pact
ed o
n se
ason
ality
of
case
s
Dat
a on
SP
and
AQ e
ffica
cy a
nd
mol
ecul
ar m
arke
rs o
f res
istan
ce
Whe
re C
HW
s ar
e in
pla
ce, i
nvol
ving
th
em in
SM
C c
ampa
igns
may
be
a co
st-e
ffect
ive
appr
oach
but
this
requ
ires
care
ful m
onito
ring
Com
plia
nce
with
all
SP+A
Q d
oses
re
mai
ns a
maj
or c
halle
nge
to S
MC
im
pact
. Car
eful
com
mun
icat
ion
stra
tegi
es a
re re
quire
d to
ens
ure
adhe
renc
e
Man
y co
untr
ies
are
faci
ng
diffi
culti
es a
sses
sing
the
impa
ct o
f SM
C fr
om ro
utin
e da
ta. T
here
fore
, th
is in
terv
entio
n, li
ke a
ll ot
her
inte
rven
tions
, sho
uld
be u
nder
pinn
ed
by a
goo
d m
onito
ring
and
eval
uatio
n fra
mew
ork.
Con
tinuo
us m
onito
ring
of S
P an
d AQ
effi
cacy
in c
lear
ing
para
sites
is c
ritic
al
WH
O T
ECH
NIC
AL B
RIEF
FO
R C
OUN
TRIE
S PR
EPAR
ING
MAL
ARIA
FUN
DIN
G R
EQUE
STS
FOR
THE
GLO
BAL
FUND
(202
0–20
22)
65
INTE
RVEN
TIO
N TY
PEC
URRE
NT
REC
OM
MEN
DAT
ION
POLI
CY
ADAP
TATI
ON
CO
NSID
ERAT
IONS
FO
R IN
TERV
ENTI
ON
TARG
ETIN
G
ANAL
YTIC
AL C
ONS
IDER
ATIO
NS A
ND
RATI
ONA
LEKE
Y D
ATA
AND
ARE
AS F
OR
MO
NITO
RING
STRA
TEG
IC C
ONS
IDER
ATIO
NS
SMC
(sea
sona
l m
alar
ia c
hem
o-pr
even
tion)
(c
ont.)
Perio
ds o
f unu
sual
dro
ught
or r
ainf
all
can
caus
e an
omal
ies
in s
easo
nalit
y an
d da
ta fr
om a
t lea
st fi
ve y
ears
sh
ould
be
used
to d
efine
rain
fall
seas
onal
ity.
A de
cisio
n to
exp
and
the
age
rang
e fo
r SM
C to
chi
ldre
n be
low
10 y
ears
of
age
in S
MC
elig
ible
are
as s
houl
d be
bas
ed o
n ev
iden
ce s
how
ing
subs
tant
ial i
ncid
ence
in th
is ag
e gr
oup.
As
this
is ab
ove
the
age
limit
of 5
yea
rs re
com
men
ded
by W
HO
, ex
pans
ion
of a
ge ra
nge
shou
ld n
ot
com
prom
ise h
igh
cove
rage
in U
5 ch
ildre
n, th
e m
ost v
ulne
rabl
e ag
e-gr
oup.
If th
e ag
e ra
nge
is ex
pand
ed, a
goo
d ev
alua
tion
fram
ewor
k sh
ould
be
esta
blish
ed to
ass
ess
impa
ct.
IPTp
(in
term
itten
t pr
even
tive
trea
tmen
t in
preg
nanc
y)
In m
alar
ia-e
ndem
ic
area
s in
Afr
ica,
pr
ovid
e in
term
itten
t pr
even
tive
treat
men
t w
ith S
P to
all
wom
en
in th
eir fi
rst o
r sec
ond
preg
nanc
y (S
P-IP
Tp)
as p
art o
f ant
enat
al
care
. Dos
ing
shou
ld
star
t in
the
seco
nd
trim
este
r and
dos
es
shou
ld b
e gi
ven
at
leas
t 1 m
onth
apa
rt,
with
the
obje
ctiv
e of
en
surin
g th
at a
t lea
st
3 do
ses
are
rece
ived
.
Cur
rent
gui
delin
es (w
ww
.who
.int/
repr
oduc
tiveh
ealth
/pub
licat
ions
/m
ater
nal_
perin
atal
_hea
lth/a
nc-
posit
ive-
preg
nanc
y-ex
perie
nce/
en/)
reco
mm
end
ante
nata
l car
e m
odel
s w
ith a
min
imum
of e
ight
co
ntac
ts.
