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WORLDMALARIAREPORT 2011

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REPORT 2011

WHO Global Malaria Programme

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WHO Library Cataloguing-in-Publication Data

World malaria report : 2011.

1.Malaria - prevention and control. 2 Malaria - economics. 3.Malaria - epidemiology. 4.National health programs - utilization. 5.Insecticide-treated bednets.6.Antimalarials - therapeutic use. 7.Drug resistance. 8.Disease vectors. 9.Malaria vaccines. 10.World health. I.World Health Organization.

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World Health Organization 2011

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with the reader. In no event shall the World Health Organization be liable for damages arising from its use.'HVLJQDQGOD\RXWSDSULNDDQQHF\FRP

Cover photo IreneAbdouPhotography.com

Printed in Switzerland

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Contents

Foreword .................................................................................................................................................................................v

Acknowledgements ........................................................................................................................................................................vi

Abbreviations ...............................................................................................................................................................................vii

Summary and Key Points ...........................................................................................................................................................viii

Chapter 1 Introduction................................................................................................................................................................1

Chapter 2 Goals, targets, policies and strategies for malaria control and elimination .........................................3

2.1 Goals and targets for malaria control and elimination...............................................................................................................3

2.3 Malaria elimination .........................................................................................................................................................9

2.4 Indicators ...................................................................................................................................................................10

2.5 Policy development .......................................................................................................................................................10

Chapter 3 Financing malaria control...................................................................................................................... 15

3.1 Resource requirements ..................................................................................................................................................15

'RPHVWLFoQDQFLQJRIPDODULDFRQWURO ................................................................................................................................16

3.4 Categories of expenditure by source of funds........................................................................................................................17

3.5 Potential Savings .........................................................................................................................................................17

3.6 Potential for increased funds for malaria control...................................................................................................................22

3.7 Conclusions.................................................................................................................................................................24

Chapter 4 Vector Control.......................................................................................................................................... 27

4.1 ITN policy and implementation .........................................................................................................................................27

4.2 IRS policy and implementation .........................................................................................................................................30

4.3 Malaria vector insecticide resistance.................................................................................................................................30

4.4 Conclusions.................................................................................................................................................................34

Chapter 5 Preventive therapies for malaria .......................................................................................................... 35

5.1 Intermittent preventive treatment......................................................................................................................................35

5.2 New therapeutic tools for malaria prevention .......................................................................................................................36

5.3 Conclusions.................................................................................................................................................................37

Chapter 6 Diagnostic testing and treatment of malaria...................................................................................... 39

6.1 Diagnostic testing for malaria ..........................................................................................................................................39

6.2 Treatment of malaria .....................................................................................................................................................43

6.4 Antimalarial drug resistance ............................................................................................................................................46

6.5 Conclusions.................................................................................................................................................................48

Chapter 7 Impact of malaria control....................................................................................................................... 51

7.1 Assessing trends in the incidence of disease ........................................................................................................................51

7.2 African Region..............................................................................................................................................................52

7.3 Region of the Americas...................................................................................................................................................60

7.4 Eastern Mediterranean Region .........................................................................................................................................62

7.5 European Region...........................................................................................................................................................64

7.6 South-East Asia Region...................................................................................................................................................66

:HVWHUQ3DFLoF5HJLRQ...................................................................................................................................................68

7.8. Malaria elimination.........................................................................................................................................................70

7.9 Imported malaria, 20012010 ..........................................................................................................................................70

7.10 Global estimates of malaria cases and deaths 2000-2009........................................................................................................72

7.11 Conclusions.................................................................................................................................................................74

Profiles ............................................................................................................................................................. 79

Annexes ........................................................................................................................................................... 183

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Foreword

Dr Margaret Chan

Director-General

World Health Organization

7KHoQGLQJVLQWKH World Malaria Report 2011 show that weDUH PDNLQJ VLJQLoFDQW DQG GXUDEOH SURJUHVV LQ EDWWOLQJ D PDMRUSXEOLFKHDOWKSUREOHP&RYHUDJHRIDWULVNSRSXODWLRQVZLWKPDODULDSUHYHQWLRQDQG FRQWURO PHDVXUHV LQFUHDVHGDJDLQ LQ DQGresulted in a further decline in estimated malaria cases and deaths.$QGWKHPDODULDPDSFRQWLQXHVWRVKULQN,Q,ZDVSOHDVHG

