Tropical Health Matters

Rwanda’s First Malaria Forum has just concluded in Kigali, producing recommendations to help the country, which is already experiencing very low levels of malaria transmission, develop strategies for the path to malaria elimination. After a series of informative talks other countries in the region and international support organizations, working groups distilled the learning from the forum into suggestions for strategic planning. Below we present the deliberations of the Working Group on Surveillance, Monitoring and Evaluation. Group members included Irenee Umulisa, J. Bosco Ahoranayezu, John MacArthur, Arielle Mancuso, Aafje Rietveld, Eric Tongren, Anna Winters.

Preamble: A paradigm change is necessary within the national malaria surveillance system in order to take Rwanda from the stage of malaria control to pre-elimination. Stratification (epidemiological, entomological and environmental) will be used as the basis for applying different programme approaches in the different parts in the country, including surveillance approaches. In high burden strata, the quality of malaria control surveillance will be optimized. In low endemic strata, WHO recommended elimination surveillance approaches will be piloted and gradually introduced to field-try forms & procedures and build systems capacity.

Goals and Vision: By 2017, every febrile patient on the Rwandan territory will visit a health facility within 48 hours for diagnosis and treatment. Under 5s will be treated at community level within 24 hours. A microscopy and RDT quality assurance system (including external quality control) will be in place, ensuring reliable diagnosis at all diagnostic facilities. Every malaria case diagnosed with RDT and treated at community level will be reported to the health center level within 24 hours, accompanied by a microscopy slide for confirmation of diagnosis.

All malaria cases will be reported into one centralized HMIS, irrespective of the health providers who diagnosed and treated them (public, private, community, army, etc.) and irrespective of the way they were detected (ACD, PCD, surveys).

Health centers in low and moderate malaria burden strata will carry out “enhanced malaria surveillance” allowing foci investigation and classification. Health centers in endemic areas will forward line-listings of patients (ideally also with information about recent travel) to the district level with copy to the central level on weekly basis. Central level will compile from these data weekly updated mapping by village level and track cases against epidemic thresholds.

Strategic objectives and action points:

By 2012, update the stratification map of Rwanda’s malaria burden by including data from HMIS, SIS-COM and any other sources of malaria patient data that may be available. The objective is to be all-inclusive: in malaria elimination every case counts. A more in-depth stratification using entomological and environmental variables and intervention coverage will follow.

• Merge SIS-COM (community) data collection with existing HMI
• Use the map to identify 3-4 zones for stratification of surveillance and intervention methods based upon malaria burden.

By 2013, develop/update the surveillance plan to direct the MOH malaria surveillance strategies over the coming 5 years within the changing epidemiological settings, with a view to (a) attain malaria pre-elimination programme status in low and moderate burden strata by 2017; and (b) maintain and improve upon the current control achievements in higher burden strata.

• Improve and coordinate data management and timeliness.
• Include a plan for human resources necessary to undertake enhanced surveillance.
• Include a timeline to achieve strategic objectives and action points.

By 2014, set up the systems to enable and ensure that all suspected malaria cases (100%) are diagnostically confirmed using available tools and in a timely fashion within both public and private clinics.

• Develop (guided by OR) for each strata a clear case definition of a suspected malaria case who should be tested, ranging from a broad definition (fever) in highly endemic areas to a more restricted definition (perhaps including a travel history or additional symptoms) in low endemic areas. Communicate these definitions to all health care providers and the public in the various strata. The purpose is to ensure that every potential malaria case is promptly tested, without unduly overburdening the health workers in low endemic areas.
• Monitor the use of antimalarials by various health facilities against the numbers of cases diagnosed and reported.

By 2015, pilot “enhanced malaria surveillance” in 1-3 low endemic districts

• In low and moderate burden areas, begin line listing all confirmed malaria cases including travel history and household location with the goal to map cases (2015-2017). Focus initial line listing and case mapping within Kigali or another accessible low burden district (2013).
• By 2014, engage the private sector physicians in Kigali for cooperation in malaria surveillance activities (working with the Rwanda medical association). Enforce full cooperation of the private sector by 2017. Restrict availability of antimalarial medicines to registered facilities with access to diagnostic capacity.
• In low and moderate burden areas, begin collecting weekly malaria data at the health facility level.
• Gradually include immediate notification and due programme follow up (investigation, classification) of cases detected, starting with one district where this seems doable.
• Explore business/private coalitions to support a longer term vision of a malaria-free Kigali / tourism areas.

