Category Archives: Elimination

The Monkey on the Back of Malaria Elimination

Concerning malaria elimination, “WHO grants this certification when a country has proven, beyond reasonable doubt, that the chain of local transmission of all human (emphasis added) malaria parasites has been interrupted nationwide for at least the past 3 consecutive years.” This target is challenging enough, but becomes more complicated when we consider that zoonotic transmission of malaria among monkeys and humans has been documented in Brazil and Southeast Asia. We cannot expect monkeys to sleep under bednets, so creative and realistic solutions are needed.

The Malaria Eradication Research Agenda (malERA) recognizes this problem. Plasmodium knowlesi, originally found in macaque monkeys in Southeast Asia has been dubbed the fifth human malaria due to its spread to people as deforestation has disturbed the habitat of the monkeys. In particular malERA addresses the challenge of understanding the upward trend of this malaria infection in that region and the need for better understanding of transmission dynamics and proper diagnosis.

The danger of P. knowlesi is heightened by difficulties in diagnosing it and distinguishing it from other malaria species. “Recently, the prevalence of human infection with a simian malaria parasite, P. knowlesi, has become an important issue in a wide area of Southeast Asia. The identification of this parasite by microscopy is very difficult because it resembles the P. malariae parasite. However, the symptoms caused by P. malariae and P. knowlesi are very different, with only P. knowlesi causing severe and life-threatening malaria” (Komaki-Yasuda et al.)

Reports from Brazil highlight another ‘simian hotspot.’ While P. Knowlesi represents monkey infections reaching humans, the opposite may have happened to establish a reservoir in the New World. “P. vivax lineages appearing to originate from Melanesia that were putatively carried by the Australasian peoples who contributed genes to Native Americans. Importantly, mitochondrial lineages of the P. vivax-like species P. simium are shared by platyrrhine monkeys and humans in the Atlantic Forest ecosystem, but not across the Amazon, which most likely resulted from one or a few recent human-to-monkey transfers.”  But looking even further back in natural history, Escalante and colleagues found, “compelling evidence that P. vivax is derived from a species that inhabited macaques in Southeast Asia.”

A recent study in this area found the worrying results that, “The low incidence of cases and the low frequency of asymptomatic malaria carriers investigated make it unlikely that the transmission chain in the region is based solely on human hosts, as cases are isolated one from another by hundreds of kilometers and frequently by long periods of time, reinforcing instead the hypothesis of zoonotic transmission.”

In Africa, Linda Duval and co-researchers, who found P. falciparum in blood samples from two chimpanzees belonging to two different subspecies, warn that, “If malignant malaria were eradicated from human populations, chimpanzees, in addition to gorillas, might serve as a reservoir for P. falciparum,”

It appears that the dynamics between monkeys, malaria and humans has a long history. Even once certified malaria-free countries face the threat of imported malaria from people crossing borders. Now we must recognize that the threat may already live within borders. So since existing malaria interventions to protect humans from malaria cannot be applied to monkeys, accelerated research on the genetics of the parasite and the mosquito is needed to prevent both primate groups from getting malaria.

The Long and Winding Worm, 1986-2018

Recent reports draw attention that Guinea Worm persisted in small numbers in 2017 in two countries, Chad and Ethiopia. Mali and South Sudan were the only other two countries monitored because of recent cases, but each reported none for 2017.

Guinea Worm Wrap-Up #251

We recall that 32 and 23 years have passed since the challenge to eradicate the disease was posed and the hoped for date of eradication was to be achieved. There is no doubt that the 30 cases reported in 2017 is a gigantic drop from the 3.5 million estimated globally when the war on the worm started in 1986.

To date eradication has been achieved for only small pox (though its reemergence from labs as a potential biological war agent is feared). Could it return as global warming melts permafrost (and bodies) in the permafrost of northern latitudes?

Besides Guinea Worm, only polio and malaria have received calls for eradication (malaria for the second time in history). One wonders if even small pox could be eradicated in today’s world of conflicted and failed states – the last case of smallpox was in Somalia. Both Ethiopia and Chad border South Sudan’s civil conflicts.

What had made guinea worm, like smallpox, imminently eradicable was the fact that humans were the main reservoirs of infection (not counting the defenseless crustacean, the cyclops, that served as an intermediate host for work larvae). That has not changed. WHO observed that in Ethiopia both baboons and dogs have been infected with guinea worm in the same communities where humans suffer from the disease. While it was possible to ‘contain’ the infection in dogs, that is preventing them from contaminating water supplies, it was not surprisingly difficult to do the same for baboons. The dog problem has existed in Chad for at least 5 years.