WREHDEOHWRFHUWLI\$UPHQLDDVEHLQJIUHHRIPDODULDDWULEXWHWRWKLVFRXQWU\VH[FHOOHQWVXUYHLOODQFHDQGUHVSRQVHFDSDFLW\DQGattention to the public health basics. In a world starved of goodQHZVWKHVHDUHZHOFRPHGHYHORSPHQWV

%XW ZRUULVRPH VLJQV VXJJHVW WKDW SURJUHVV PLJKW VORZHVSHFLDOO\ LQ YLHZRI SURMHFWHGGHFUHDVHV LQ WKHIXQGLQJQHHGHGWRoQDQFHXQLYHUVDODFFHVVWROLIHVDYLQJPDODULDSUHYHQWLRQDQGcontrol measure. International funding for malaria appears to haveSHDNHGDW86ELOOLRQZHOOVKRUWRIWKH86WR ELOOLRQWKDWDUH UHTXLUHG:KLOH QHZ FRPPLWPHQWV VXFKDV WKRVH IURP WKH8QLWHG .LQJGRP KDYH EHHQ LQGLVSHQVDEOH IRU PDLQWDLQLQJ RXUFXUUHQWJDLQVWKH\DUHQRWVXIoFLHQWWRDFKLHYHWKHJRDOVWKDWWKH

JOREDOPDODULDFRPPXQLW\KDVVHW,QHQGHPLFFRXQWULHVGRPHVWLFspending on malaria often remains inadequate. The implicationsRIWKHVHIXQGLQJVKRUWIDOOVDUHIDUUHDFKLQJDVVXFFHVVLQPDODULDcontrol is crucial for achievement of the health-related Millennium'HYHORSPHQW*RDOVHVSHFLDOO\LQ$IULFD

7KHQH[WIHZ\HDUVZLOOEHFULWLFDOLQWKHoJKWDJDLQVWPDODULD:HNQRZIURPH[SHULHQFHKRZ IUDJLOH RXU JDLQVDUH:KLOH WKHdistribution of hundreds of millions of long-lasting insecticidalPRVTXLWRQHWVRYHUWKHSDVWVHYHUDO\HDUVKDVEHHQDUHPDUNDEOHDFKLHYHPHQWWKDWKDVVDYHGKXQGUHGVRIWKRXVDQGVRIOLYHVWKRVHQHWVQRZRUZLOOVRRQQHHGUHSODFLQJ'DWDLQWKLVUHSRUWVKRZWKDWWKHYDVWPDMRULW\RIGLVWULEXWHGQHWVDUHXVHGDQGWKDWWKHSULPDU\

barrier to universal coverage remains access. It is our responsibilityto ensure that these and other life-saving commodities reachall who need them before our hard-won progress slips away.$FKLHYLQJWKLVZLOOUHTXLUHOHDGHUVKLSDWJOREDOQDWLRQDODQGORFDOlevels. It will also require innovation. If the mosquito nets can bePDGHPRUHGXUDEOHJLYLQJWKHPDOLIHRIoYH\HDUVLQVWHDGRIWKUHHWKHVWUDLQRQIUDJLOHKHDOWKV\VWHPVFRXOGEHJUHDWO\UHGXFHGWKHULVNRIUHVXUJHQFHVLQPDODULDFRXOGEHPLQLPL]HGDQGKXQGUHGVof millions of dollars could be saved.

Parasite resistance to antimalarial medicines remains a realand ever-present danger to our continued success. While efforts tocontain artemisinin resistance on the CambodiaThailand border

appear to have dramatically reduced the burden of malaria dueto Plasmodium falciparum DQG WKH SUREOHP FXUUHQWO\ UHPDLQVFRQoQHGWRWKH0HNRQJUHJLRQZHDUHQRZVHHLQJHDUO\HYLGHQFH

of artemisinin resistance in Myanmar and Viet Nam. There is anXUJHQWQHHGWRGHYHORSDQ$VLDZLGHIUDPHZRUNWRHQVXUHVXVWDLQHGDQGFRRUGLQDWHGDFWLRQDJDLQVWWKLVSXEOLFKHDOWKWKUHDWZKLOHDWthe same time continuing to press for the withdrawal from thePDUNHWRIRUDODUWHPLVLQLQPRQRWKHUDSLHVZKLFKDUHRQHRIWKHPDMRUIDFWRUVIRVWHULQJWKHHPHUJHQFHDQGVSUHDGRIDUWHPLVLQLQresistance. These monotherapies are still widely available despiterepeated calls for action from the World Health Assembly.