By 2015, pilot line listing in one endemic district, increasing to all endemic districts by 2017

• Integrate training and data management into existing community health worker programs.
• Develop and deploy a system for active case detection (ACD) as part of case investigation at the community level.
• Map all confirmed cases which are passively and actively detected.
• Develop epidemic thresholds for comparison against weekly case loads.

By 2013, review and start to address the factors that contribute to malaria mortality in Rwanda.

• Conduct death audits for all reported malaria cases that occurred in 2012. The purpose is to identify risk factors for delays in treatment / inadequate treatment that can be addressed by NMCP programme interventions. Use this study to strengthen collaboration of the NMCP with the national school of public health (or equivalent) by engaging a team of university students / scientists in the study.
• Explore possibilities for increasing the use of pre-referral treatment with rectal artesunate, based on an understanding of the barriers and behaviours for accessing pre-referral treatment.
• By 2015, carry out death audits for all reported malaria deaths as they occur, to adjust and target programme interventions.

Continue drug and insecticide resistance monitoring to guide drug and insecticide policies.

Recommendations:

• By 2014, initiate “enhanced malaria surveillance” following WHO recommended strategies for the elimination phase in 1 low endemic district, increasing to 3 districts by 2015 and all low-endemic districts by 2017. This includes investigation, classification and mapping of cases and transmission foci.
• By 2015, institute line listing in one endemic district, increasing to all endemic districts by 2017.
• Encourage and facilitate information sharing among all partners in malaria control.
• Use available resources in a manner that allows continued high quality surveillance in endemic areas combined with gradual introduction of elimination approaches in low endemic districts. Adopt the philosophy of first building up enhanced surveillance systems and then expanding the system as resources and malaria burdens allow.
• Consider including Kigali within the first pilot districts for enhanced surveillance, given the low prevalence and focalized transmission patterns, and to encourage political will.
• Conduct death audits in order to measure progress towards the goal of zero malaria deaths.

The Roll Back malaria Partnership supports four sub-regional networks (SRNs) in East, Southern, Central and West Africa. The SRNs are a mechanism for strengthening South-South collaboration in the fight against malaria. Such collaboration is essential as neighboring countries move closer to elimination and policies and transmission patterns in one can affect the success of elimination efforts in another.

The collaboration is particularly visible and active in the Southern African SRN (SARN), where a meeting has just concluded to plan action along the Angola-Namibia border – otherwise known as the Trans-Kunene Cross-border Malaria Initiative (TKMI). Similar initiatives are ongoing among all of the ten partners  who include  Botswana, Madagascar, Malawi, Mozambique, Namibia, South Africa, Swaziland, URT-Zanzibar, Zambia, Zimbabwe.

The northern border area of Namibia is its only malaria endemic region. While the area of Angola just across the border has similar transmission patterns, the whole of Angola farther north is highly endemic.  Angola’s actions can therefore, affect the fate of malaria elimination in Namibia.

At the TKMI meeting in August 2012 Stakeholders reviewed activities during the 2011-12 malaria transmission season and affirmed commitment of the two governments to continue to work together to eliminate malaria in their cross-border region. An important component of collaborative work is the synchronization of operations and harmonization of policies and guidelines such as joint Monitoring and Evaluation and data systems including exchange of information and best practices will ensure that all cases are reported and traced jointly along the border.

Another crucial area of collaboration, according to SARN Leadership, is removal of border immigration restrictions and customs requirement will speed up movement malaria workers and malaria commodities especially during epidemics, cross-border referrals, joint outreaches and joint operations/campaigns such as IRS, Larviciding and LLINs mass distribution. This also helps to resolve bottlenecks related to delivery.

Policy and program guidelines for elimination recommended by the stakeholders included test, treat and trace, and hence, they stressed the need for using rapid diagnostic tests and training all health staff in the region to be proficient in these.  Prompt and appropriate case management was also outlined including the need, an mentioned above, for easy cross-border movement of supplies of malaria medicines.  Indoor residual spraying is a very appropriate strategy in these low and unstable transmission areas, and will be more effective if communities on both sides of the border are covered equally.

The TKMI meeting ended with a declaration of the collaborating partners. They observed that the considerable effort in malaria control in the two countries had  “produced good results in the drastic reduction of mortality and morbidity caused by this disease,” and pledged that this will continue through “reinforcement of
harmonization of policies and strategic components.”