Another problem in Ethiopia was the infection of seasonal laborers who could potentially take the disease back to other areas of the country. Although a system of rewards had been put in place this did not lead to the timely identification of all cases by either community members or health workers.

The road to disease eradication is clearly not a straight line from A to B. The twists and turns should be expected as time passes because ideally an eradication should be a short-term effort that is time-limited in order to provide a clear focus and adequate funding on the end goal.

What are the implications for malaria and polio? Conflict led to the hiding of polio cases in Nigeria and longer term efforts allowed vaccine derived poliovirus to emerge. Malaria is now found in Monkeys in Malaysia and Brazil, and parasite resistance to medicines and vector resistance to pesticides threatens effective interventions.

Time is not a commodity that favors eradication. In these days of plateauing financial support for global health, the call for eradicating deadly and economically debilitating infections needs to be louder.

Asymptomatic and Sub-Microscopic Malaria: a Challenge to Elimination Efforts

WHO says that, “In settings where malaria is actively being eliminated or has been eliminated, a “case” is the occurrence of any confirmed malaria infection with or without symptoms.” Several recent studies describe the importance of paying attention to asymptomatic infections.

In the Bagamoyo District of Tanzania Sumari and colleagues collected blood samples and examined them for Plasmodium falciparum prevalence using rapid diagnostic test (RDT), light microscopy (LM) and reverse transcription quantitative PCR. While overall prevalence was higher in symptomatic children using all three methods, asymptomatic children had a higher prevalence of gametocytes using light microscopy and PCR.  They concluded that, “The higher gametocytemia observed in asymptomatic children indicates the reservoir infections and points to the need for detection and treatment of both asymptomatic and symptomatic malaria.”

The health effects of asymptomatic plasmodial infections (API) on children were documented in Rwanda. These included “Plasmodium infection was associated with anaemia, fever, underweight, clinically assessed malnutrition and histories of fever, tiredness, weakness, poor appetite, abdominal pain, and vomiting” and were generally more common with submicroscopic infection.

Besides children other groups are at risk from API.  Malaria during pregnancy is a life and health threat to both the pregnant woman and the unborn child. Thirty-seven percent of asymptomatic pregnant women who had just delivered in Colombia were found to have parasitemia. Using microscopy only 8% were identified, such that without PCR the true extent of the problem would not have been identified. Thus, there is also concern for submicroscopic malaria and well as API generally. Asymptomatic and submicroscopic infections in areas co-endemic for P. falciparum and P. vivax are major contributors to anemia, not only in children but also in adults.

Working along the China-Myanmar border area, Zhao et al. explained that, “Sensitive methods for detecting asymptomatic malaria infections are essential for identifying potential transmission reservoirs and obtaining an accurate assessment of malaria epidemiology in low-endemicity areas aiming to eliminate malaria.” Thus they tried three molecular detection methods side-by-side, namely nested PCR targeting the rRNA genes, nested RT-PCR to detect parasite rRNA, and CLIP-PCR to detect parasite rRNA.

Interestingly the presence of fever is no guarantee that malaria parasites will be found. A study in Gabon demonstrated that among febrile patients only 1% had parasites found through microscopy compared to 32% through molecular testing. These studies have demonstrated the need for a better understanding of malaria transmission across different zones and strata in a country in the light of asymptomatic and submicroscopic malaria, especially gametocytemia. This should lead to better targeting of case detection, improved treatment and better compliance with preventive measures.

Enhancing Civilian-Military Cooperation to Accelerate Malaria Elimination in Southeast Asia

Our colleague Sara Canavati attended the recent meeting on civilian and military collaboration to eli8minate malaria in Southeast Asia. Herein she shares some of the highlights of the meeting. Sara is affiliated with both the Centre for Biomedical Research, Burnet Institute, Melbourne, Australia and the Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok.

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The Heads of State from ASEAN member nations stated their commitment to an “Asia Pacific free of Malaria by 2030” at the 9th East Asia Summit. This mandate for a malaria-free Asia Pacific creates an unprecedented opportunity to strengthen ties between civilian and military health systems and regional militaries.