One way to curb the continued emergence and spread ofantimalarial drug resistance is to ensure that all patients withVXVSHFWHGPDODULDUHFHLYHDGLDJQRVWLFWHVWDQGWKDWRQO\WKRVHZLWKFRQoUPHG Plasmodium infection receive antimalarial treatment.:KLOHZH VWLOOKDYHD ORQJ ZD\ WRJR WKLV UHSRUWGHPRQVWUDWHVFRQWLQXHGSURJUHVVZLWKUHJDUGWRGLDJQRVWLFWHVWLQJLQ$IULFDDQGa doubling in the number of rapid diagnostic tests supplied byPDQXIDFWXUHUVWRPLOOLRQLQDVZHOODVQRWDEOHLQFUHDVHVin product performance.

7RDGGWRRXUOLVWRIZRUULHVWKHWKUHDWRILQVHFWLFLGHUHVLVWDQFHDSSHDUVWREHJURZLQJUDSLGO\&XUUHQWO\ZHDUHKLJKO\GHSHQGHQWRQWKHS\UHWKURLGVDVWKH\DUHWKHRQO\FODVVRILQVHFWLFLGHVXVHGon insecticide-treated mosquito nets. Resistance to pyrethroids hasQRZEHHQLGHQWLoHGLQDZLGHYDULHW\RIVHWWLQJVPDQ\RIWKRVHLQthe most highly malaria-endemic countries of Africa. In response toWKLVWKUHDWDQGDVUHTXHVWHGE\WKH:RUOG+HDOWK$VVHPEO\:+2LVFXUUHQWO\ZRUNLQJZLWKDZLGHYDULHW\RIVWDNHKROGHUVWRGHYHORSD*OREDO3ODQIRU,QVHFWLFLGH5HVLVWDQFH0DQDJHPHQWLQPDODULDYHFWRUVZKLFKZLOOEHUHOHDVHGLQHDUO\

In the face of economic uncertainties and potential threats

from parasite resistance to antimalarial medicines and mosquito

UHVLVWDQFHWRLQVHFWLFLGHVZHPXVWUHPDLQGHWHUPLQHG,IZHWDNHfull advantage of the malaria prevention and control tools we have

WRGD\ZKLOHPLWLJDWLQJSRWHQWLDOWKUHDWVWKURXJKFRQVWDQWYLJLODQFHDQGWLPHO\UHVSRQVHWKHQZHZLOOVXVWDLQDQGH[WHQGWKHUHPDUNDEOHgains that have been made. The citizens of malaria-endemic

countries are all counting on us. We must not let them down.

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Acknowledgements

Numerous people contributed to the production of the World

Malaria Report 2011. The following collected and reviewed data

IURPPDODULDHQGHPLFFRXQWULHV$KPDG:DOLG6HGLTL$IJKDQLVWDQ+DPPDGL 'MDPLOD $OJHULD 1LOWRQ 6DUDLYD $QJROD /XVLQH

3DURQ\DQ $UPHQLD 9LNWRU *DVLPRY $]HUEDLMDQ $ 0DQQDQ%DQJDOL%DQJODGHVK

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Abbreviations

$%(5 $QQXDOEORRGH[DPLQDWLRQUDWHACD Active case detectionACT Artemisinin-based combination therapy$,'6 $FTXLUHGLPPXQRGHoFLHQF\V\QGURPH

ALMA African Leaders Malaria AllianceAMI Amazon Malaria Initiative$0)P $IIRUGDEOH0HGLFLQH)DFLOLW\IRUPDODULDAMP Alliance for Malaria PreventionCCM Community case management&'& 86&HQWHUVIRU'LVHDVH&RQWURODQG3UHYHQWLRQCHAI Clinton Health Access InitiativeCRESIB Barcelona Centre for International Health ResearchDDT Dichloro-diphenyl-trichloroethane'),' 7KH8QLWHG.LQJGRP'HSDUWPHQWIRU,QWHUQDWLRQDO

DevelopmentDHS Demographic and health survey'73 'LSKWHULDWHWDQXVSHUWXVVLV

),1' )RXQGDWLRQIRU,QQRYDWLYH1HZ'LDJQRVWLFV* *URXSRIQDWLRQV*3' *OXFRVHGHK\GURJHQDVH*+*86) *OREDO+HDOWK*URXS8QLYHUVLW\RI6DQ)UDQFLVFR*OREDO)XQG 7KH*OREDO)XQGWRoJKW$LGV7XEHUFXORVLVDQG