The two countries’ stakeholders recognized that common efforts to improve logistics such as “infrastructures, transport, immigration and customs along the common” were just as important as harmonizing program policies and guidelines. In closing “two parties promised to engage in a process of mobilizing more
resources and partnerships at different levels, with the aim to accelerate the universal coverage along the common border border.” This spirit of collaboration is needed throughout malaria endemic regions.

Press Release from APMEN

In an important step toward achieving malaria elimination, Vietnam officially joins the Asia Pacific Malaria Elimination Network (APMEN) today. APMEN brings together countries in the Asia Pacific that have adopted a national or sub-national goal for malaria elimination, and connects them with a broad range of regional and global malaria partners to develop best practices for eliminating malaria and to efficiently address region-specific challenges, like Plasmodium vivax.

Vietnam has made great strides in improving the health of its citizens, which includes reducing the risk of malaria throughout the country. Malaria deaths have plummeted by 91% in the last decade, from 71 deaths in 2000 to 14 in 2011. Reported cases of malaria have also dropped by 85%, declining from 300,000 cases to 45,000 in 2011. However, similar to other countries in the Asia Pacific region, Vietnam faces substantial challenges to eliminating malaria, which include the increasing spread of drug-resistant malaria parasites and continuous movement of populations between malaria-free and malaria-endemic areas.

The most malarious regions in Vietnam – remote, forested areas – are also the country’s hardest places to reach, and require more responsive surveillance systems to effectively track down and treat malaria cases. By joining APMEN, Vietnam aims to harness the region’s collective experience, research findings and program recommendations to take on the final – and perhaps most difficult – steps to eliminating malaria. Vietnam’s malaria program, the National Institute for Malariology, Parasitology, and Entomology (NIMPE), recently completed its National Strategy for Malaria Control, Prevention and Elimination 2011-2015. With this strategic plan,

Vietnam outlined its goals of controlling and reducing malaria in higher burden areas, and the implementation of a spatially progressive malaria elimination strategy in low transmission regions. APMEN is a country-led network focused on generating and disseminating evidence-based information on what works to drive down malaria and achieve elimination in the Asia Pacific.

APMEN was developed in 2009 in response to a call to action by countries in the region to tackle malaria elimination. With Vietnam as the newest addition, APMEN connects its 12 other network countries— Bhutan, Cambodia, China, Democratic People’s Republic of Korea, Indonesia, Malaysia, Philippines, Republic of Korea, Solomon Islands, Sri Lanka, Thailand and Vanuatu— in an effort to learn from each other’s malaria program approaches, translate research into action and consider optimal program implementation.

More reading about eliminating malaria in Vietnam can be found through the UCSF Global Health Group’s country profiles. APMEN country partners work together to sustain the gains made in malaria control and ensure financial and political support for malaria elimination in the region. Further information regarding APMEN can be viewed at www.apmen.org.

Nancy Fullman shares highlights of Asia Pacific Malaria Elimination Network (APMEN) fourth annual meeting.

The twelve-country Asia Pacific Malaria Elimination Network (APMEN) is generating knowledge on what works to sustain the gains in malaria control and elimination during a time of malaria funding uncertainty. With the Republic of Korea as its host, the 2012 APMEN annual meeting takes place May 7 –11th 2012 in Seoul with the theme of “Efficiency in Elimination.” Focused on pressing malaria issues in the Asia Pacific region, APMEN countries and partners will discuss antimalarial drug resistance, cross-border importation of malaria cases, and maximizing program efficiency by identifying malaria “hot spots” and focusing interventions in these areas.

As the fourth of its kind, this APMEN meeting’s theme of “efficiency” reflects the urgent global need to maintain and expand malaria programs, in spite of substantial funding shortages related to the global financial crisis (e.g., postponed grants from the Global Fund to Fight AIDS, Tuberculosis and Malaria)

With this meeting APMEN country representatives and partners aim to learn from country success stories – such as Cambodia’s impressive 35% reduction of malaria from 2010 to 2011 – and discuss strategic approaches for addressing the looming challenges of spreading artemisinin resistance and reducing the prevalence of Plasmodium vivax in the Asia Pacific. Although P. vivax is thought to account for fewer malaria deaths worldwide than P. falciparum (i.e., most prevalent strain of malaria in Sub-Saharan Africa), P. vivax is a main source of severe illness throughout the Asia Pacific region. Further, P. vivax currently has fewer effective treatment options than P. falciparum, which is a key research and investment issue identified by APMEN partners.