On 26-28 June 2017, the Armed Forces Research Institute of Medical Science (AFRIMS) organized a meeting titled: “Enhancing Civilian-Military Cooperation to Accelerate Malaria Elimination in Southeast Asia” in Bangkok, Thailand. The meeting brought together Ministry of Defense and Ministry of Health malaria officials from Myanmar, Thailand, Cambodia, Laos, Indonesia, Vietnam, Australia, and the United States.

Since malaria is a common problem in the military, and since malaria does not know borders, regional collaborations involving all affected populations are important to achieve malaria elimination. The meeting was instrumental for reviewing existing military and civilian national malaria collaborations, identifying and prioritize key areas of mutual military-civilian interest, and discussing ways in which regional militaries can assist national malaria elimination goals.

Three action points on how the civilian and military sectors can more effectively collaborate to achieve elimination in four areas of mutual interest (Case Detection and Management and Disease Prevention; Surveillance, Monitoring and Evaluation; Operational Research/Training and Advocacy) were identified and documented by meeting attendees through a breakout team format.

Advocacy for malaria elimination was the theme that military attendees found most challenging due to the hierarchical structure of the military.  Among several presentations, East Africa Malaria Task Force and Experiences from African Military Medical Departments were shared to serve as an example of military-advocacy. Financing was another key barrier identified. The chair of the regional steering committee (RSC) for the Global Fund, Prof Arjen Dondorp and The Global Fund to Fight AIDS, Tuberculosis and Malaria (GFTAM) Geneva assured their support and commitment to finance military operations for malaria elimination in South East Asia. This was a historical achievement as this will be the first time ever the GFTAM finances the military for malaria elimination.

One significant outcome of the meeting is that the military will now be represented in the RSC for the Global Fund “Regional Artemisinin-resistance Initiative 2 Elimination (RAI2E)” malaria grant.

Links to some of Sara’s recent malaria publications:

Ghana – spotlight on malaria indicators

The Demographic and Health Surveys has released a brief on key indicators from the Ghana Malaria Indicator Survey of 2016. While much of the malaria community is discussing the elimination framework and processes, the reality is that many high burden countries are still trying to scale up basic interventions to achieve universal coverage.

The overall prevalence across the country in children aged 6-59 months at the time of the survey was 27% using Rapid Diagnostic test and 20% using microscopy.  Among children reporting fever in the previous two weeks care/advice was sought for only 72%. Although only only 30% received some sort of blood based diagnostic test, 61% of the febrile children were given the antimalarial artemisinin-based combination therapy drugs.

Children are still being treated without the benefit of parasitological testing, a key procedure highlighted in WHO case management guidelines. Presumptive treatment for malaria without testing means that a child could inappropriately receive antimalarial drugs and die of another underlying febrile illness. Appropriate testing and adherence to test results is one of the main areas of focus of Ghana’s grants from the US President’s Malaria Initiative. Improved testing is also an important element in Ghana’s current Global Fund support. Clearly more value for money is needed from these inputs.

Preventive measures as documented in the MIS fare somewhat better., but at present only 73% of households own an insecticide treated bednet. When considering the recommended 1 net for every 2 household members, the indicator drops to 50%. Concerning the typical ‘vulnerable’ populations, we see that only 52% of children below the age of 5 years slept under an ITN the night before the survey; only 50% of pregnant women did likewise.

Malaria prevention in pregnancy results reflect the fact that Ghana has promoted at least three IPTp doses for around ten years. Most pregnant women (78% ) had received the previously recommended minimum of two doses, and now 60% have received at least three doses.

One of the important issues stressed in WHO’s new malaria elimination framework is stratifying the country by prevalence to the lowest level possible in order to plan appropriate interventions. Fortunately the Ghana 217 MIS key indicator brief does stratify prevalence and intervention coverage by region.  Prevalence through RDT testing ranges from nearly 5% in the urbanized greater Accra area to 44% in the Central Region. Interestingly ITN use is nearly 20% higher in Central than greater Accra.

Hopefully future planning in Ghana will build on this stratification. Better mobilization of donor, national and private sector resources will address likely issues of stock-outs and increase the likelihood of universal coverage of basic interventions that is needed to move the country along the road to malaria elimination.

Nepal on the Path to Malaria Elimination

Jhpiego’s Emmanuel Le Perru has been placed with Nepal’s malaria control program by the Maternal and Child Survival Program (USAID) to strengthen the agency’s overall response to malaria as well as ensure top performance of Nepal’s Global Fund Malaria grant. Emmanuel shares his experiences with us here.