Cou
ntrie
s th
at h
ave
rece
ntly
redu
ced
thei
r tra
nsm
issio
n su
bsta
ntia
lly s
houl
d no
t disc
ontin
ue IP
Tp
Info
rmat
ion
that
can
hel
p st
ratif
y su
b-na
tiona
lly th
e co
vera
ge o
f AN
C
by v
isit i
s cr
itica
l to
optim
izin
g an
d sc
alin
g up
IPTp
. Suc
h in
form
atio
n ca
n be
obt
aine
d fro
m a
com
bina
tion
of
rout
ine
and
hous
ehol
d su
rvey
dat
a.
Subn
atio
nal e
stim
ates
of b
urde
n of
mal
aria
suc
h as
inci
denc
e an
d pa
rasit
e pr
eval
ence
Subn
atio
nal A
NC
cov
erag
e da
ta
Info
rmat
ion
on fe
rtili
ty ra
tes
to d
efine
ex
pect
ed p
regn
anci
es s
ub-n
atio
nally
Info
rmat
ion
on n
umbe
r of w
omen
re
ceiv
ing
IPTp
by
dose
at h
ealth
fa
cilit
ies.
Com
bine
d w
ith d
ata
on
expe
cted
pre
gnan
cies
, IPT
p co
vera
ge
in th
e po
pula
tion
can
be e
stim
ated
.
IPTp
with
SP
is a
low
cos
t and
effi
caci
ous
inte
rven
tion
to a
vert
the
cons
eque
nces
of m
alar
ia in
pr
egna
ncy
to m
othe
r and
chi
ld.
Con
tinuo
us S
P re
sista
nce
mon
itorin
g is
need
ed, p
artic
ular
ly o
f sex
tupl
e m
utat
ions
INTE
RVEN
TIO
N TY
PEC
URRE
NT
REC
OM
MEN
DAT
ION
POLI
CY
ADAP
TATI
ON
CO
NSID
ERAT
IONS
FO
R IN
TERV
ENTI
ON
TARG
ETIN
G
ANAL
YTIC
AL C
ONS
IDER
ATIO
NS A
ND
RATI
ONA
LEKE
Y D
ATA
AND
ARE
AS F
OR
MO
NITO
RING
STRA
TEG
IC C
ONS
IDER
ATIO
NS
SMC
(sea
sona
l m
alar
ia c
hem
o-pr
even
tion)
In a
reas
with
hig
hly
seas
onal
mal
aria
tra
nsm
issio
n in
the
sub-
Sahe
l reg
ion
of A
fric
a, p
rovi
de
seas
onal
mal
aria
ch
emop
reve
ntio
n (S
MC
) with
mon
thly
am
odia
quin
e +
SP
for a
ll ch
ildre
n ag
ed
< 6
year
s du
ring
each
tran
smiss
ion
seas
on.
SMC
is c
urre
ntly
impl
emen
ted
in a
reas
with
sig
nific
ant
mal
aria
sea
sona
lity
in th
e Sa
hel (
betw
een
the
Saha
ra to
th
e no
rth
and
the
Suda
nese
Sa
vann
a to
the
sout
h) a
nd in
the
sava
nnah
are
as o
f Cen
tral a
nd
Wes
t Afr
ican
cou
ntrie
s w
here
m
ore
than
60%
of t
he a
nnua
l in
cide
nce
of m
alar
ia o
ccur
s w
ithin
4 m
onth
s an
d w
here
SP
and
AQ re
tain
thei
r ant
imal
aria
l effi
cacy
. SM
C is
unl
ikely
to b
e co
st-e
ffect
ive
at a
n in
cide
nce
rate
bel
ow 0
.1 ep
isode
s pe
r chi
ld
per s
easo
n.
Whe
re ro
utin
e da
ta a
re u
sed,
car
e sh
ould
be
take
n th
at th
ese
are
adju
sted
for t
estin
g, re
port
ing
and
treat
men
t see
king
rate
so
that
an
estim
ate
clos
e to
the
true
pop
ulat
ion
inci
denc
e ca
n be
qua
ntifi
ed.