Malaria*0$3 *OREDOPDODULDDFWLRQSODQ*03 *OREDO0DODULD3URJUDPPH:+2*3$5& *OREDO3ODQIRU$UWHPLVLQLQ5HVLVWDQFH

Containment*3,50 *OREDO3ODQIRU,QVHFWLFLGH5HVLVWDQFH0DQDJHPHQW

in malaria vectors+,9 +XPDQLPPXQRGHoFLHQF\YLUXV

HMIS Health management information system,$(* ,QWHU$JHQF\DQG([SHUW*URXSRQ0'*,QGLFDWRUViCCM Integrated community case managementIDA International Development Association,(& ,QIRUPDWLRQHGXFDWLRQDQGFRPPXQLFDWLRQIHME Institute for Health Metrics and EvaluationIM IntramuscularIPTi Intermittent preventive treatment in infantsIPTp Intermittent preventive treatment in pregnancyIRS Indoor residual sprayingITN Insecticide-treated mosquito net.GU .QRFNGRZQUHVLVWDQFHLSM Larval Source Management

LLIN Long-lasting insecticidal net0'* 0LOOHQQLXP'HYHORSPHQW*RDO0(5* 5%00RQLWRULQJDQGHYDOXDWLRQUHIHUHQFHJURXSMICS Multiple indicator cluster surveyMIS Malaria indicator surveyMPAC Malaria Policy Advisory CommitteeMVI Malaria Vaccine Initiative1*2 1RQJRYHUQPHQWDORUJDQL]DWLRQNMCP National malaria control programme2'$ 2IoFLDOGHYHORSPHQWDVVLVWDQFHOECD Organisation for Economic Co-operation and

DevelopmentOP Organophosphate

PATH Program for Appropriate Technology in HealthPCD Passive case detectionPDS Panel detection score30, 7KH863UHVLGHQWV0DODULD,QLWLDWLYH345 7KH*OREDO)XQGV3ULFHDQG4XDOLW\5HSRUWLQJ4$ 4XDOLW\DVVXUDQFH

5$95('$ $PD]RQ1HWZRUNIRUWKH6XUYHLOODQFHRIAntimalarial Drug Resistance

R4D Results for Development5%0 5ROO%DFN0DODULD3DUWQHUVKLS

RDT Rapid diagnostic testRH Relative humidity6$*( :+26WUDWHJLF$GYLVRU\*URXSRI([SHUWVRQ

ImmunizationSMC Seasonal malaria chemopreventionSPR Slide positivity rate7(* 7HFKQLFDOH[SHUWJURXSTDR Special Programme for Research and Training in

Tropical Diseases81,&() 8QLWHG1DWLRQV&KLOGUHQV)XQG816( 2IoFHRIWKH8QLWHG1DWLRQV6SHFLDO(QYR\IRU

Malaria86$,'8QLWHG6WDWHV$JHQF\IRU,QWHUQDWLRQDO'HYHORSPHQW

WER WHO Weekly Epidemiological ReportWHA World Health AssemblyWHO World Health OrganizationWHOPES WHO Pesticide Evaluation Scheme

Abbreviations of antimalarial medicines

$4 $PRGLDTXLQHAL Artemether-lumefantrineAM ArtemetherART ArtemisininAS Artesunate

CL Clindamycin&4 &KORURTXLQH' 'R[\F\FOLQHDHA Dihydroartemisinin04 0HpRTXLQH14 1DSKURTXLQH3* 3URJXDQLO334 3LSHUDTXLQH34 3ULPDTXLQH3

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Summary and Key Points

The World Malaria Report 2011 summarizes informationreceived from 106 malaria-endemic countries and other sourcesand updates the analyses presented in the 2010 report. It highlightscontinued progress made towards meeting the international targets

for malaria control set for 2010 and 2015.

,QWHUQDWLRQDOIXQGLQJIRUPDODULDFRQWUROKDVFRQWLQXHGWRULVH

WRDSHDNRI86ELOOLRQLQ7KHDPRXQWVFRPPLWWHGWRPDODULDZKLOHVXEVWDQWLDOVWLOOIDOOVKRUWRIWKHUHVRXUFHVUHTXLUHGWRUHDFKPDODULDFRQWUROWDUJHWVHVWLPDWHGDWPRUHWKDQ86ELOOLRQ SHU\HDU IRU WKH\HDUV q0RUHRYHUIXQGLQJLV