From 3,000 cases in 2010, Nepal reported around 1,000 cases in 2016, including 85% Plasmodium vivax cases. However private sector reporting is almost null so number of total cases may be the double. Nepal’s National Malaria Strategic Plan (NMSP) targets Elimination by 2022 (0 indigenous cases) with WHO certification by 2026.

Ward Level Micro-stratification is an important step for targeting appropriate interventions. Key interventions in the NMSP include case notification system by SMS (from health post workers or district vector control inspectors) to a Malaria Disease Information System, later to be merged with DHIS2. Case investigation teams conduct case and foci profiling as well as “passive cases” active detection and treatment (including staff from district such as surveillance coordinator, vector control inspector, and entomologist).

Malaria Mobile Clinics actively search/treat new cases in high risk areas (slums, brick factories, river villages or flooded areas, migrant workers villages, etc.). PCR diagnosis with Dry Blood Spot or Whole Blood is used to identify low density parasite cases, relapses or re-introduction. Coming up in April-June 2018 will be a Pilot of MDA (primaquine) for Plasmodium vivax in isolated settings (80% of cases in the country are P vivax).

Recent successes in the national malaria effort include the number of cases notified by SMS went from 0% to 45%. Also the number of cases fully investigated went from 22% to 52%, though this needs to go up to 95% for elimination. 73% of districts are now submitting timely malaria data reports per national guidelines, an increase from 52% in November 2015.

The border runs right through this town making importation of malaria cases easy

The Global Fund (GFATM) malaria grant rating went from B2 to A2. Nepal Epidemiology Disease Control Division (EDCD), WHO and GFATM are keen to pilot MDA for P vivax in isolated setting which MCSP/Jhpiego Advisor taking the lead.

Moving forward the malaria elimination effort needs to address Indo-Nepal Cross boarder collaboration since 45% cases are imported. Hopefully WHO will help EDCD Nepal to propose a plan of action to India. The program still needs to convince partners of relevance of malaria mobile clinics vs community testing and of the relevance of MDA for P vivax. More entomological and PCR/laboratory expertise is needed. With these measures malaria elimination should be in sight.

Malaria Day 17 Years Later: Documenting and Investing to End Malaria

The first time the global community observed a day devoted to tackling the problem of malaria was April 25th 2001. This was agreed upon at the African Summit on Roll Back Malaria held in Abuja, Nigeria in 2000. The first seven annual observances were titled “Africa Malaria Day,” and recognized that the largest global burden of the disease affects people on the African continent. As thoughts moved toward elimination, the importance of addressing all endemic communities resulted in the first “World Malaria Day” in 2008.

Thus on April 25th 2017 we are observing the 17th Malaria Day overall and the 10th anniversary of World Malaria Day. This observance has been complimented over the years with a malaria day for the Southern African Development Community and for countries in the Americas.

Each year Malaria Day has had a theme or themes to help focus education and advocacy. Regardless of the theme, the special day has been a time to mark progress and rally partners from the global to community level to continue the fight against the disease. The list below shows some of the issues/themes raised on the past Malaria Days. As noted, in some years advocacy efforts dealt with more than one key idea, though all are not presented.

  • 2001 – Africa Malaria Day 2001: The First Africa Malaria Day; Malaria – A Crisis With Solutions; A Malaria Free-World
  • 2002 – Mobilizing Communities to Roll Back Malaria
  • 2003 – Insecticide Treated Nets and effective malaria treatment for pregnant
  • women and young children
  • 2004 – A Malaria-Free Future: Children for Children to Roll Back Malaria
  • 2005 – Unite against malaria: Together we can beat malaria
  • 2006 – Get Your ACT Together: Universal Access to Effective Malaria Treatment is a Human Right
  • 2007 – Leadership and Partnership for Results
  • 2008 – Malaria, A Disease without Borders
  • 2009 – Counting Malaria Out
  • 2010 – Counting Malaria Out; (and in the Africa Region) Communities engage to conquer malaria!
  • 2011 – Achieving Progress and Impact
  • 2012 – Sustain Gains. Save Lives. Invest in Malaria
  • 2013-15 – Invest in the Future: Defeat Malaria
  • 2016-17 – End Malaria for Good

In sum these themes emphasize the importance of access to malaria interventions, documenting that access, using the data to stimulate more investment ultimately leading to an end (elimination) of malaria. The most recent World Malaria Report (2016) provides several important examples of the progress so far.