Since 2009, APMEN has brought together countries in the Asia Pacific that have adopted a national or subnational goal for elimination, as well as a broad range of key academic, development, non-governmental, and private sector partners. Through its regional network collaborations and annual gatherings, APMEN promotes the exchange of best practices, early introduction of innovative strategies, and support needed for country malaria control programs to push toward their goals for malaria elimination.

In 2012, work from several APMEN countries, including documentation of Bhutan’s malaria elimination efforts and subnational surveillance programs in the Solomon Islands, has received international attention. With Cambodia’s recent welcome to APMEN as the network’s twelfth country partner, this year’s APMEN meeting in Seoul aims to further broaden the dialogue among country partners and harness the region’s collective expertise to improve malaria elimination efforts in the Asia Pacific region.

Further information regarding APMEN can be found at www.apmen.org.

Rwanda on track to zero deaths from malaria by 2015

By Dr. Corine Karema

Today, April 25th, the world will be commemorating Malaria Day as stipulated in the Abuja Declaration of 2000. Just like the previous years, Rwanda will join the rest of the world in commemorating this day by highlighting achievements in controlling Malaria while also renewing commitment of achieving zero targets of malaria related deaths by 2015.

The theme for this year’s World Malaria Day is “Sustain Gains, Save Lives: Invest in Malaria”, a theme that is testimony to the renewed global commitment of finding lasting solutions for eliminating Malaria from our midst.  For Rwanda, a country that has registered significant progress in combating Malaria, this commitment is a shared vision for which we attach greater value.

Coming up with sustainable and investment solutions for Malaria control is a new discourse which underlines the importance of continued investment in combating this disease with the view of propelling malaria-endemic countries along the path of achieving the health and poverty related Millennium Development Goals by 2015. Here in Rwanda, the battle against Malaria has not been an easy one. It has called for strategic interventions, committed leadership of our government and support from development partners to register progress that we see today across the country.

I will share with you some of the outstanding achievements we have registered over the past years, many of which are captured in the recently released 2010 Demographic Health Survey (DHS). The recent scaling up of interventions has made significant progress:

• reductions in morbidity by 87% from 1,669,614 malaria cases in 2005 to 212,200 cases in 2011 and
• reduced mortality by 76% from 1,582 deaths in 2005 to 380 deaths in 2011.

This reduction is as a result of scaling up of preventive measures especially coverage and use of long lasting insecticidal nets (LLINs) which according to the 2010 DHS results…

• 82% of households have at least one LLIN
• 72% of pregnant women slept under their nets and
• 70% of children under-five years were using bed nets

Previously and as the case is in most developing countries, Malaria is treated based on signs and symptoms. However, Rwanda is one of the few countries in the world today where up to 94 percent of Malaria cases are laboratory through microscopy or rapid diagnostic tests at all levels of health care structure including the community level.

The involvement of Community Health Workers (CHWs) in early diagnosis and treatment of children Under-five years has also had an impact on malaria incidence throughout the country as currently 95% of children are tested and treated for malaria within 24 hours of symptoms onset.

In addition, Malaria control activities have been integrated and decentralized at all levels including –

• a strong CHWs network which facilitates community involvement and participation,
• the community health insurance scheme also known as Mutuelles de Sante and
• a strong Health Management Information Systems (HMIS) including the web based community health information system (SIS.com)

The above interventions are strengthened by use of mobilisation and sensitisation campaigns using different channels of communication. The advocacy and social mobilisation is oriented towards intensifying different efforts to sustain the gains made as the country moves towards pre-elimination phase of malaria as outlined in the new Malaria Strategic Plan (2012-2017).

To emphasize on the importance of the World Malaria Day, this year’s event will be held during the scheduled Rwanda Malaria Forum that will be held in Kigali in mid June 2012. The Forum will bring together malaria experts from international community who will deliberate on the challenges African countries and in particular, Rwanda, face in malaria control and how to overcome them.

The recommendations of the forum will guide our sector in finalizing the new Malaria Strategic Plan that outlines Rwanda’s strategies from malaria control to pre-elimination phase by 2017. A series of activities to run for a week have also been planned to reach community levels where different interventions of promoting awareness on preventive measures will be discussed with input from community leaders.

Therefore, as we mark this day in Rwanda, we take pride of our achievements but also remain mindful and conscious of the challenges ahead a in realising the ambitious target of having a Rwanda that is free from Malaria.