Furt
herm
ore,
cau
tion
is re
quire
d w
hen
usin
g re
cent
dat
a w
hich
may
in
clud
e th
e im
pact
of S
MC
as
thes
e m
ay e
xclu
de a
reas
whe
re in
cide
nce
has
redu
ced
due
to S
MC
To d
efine
tran
smiss
ion
thre
shol
ds
for S
MC
whe
re in
cide
nce
data
is
unre
liabl
e or
una
vaila
ble,
par
asite
pr
eval
ence
cou
ld b
e us
ed in
stea
d fo
r mos
t sub
Sah
aran
Afr
ica
coun
trie
s. A
thre
shol
d of
>5%
par
asite
pr
eval
ence
in th
e U
5 ag
e gr
oup
may
be
con
sider
ed. S
uch
info
rmat
ion
is av
aila
ble
from
hou
seho
ld s
urve
ys o
r pa
rasit
e pr
eval
ence
map
s m
odel
ed
used
sta
tistic
al m
etho
ds.
Whe
re s
urve
illan
ce d
ata
is un
relia
ble
to q
uant
ify s
easo
nalit
y in
inci
denc
e,
60%
of ra
infa
ll in
4 c
onse
cutiv
e m
onth
s is
a re
ason
able
sub
stitu
te.
Rain
fall
seas
onal
ity d
ata
may
be
ava
ilabl
e fro
m n
atio
nal
met
ereo
logi
cal d
epar
tmen
ts, b
ut
thes
e ar
e of
ten
from
few
wea
ther
st
atio
ns th
at d
o no
t allo
w fo
r es
timat
ion
of s
easo
nalit
y in
eac
h su
bnat
iona
l uni
t. C
ombi
ning
thes
e da
ta w
ith s
atel
lite
deriv
ed ra
infa
ll da
ta a
vaila
ble
onlin
e sh
ould
be
cons
ider
ed.
Rout
ine
case
dat
a to
qua
ntify
in
cide
nce
Dat
a on
test
ing,
repo
rtin
g an
d tre
atm
ent s
eeki
ng ra
tes
to a
djus
t ro
utin
e ca
se d
ata
Subn
atio
nal m
odel
ed e
stim
ates
of
para
site
prev
alen
ce
Met
eoro
logi
cal a
nd o
nlin
e m
onth
ly
rain
fall
data
Info
rmat
ion
on p
ast S
MC
sca
le u
p an
d ot
her i
nter
vent
ions
that
may
ha
ve im
pact
ed o
n se
ason
ality
of
case
s
Dat
a on
SP
and
AQ e
ffica
cy a
nd
mol
ecul
ar m
arke
rs o
f res
istan
ce
Whe
re C
HW
s ar
e in
pla
ce, i
nvol
ving
th
em in
SM
C c
ampa
igns
may
be
a co
st-e
ffect
ive
appr
oach
but
this
requ
ires
care
ful m
onito
ring
Com
plia
nce
with
all
SP+A
Q d
oses
re
mai
ns a
maj
or c
halle
nge
to S
MC
im
pact
. Car
eful
com
mun
icat
ion
stra
tegi
es a
re re
quire
d to
ens
ure
adhe
renc
e
Man
y co
untr
ies
are
faci
ng
diffi
culti
es a
sses
sing
the
impa
ct o
f SM
C fr
om ro
utin
e da
ta. T
here
fore
, th
is in
terv
entio
n, li
ke a
ll ot
her
inte
rven
tions
, sho
uld
be u
nder
pinn
ed
by a
goo
d m
onito
ring
and
eval
uatio
n fra
mew
ork.
Con
tinuo
us m
onito
ring
of S
P an
d AQ
effi
cacy
in c
lear
ing
para
sites
is c
ritic
al
66
INTE
RVEN
TIO
N TY
PEC
URRE
NT
REC
OM
MEN
DAT
ION
POLI
CY
ADAP
TATI
ON
CO
NSID
ERAT
IONS
FO
R IN
TERV
ENTI
ON
TARG
ETIN
G
ANAL
YTIC
AL C
ONS
IDER
ATIO
NS A
ND
RATI
ONA
LEKE
Y D
ATA
AND
ARE
AS F
OR
MO
NITO
RING
STRA
TEG
IC C
ONS
IDER
ATIO
NS
IPTi
(int
erm
itten
t pr
even
tive
trea
tmen
t of
infa
nts)
In a
reas
of
mod
erat
e-to
-hig
h m
alar
ia tr
ansm
issio
n in
Afr
ica,
whe
re
SP is
stil
l effe
ctiv
e,
prov
ide
inte
rmitt
ent
prev
entiv
e tre
atm
ent
with
SP
to in
fant
s (<
12 m
onth
s of
age
) (S
P-IP
Ti) a
t the
tim
e of
the
seco
nd
and
third
roun
ds o
f va
ccin
atio
n ag
ains
t D
TP a
nd v
acci
natio
n ag
ains
t mea
sles.