  • Households with least one ITN increased to 79% in 2015
  • 53% of the population at risk slept under an ITN in 2015 in Africa increasing from 30% in 2010
  • The proportion of suspected malaria cases receiving a parasitological test in the public sector increased from 40% in the WHO African Region in 2010 to 76% in 2015
  • In 2015, 31% of eligible pregnant women received three or more doses of intermittent preventive treatment in pregnancy (IPTp) among 20 countries with sufficient data, a major increase from 6% in 2010

In addition to noting progress, the report also points out gaps in appropriate care seeking for malaria, attendance at antenatal care clinics, and adequate numbers of nets for a household. As implied in the IPTp data, there is the additional problem of obtaining timely and accurate date to document progress and/or gaps. Looking at the Malaria Day themes around investing, we know that unless one can show investors results, it will be difficult to “End Malaria for Good.”

A malaria elimination framework that includes high prevalence countries, too

When the Nigeria Malaria Control Program changes its name to Nigeria Malaria Elimination Program (NMEP) a few years ago, people wondered whether this was getting too far ahead of the situation in one of the highest burden malaria countries in the world. The recently released Framework for Malaria Elimination by the Global Malaria Program of WHO shows that all endemic countries can fit into the elimination process.

Recent Webinar by WHO’s Global Malaria Program stressed that all countries have a role in malaria elimination

The Framework stresses that, “Every country can accelerate progress towards elimination through evidence-based strategies, regardless of the current intensity of transmission and the malaria burden they may carry.” The Three pillars of the malaria elimination framework have room for high burden countries. Pillar 1 states that, “Ensure universal access to malaria prevention, diagnosis and treatment.”

First it is important to understand that the Framework defines malaria elimination as the cessation of indigenous mosquito-borne transmission of malaria throughout a country. The Framework also observes that even within countries there are diverse transmission areas. Some are not amenable to malaria transmission, while others may be amenable but do not experience transmission.

It is important to realize that malaria transmission in most countries is characterized by diversity and complexity. Areas where transmission is occurring range from very low transmission zones where hotspots erupt to high levels of ongoing transmission. Thus even high burden countries may have variation that require development of intervention packages tailored to the specific transmission setting.

This stratification and development of appropriate intervention packages requires, “Excellent surveillance and response are the keys to achieving and maintaining malaria elimination; information systems must become increasingly ‘granular’ to allow identification, tracking, classification and response for all malaria cases (e.g. imported, introduced, indigenous).” This should lead to “subnational elimination targets as internal milestones.”

For high burden countries key components of Pillar 1 is, “Vector control strategies, such as use of insecticide-treated mosquito nets (ITNs/LLINs) and indoor residual spraying (IRS), together with case management (prompt access to diagnosis and effective treatment) are critical for reducing malaria morbidity and mortality, and reducing malaria transmission.”

Recommendations like ensuring political commitment, private sector involvement and establishment of an independent advisory committee are valuable at all stages of elimination. A challenge for high burden countries will be maintaining political commitment over many years. Early involvement of the private sector will boost coverage of major interventions. An independent advisory/monitoring group will help track data and progress.

It is important to put in place good monitoring systems to ensure that program coverage is well targeted, achieved and maintained. “Systematic tracking of programme actions over time, including budget allocations and adherence to standard operating procedures.” This enables accountability and enhances political commitment.

Finally the Malaria Atlas Project has mapped most recent data, and as we can see Nigeria does have a variety of transmission settings. We know now that the decision of Nigeria’s malaria program to update its name was appropriate. Hopefully not only the NMEP but also the various state malaria programs will look at their malaria transmission strata and plan according toward elimination.

Leadership and Support for Malaria Pre-Elimination in Nepal

Emmanuel Le Perru, Jhpiego field staff in Nepal, shared his experiences in aiding the malaria pre-elimination efforts in the country during a retreat that preceded the 65th Annual Meeting of the American Society of Tropical Medicine and Hygiene in Atlanta. Here are some highlights of his talk.

risk-mapMalaria Pre-Elimination efforts are targeting 0 deaths as well as investigation of 100% of confirmed cases in Nepal. Systematic entomology investigation/interventions are required. Glucose-6-Phosphate Dehydrogenase deficiency (enzyme genetic defect causing hemolysis with primaquine) testing for Plasmodium vivax in high G6PDd prevalence communities is required. Cases should receive treatment within 72 hours of symptoms for Pf (to quickly prevent transmission and gametocyte reservoir). There is also a need to distinguish between indigenous and imported cases.