The Author is Head of Malaria and Other Parasitic Diseases Division Rwanda Biomedical Center/IHPDPC, Follow: Twitter @ckarema

News this week from The Lancet confirming suspicions of malaria parasite resistance to artemisinin-based drugs deals a double blow to malaria control efforts coming just a few months after announcements by Global Fund to cancel Round 11 funding.  Pressure on malaria drugs is nothing new, especially since the same problem has arisen in the same region of the world for two previous and cheaper mainstays of malaria case management.

In all our hopes for rolling back malaria over the past 14 years, did we tell ourselves that such resistance was this time not inevitable?   Unlike in previous waves of resistance, this time we should have been better prepared with effective anti-vector measures. BUT this assumes that we have met our RBM targets and are happily progressing toward 2015 expecting no more malaria deaths.

We get reports that scale-up and case reduction are occurring, such as a recent newspaper article from Jigawa State in Nigeria, but basically we have not achieved our 2010 scale-up targets – so what will come first – 2015 success or the wave of parasite resistance spreading out from Southeast Asia?

The hopes of the current RBM effort were based on the fact that by 2000 we had 3-4 effective anti-malaria interventions, unlike the reliance on mainly one during the first stab at eradication.  Unfortunately the question is still the same as it was in the 1950s-60s – are our health systems strong enough to deliver the goods? More effective interventions that do not reach people will not present a strong bulwark against spreading drug resistance.

Frustration may mount even more when we realize that all the insecticide treated nets distributed over the prolonged period of campaigns from 2009-2012 will need to be replaced, mostly well before 2015.  Our coverage to date has not been adequate, our funding is threatened – what guarantees that we can keep up with adequately containing malaria before the resistant strains of the parasite reach Africa where the bulk of cases and deaths occur?

Some of our ‘easy’ eradication targets like guinea worm and polio are still flaunting their capacity to harm.  These like other previous efforts are at risk from donor fatigue.  Malaria, which is more complex than those two diseases, is at even greater risk. The RBM Partnership needs to develop a serious and workable strategy to get well ahead to the resistance wave NOW.

Malaria incidence and prevalence has been dropping quickly in Rwanda, below 2% in children under 5 years old. Malaria in Pregnancy (MIP) is still a risk some and may be more severe as the disease becomes rare and immunity reduces. The US President’s Malaria Initiative is supporting a prevalence study of MIP through its Maternal and Child Health Integrated Program (MCHIP) and the National Malaria Control Program (NMCP) so that appropriate data will become available to design appropriate MIP interventions as the country moves towards malaria elimination.

The study focuses on pregnant women during their first visit to focused antenatal care (FANC) for their current pregnancy. Four FANC visits promote maternal and newborn health through 1) Early detection and treatment, 2) Prevention of complications and disease, 3) Birth preparedness and 4) Health promotion.

The study of over 4000 women is at the half way mark. Supervisory visits determine if data such as RDT, Microscopy and PCR tests, are being gathered correctly.

Pictured here are Alice and Donatien who are nurses based at Gakoma Health center in Gisagara District and were trained for the the MIP prevalence study. They are seen here taking blood samples for the study. They have integrated the study procedures into the routine FANC they provide. This makes it easier for the client as well as the nurses who also extract study data on age, parity, hemoglobin, bednet ownership and fever history which is normally collected as part of FANC.

Since data collection began in late December, Alice and Donatien have enrolled about half of their target number of clients.  When the results from all 38 health centers across the country are compiled in April, the National Malaria Control Program will have valuable information to plan how best to protect pregnant women as the country moves closer to malaria elimination.

Agente Santé Maternelle (ASM) are one of four types of Rwandan Community Health Workers (CHWs) which include community case management and social mobilization workers who are selected by their own villagers and serve as volunteers.

ASM identify, follow, educate and refer pregnant women in their villages to the nearest health center. During the USAID ACCESS Project in Rwanda, Jhpiego assisted the Ministry of Health to adapt UNICEF training materials for ASMs. MCHIP is continuing the work and focuses on training and kitting ASMs in five Districts.

Alphonsine, an ASM from Karubondo village near Gikondo Health Center keeps a record book of pregnant women she is following. Her village has 179 households, 696 residents and 124 women of reproductive age (WRA).

The program ensures that ASM have manageable case loads. Since her training by MCHIP in August 2011, Alphonsine has seen 17 clients and now is following 9 pregnant women.

Health education materials such as a flipchart for the ASMs include emphasis on bednet use and prompt treatment of fevers. AMS also have a carry bag, boots, umbrella, thermometer, and a torch.

Some women are reluctant to reveal their pregnancies because of social issues like being a widow or a teenager. The AMS must work hard to gain trust so women confide in her. Volunteer work as ASM must fit in with her hard work as a farmer.