In re
cent
tim
es, a
s m
ost
coun
trie
s ha
ve b
ecom
e re
liant
on
AC
Ts (w
ithou
t SP)
for
mal
aria
cas
e m
anag
emen
t, fe
w a
re m
onito
ring
leve
ls of
SP
resis
tanc
e.
For p
ract
ical
pur
pose
s, co
untr
ies
can
use
para
site
prev
alen
ce th
resh
old
of >
10%
to d
efine
are
as th
at h
ave
suita
ble
trans
miss
ion
for I
PTi.
In a
reas
whe
re p
reva
lenc
e Pf
dhps
54
0 is
grea
ter t
han
50%
and
less
th
an 9
0% c
ount
ries
are
enco
urag
ed
to a
sses
s th
e effi
cacy
of I
PTi-
SP in
ch
ildre
n un
der 1
bef
ore
cons
ider
ing
scal
e-up
.
Mod
eled
est
imat
es o
f tra
nsm
issio
n an
d bu
rden
Subn
atio
nal e
stim
ates
of S
P re
sista
nce,
bas
ed o
n m
olec
ular
m
arke
rs
Subn
atio
nal e
stim
ates
of E
PI
cove
rage
(esp
ecia
lly D
PT2,
3 a
nd
mea
sles)
Dist
ribut
ion
of p
opul
atio
n of
infa
nts
An e
valu
atio
n fra
mew
ork
shou
ld
be e
stab
lishe
d to
ass
ess
impa
ct.
Idea
lly th
is sh
ould
incl
ude
both
un
com
plic
ated
and
sev
ere
case
s as
w
ell a
naem
ia in
infa
nts.
Mas
s dr
ug
adm
inis
trat
ion
(MD
A)
Ther
e is
no fo
rmal
reco
mm
enda
tion
for M
DA.
WH
O’s
curr
ent p
ositi
on is
bas
ed o
n hi
stor
ical
doc
umen
ts,
upda
ted
by tw
o Ex
pert
Revi
ew G
roup
s (E
RG).
The
2015
ER
G’s
repo
rt (h
ttps:
//w
ww
.who
.int/
mal
aria
/mpa
c/m
pac-
sept
2015
-erg
-mda
-rep
ort.p
df) w
as fu
rthe
r en
dors
ed b
y M
PAC
in S
epte
mbe
r 201
5. A
sec
ond
ERG
(O
ctob
er 2
018
(http
s://
ww
w.w
ho.in
t/m
alar
ia/m
pac/
mpa
c-ap
ril20
19-s
essio
n7-e
rg-m
ass-
adm
nist
ratio
n-dr
ug-r
epor
t.pd)
), in
trodu
ced
som
e m
inor
mod
ifica
tions
. Th
ese
wer
e ev
alua
ted
by M
PAC
(Apr
il 20
19) w
hich
re
ques
ted
the
upda
ted
reco
mm
enda
tions
be
proc
esse
d th
roug
h th
e G
uide
lines
Rev
iew
Com
mitt
ee. T
his
is cu
rren
tly b
eing
pla
nned
.
The
curr
ent M
DA
impl
emen
tatio
n m
anua
l (ht
tps:
//w
ww
.w
ho.in
t/do
cs/d
efau
lt-so
urce
/doc
umen
ts/p
ublic
atio
ns/
gmp/
mas
s-dr
ug-a
dmin
istra
tion-
for-
falc
ipar
um-
mal
aria
) enc
oura
ges
cons
ider
atio
n of
this
inte
rven
tion
as fo
llow
s:
• M
alar
ia e
pide
mio
logy
– b
urde
n by
par
asite
spe
cie
• In
form
atio
n co
vera
ge o
f oth
er in
terv
entio
ns•
Leve
l and
pat
tern
s of
tran
smiss
ion
inte
nsity
• Re
leva
nt d
rug
resis
tanc
e da
ta•
Leve
ls an
d lo
catio
n of
epi
dem
ics
and
com
plex
em
erge
ncie
s•
Popu
latio
n se
ttlem
ents
, dem
ogra
phic
str
uctu
re, o
ccup
atio
n•
Hum
an p
opul
atio
n m
ovem
ents
, esp
ecia
lly in
elim
inat
ion
setti
ngs
To d
emon
stra
te im
pact
, MD
A m
ust b
e im
plem
ente
d at
hig
h co
vera
ge.