Jhpiego is providing technical assistance and capacity building for Nepal’s Ministry of Health pre-elimination efforts as follows:

  • Integrated Vector Management
  • Micro-stratification
  • Entomology curriculum to be conducted in medical college (need new positions)
  • Case-based Surveillance guidelines
  • Private-sector engagement (for increased reporting and product quality control/procurement such as Antigen RDTs)
  • Capacity Assessments in 9 health systems strengthening components at central and district levels (Jhpiego Malaria Implementation Guide)
  • Human resources: clear job descriptions and performance goals
  • Leadership & Management development program

gfatm-bednets-distProgram highlights include the fact that the Global Fund malaria grant rating improved from B2 (inadequate but demonstrating potential) in January 2016, but now A2 (meeting expectations) in November 2016. Concept note for operational research at 2 or 3 border check points has been developed in order to determine whether such intervention (communication & voluntary screening) is cost-effective and relevant to catch/target imported cases, raise awareness on malaria available services, detect/prevent sources of potential outbreaks. This will inform GFATM on the relevance to fund such intervention. A similar approach was done at the China-Myanmar border but was not recognized by not WHO.

Nepal's Global Fund Grant Indicators for Malaria Case Management

Nepal’s Global Fund Grant Indicators for Malaria Case Management

Although the National Malaria Strategic Plan refers to high risk groups (forest workers, national parks security personnel, refugees, prisoners, etc.) evidence is needed to back this up. A study or improved investigation forms are needed to identify such groups and use this information to design appropriate behavior change communications and other interventions.

Special Programming Highlights include proposing a focus on Closed/Isolated Settings/Foci (limited migration, duration and population) to WHO and GFATM. Considering a targeted mass drug administration (MDA) Plasmodium vivax (not yes recommended by WHO) with Primaquine/G6PD testing. Consideration is being given to new drugs in the pipeline such as Ivermectin. Molecular Testing using Polymerase Chain Reaction (PCR) to detect low parasitemia, asymptomatic or re-infection cases (Pv includes inactive/dormant sporozoites known as hypnozoites) is being proposed.

Community based testing as proposed in the Global Fund grant needs strengthening. Therefore RDT use by Female Community Health Volunteer is being considered. Active case detection is another possibility for those areas moving toward pre-elimination. As mentioned, there is also need for studies of asymptomatic infection.

Lessons learned so far for best practices for efforts in identifying specific pre-elimination interventions include the value of getting consensus at national level through the Malaria Technical Working Group. There is also need to challenge WHO recommendations and engage dialogue to get creative. At present there is a risk of a Catch 22 situation wherein the GFATM asks for innovative interventions but at the same time tries to adhere strictly WHO to existing guidance.

The Nepalese malaria program is in constant dialogue with the GFATM Fund Portfolio Manager and team on the local context and technical challenges in order to get them involved in looking for innovative solutions.

Challenges arise in malaria diagnostics. While systematic microscopy is the gold standard, quality can be poor because of low stain/re-agent quality, constant staff turnover and donor reluctance to fund additional training. Also microscopy confirmation and slide quality control are time consuming, and often this process is not clear or well followed. PCR require specific equipment, training and qualifications. Takes time to be operational.

There are opportunities moving forward.  Progress could be made if there were more “elimination experts” to position to influencer to WHO to seek and propose new interventions for the pre-elimination stage. Nepal provides an ideal opportunity to test new ideas. It will also be necessary for the national malaria program staff to receive regular technical updates on program issues such as new drugs (Ivermectin?) and on-going pilots of MDA.

Malaria Day in The Americas Forum

In commemoration of Malaria Day in the Americas 2016

The Pan American Health Organization, The UN Foundation, The Milken Institute School of Public Health at The George Washington University, and Center for Communication Programs at The Johns Hopkins Bloomberg School of Public Health

Cordially invite you to attend the

“End Malaria for Good” Forum

Featuring videos, presentations and discussions on

The work of the ‘Malaria Champions of the Americas 2016’

malariaevite-2016-americasWHEN: Thursday, November 3, 2016, TIME: 1:00 p.m. to 3:30 p.m.

WHERE: Room B, PAHO Headquarters, 525 23rd Street NW, Washington, DC—20037

RSVP: Please fill out the form at

Light refreshments will be served