ASMs encourage women to attend Antenatal Care at nearest clinic. There they will reveive free bednets. The ASM then educates the women on proper and regular net use. The ASM also refers women with danger signs in pregnancy to ANC. Such signs may be high temperature for which proper testing and treatment is needed if they have malaria.

Rwanda is closing in on malaria elimination. The various kinds of CHWs play an important role in prevention, case detection and assurance of appropriate treatment. Community vigilance is a crucial component of eliminating the disease.

We recently suggested that malaria elimination efforts learn from guidelines and manuals developed for the elimination of lymphatic filariasis. Today at the American Society for Tropical Medicine and Hygiene meeting, a presentation from the South Africa National Department of Health and its partners outlined how they are “Strengthening Malaria Information Systems in South Africa: Moving Towards Elimination.”

The presentation stressed that, “locally transmitted malaria cases have declined by 92% and malaria deaths have declined by 82% in 2010 as compared to 2000.” This serious drop in malaria cases is spurring the need recognize the transition from control strategies to efforts appropriate to the pre-elimination phase.

Currently malaria is endemic in only 3 provinces, Kwazulu Natal, Mpumalanga and Limpopo, with over 90% of cases in the latter. Thyere is a lack of standardized malaria information across these three provinces, absence of timely notification and lack of information that could aid targeting of interventions.  The national program is addressing this by identifying seven key components of an information tracking system that focuses on –

1. Rapid Diagnostic Tests
2. Geographic Information System
3. Parasitology
4. Entomology
5. Indoor Residual Spraying
6. Case Investigation
7. Notification

The three provinces have some but none has all of these embedded in a comprehensive and systematic information system that does more than track epidemics.  In addition there is emphasis on ensuring adequate human resources to undertake these tasks.

South Africa recognizes that political and financial commitment is needed in the country. There is a realistic expectation that the country cannot depend on donors to sustain their malaria information system.  Hopefully these efforts will also be adopted by the other front line malaria elimination target countries in Southern Africa.

Sessions at the current American Society of Tropical Medicine and Hygiene in Philadelphia have focused on progress in the global elimination of lymphatic filariasis (LF). Filariasis and malaria have some elements in common, such as some mosquito vectors, and possibly malaria elimination efforts could learn from LF elimination.

The duration of a typical filariasis elimination program might span around 10 years, much shorter than expected for malaria, where Roll Back Malaria has already been working hard for 13 years. Even with this difference LF elimination has important surveillance tools needed for the end game that can be adapted for malaria. As the figure here shows, the first step is mapping which can take at least a year.

Then there are at least five annual mass drug administrations (MDA) with ivermectin or DEC and albendazole.  Monitoring goes along with distribution, and as pointed out at a panel presentation at ASTMH, determines whether the program can enter Step 3 (three rounds of annual surveillance) or complete a few more MDA rounds.  Eventually the project site is certified as having eliminated filariasis.

An ASTMH symposium highlighted the challenges: “The decision to implement a mass drug administration (MDA) program for LF is based on convenience sampling to demonstrate that the prevalence of infection is greater than 1% in a selected district or implementation unit. Making the decision to stop MDA has been a challenge for countries,” when prevalence drops below 1%.

Fortunately those involved in LF have tools and guidelines to focus their efforts. These guide initial mapping and choice of diagnostic tools, ongoing program monitoring and endline Transmission Assessment Surveys (TAS)  The purpose of the guidelines is …

“Effective monitoring, epidemiological assessment and evaluation are necessary to achieve the aim of interrupting LF transmission. Th is manual is designed to ensure that national elimination programmes have available the best information on methodologies and procedures for (i) monitoring MDA, (ii) appropriately assessing when infection has been reduced to levels where transmission is likely no longer sustainable, (iii) implementing adequate surveillance aft er MDA has ceased to determine whether recrudescence has occurred, and (iv) preparing for verifi cation of the absence of transmission.”

The guideline manual provides general guidance to national programmes but reminds program managers that each program is unique and may require further technical guidance.

Several countries, especially in the Asia-Pacific Region and Southern Africa are working toward malaria elimination. Such tools adapted to malaria program needs are required. One of the challenges for the TAS is that while countries have received donations of medicines to eliminate LF, they have found it harder to find or allocate funds to do the necessary surveillance to know when to stop interventions and verify elimination. This also rings true for malaria – donors and governments should not stop funding malaria elimination until certification has been achieved.