Clo
se m
onito
ring
of e
ffica
cy o
f dru
gs
used
in M
DA
is re
quire
d to
miti
gate
ag
ains
t spr
ead
of re
sista
nce
https://www.who.int/malaria/mpac/mpac-april2019-session7-erg-mass-admnistration-drug-report.pdf?ua=1
https://www.who.int/malaria/mpac/mpac-april2019-session7-erg-mass-admnistration-drug-report.pdf?ua=1
WH
O T
ECH
NIC
AL B
RIEF
FO
R C
OUN
TRIE
S PR
EPAR
ING
MAL
ARIA
FUN
DIN
G R
EQUE
STS
FOR
THE
GLO
BAL
FUND
(202
0–20
22)
67
INTE
RVEN
TIO
N TY
PEC
URRE
NT
REC
OM
MEN
DAT
ION
POLI
CY
ADAP
TATI
ON
CO
NSID
ERAT
IONS
FO
R IN
TERV
ENTI
ON
TARG
ETIN
G
ANAL
YTIC
AL C
ONS
IDER
ATIO
NS A
ND
RATI
ONA
LEKE
Y D
ATA
AND
ARE
AS F
OR
MO
NITO
RING
STRA
TEG
IC C
ONS
IDER
ATIO
NS
Mas
s dr
ug
adm
inis
trat
ion
(MD
A) (c
ont.)
Use
of M
DA
to in
terr
upt t
rans
miss
ion
of fa
lcip
arum
m
alar
ia m
ay b
e co
nsid
ered
in a
reas
app
roac
hing
el
imin
atio
n, p
rovi
ded
ther
e is
good
acc
ess
to tr
eatm
ent,
effec
tive
vect
or c
ontro
l mea
sure
s an
d su
rvei
llanc
e an
d m
inim
al ri
sk o
f re-
intro
duct
ion
of in
fect
ion.
Giv
en th
e th
reat
of m
ultid
rug
resis
tanc
e, M
DA
may
be
con
sider
ed a
com
pone
nt m
alar
ia e
limin
atio
n eff
ort i
n th
e G
reat
er M
ekon
g su
b re
gion
, in
area
s w
ith
good
acc
ess
to tr
eatm
ent,
vect
or c
ontro
l and
goo
d su
rvei
llanc
e.
In th
e ca
se o
f mal
aria
epi
dem
ics,
MD
A ca
n be
an
initi
al
part
of th
e co
ntai
nmen
t mea
sure
s to
rapi
dly
redu
ce
mal
aria
mor
bidi
ty a
nd m
orta
lity,
alon
g w
ith th
e ur
gent
in
trodu
ctio
n of
oth
er c
ontro
l mea
sure
s.
In e
xcep
tiona
l com
plex
em
erge
ncie
s w
hen
the
heal
th
syst
em is
ove
rwhe
lmed
and
una
ble
to s
erve
the
heal
th
need
s of
the
popu
latio
n, M
DA
may
be
cons
ider
ed to
re
duce
mal
aria
mor
bidi
ty a
nd m
orta
lity.
Mas
s pr
imaq
uine
pro
phyl
actic
trea
tmen
t, re
quiri
ng
pre-
seas
onal
MD
A w
ith d
aily
adm
inist
ratio
n of
pr
imaq
uine
for t
wo
wee
ks w
ithou
t glu
cose
-6-p
hosp
hate
de
hydr
ogen
ase
(G6P
D) t
estin
g, is
not
reco
mm
ende
d fo
r th
e in
terr
uptio
n of
viv
ax tr
ansm
issio
n.
With
dia
gnos
tic te
sts
curr
ently
ava
ilabl
e, m
ass
scre
enin
g an
d tre
atm
ent (
MSA
T) a
nd fo
cal s
cree
ning
and
tre
atm
ent (
FSAT
) are
not
reco
mm
ende
d in
terv
entio
ns to
in
terr
upt m
alar
ia tr
ansm
issio
n.
See
sect
ions
5.4
and
7.3.
5 fo
r fur
ther
info
rmat
ion.
68
WH
O T
ECH
NIC
AL B
RIEF
FO
R C
OUN
TRIE
S PR
EPAR
ING
MAL
ARIA
FUN
DIN
G R
EQUE
STS
FOR
THE
GLO
BAL
FUND
(202
0–20
22)
69
WHO guidance for countries preparing malaria concept notes for The Global Fund (2020 2022)
Global Malaria ProgrammeWorld Health Organization20 Avenue AppiaCH-1211 Geneva 27Switzerland
Web: https://www.who.int/malaria
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