SURMHFWHGWRUHPDLQDWWKHVHOHYHOVRUGHFUHDVHEHIRUHXQOHVVQHZVRXUFHVRIIXQGVDUHLGHQWLoHG

7KHoQDQFLQJSURYLGHGIRUPDODULDFRQWUROKDVHQDEOHGHQGHPLF

countries to greatly increase access to insecticide-treated mosquitoQHWV,71VWKHSHUFHQWDJHRIKRXVHKROGVRZQLQJDWOHDVWRQH,71

in sub-Saharan Africa is estimated to have risen from 3% in 2000to 50% in 2011 while the percentage protected by indoor residualVSUD\LQJ,56URVHIURPOHVVWKDQLQWRLQHousehold surveys indicate that 96% of persons with accessto an ITN within the household actually use it. The number ofUDSLGGLDJQRVWLFWHVWV5'7VDQGDUWHPLVLQLQEDVHGFRPELQDWLRQ

WKHUDSLHV $&7V SURFXUHG LV LQFUHDVLQJ DQG WKH SHUFHQWDJH RI

reported suspected cases receiving a parasitological test has alsoLQFUHDVHGIURPJOREDOO\LQWRLQZLWKWKH

ODUJHVW LQFUHDVH LQ VXE6DKDUDQ $IULFD 'HVSLWH WKLV VLJQLoFDQWSURJUHVV KRZHYHU PRUH ZRUN LV QHHGHG EHIRUH WKH WDUJHW RI

universal access is attained.

Reductions in reported malaria cases of more than 50% havebeen recorded between 2000 and 2010 in 43 of the 99 countriesZLWKRQJRLQJWUDQVPLVVLRQZKLOHGRZQZDUGWUHQGVRIq

were seen in 8 other countries. There were an estimated 216PLOOLRQHSLVRGHVRIPDODULDLQRIZKLFKDSSUR[LPDWHO\

RUPLOOLRQFDVHVZHUHLQWKH$IULFDQ5HJLRQ7KHUHZHUHDQHVWLPDWHGPDODULDGHDWKVLQRIZKLFKZHUHLQ$IULFD$SSUR[LPDWHO\RIPDODULDGHDWKVJOREDOO\ZHUHRI

children under 5 years of age. The estimated incidence of malariaJOREDOO\ KDV UHGXFHG E\ VLQFH DQG PDODULDVSHFLoF

mortality rates by 26%. These rates of decline are lower thanLQWHUQDWLRQDOO\DJUHHG WDUJHWV IRU UHGXFWLRQV RI EXW

QRQHWKHOHVVWKH\UHSUHVHQWDPDMRUDFKLHYHPHQW

Resistance to artemisinins a vital component of drugs usedin the treatment of P. falciparum malaria has been reported ina growing number of countries in South-East Asia. Resistance toS\UHWKURLGVWKHLQVHFWLFLGHVXVHGLQ,71VqDQG PRVWFRPPRQO\used in IRS has been reported in 27 countries in Africa and 41FRXQWULHV ZRUOGZLGH 8QOHVV SURSHUO\ PDQDJHG VXFK UHVLVWDQFH

potentially threatens future progress in malaria control.

Internationally agreed targets and goalsfor malaria control

The year 2010 was an important milestone on the way to

achievement of internationally agreed goals and targets for

malaria control. In the light of progress made by 2010, targets for

the Global Malaria Action Plan (GMAP) of the Roll Back Malaria

Partnership were updated in June 2011.

1. The year 2010 was the date set to achieve universal coverageIRUDOOSRSXODWLRQVDWULVNRIPDODULDXVLQJORFDOO\DSSURSULDWH

LQWHUYHQWLRQV IRU SUHYHQWLRQ DQG FDVH PDQDJHPHQW DQG WR

reduce the malaria burden by at least 50% compared to thelevels in the year 2000.

2. ,QWKHOLJKWRISURJUHVVPDGHE\WKH5ROO%DFN0DODULD

5%0WDUJHWVZHUHXSGDWHGLQ-XQH7KHWDUJHWVDUHQRZ

WRLUHGXFHJOREDOPDODULDGHDWKVWRQHDU]HURE\HQG

LLUHGXFHJOREDOPDODULDFDVHVE\IURPOHYHOVE\

HQGDQGLLLHOLPLQDWHPDODULDE\HQGLQQHZ

FRXQWULHVVLQFHLQFOXGLQJLQWKH:+2(XURSHDQ5HJLRQ

These targets will be met by: achieving and sustaining universalDFFHVV WR DQG XWLOL]DWLRQ RI SUHYHQWLYH PHDVXUHV DFKLHYLQJ

universal access to case management in the public and privateVHFWRUVDQGLQ WKHFRPPXQLW\LQFOXGLQJDSSURSULDWHUHIHUUDO

and accelerating the development of surveillance systems.

Financing malaria control

The funds committed to malaria control from international

sources are expected to peak in 2011 at US$ 2 billion and remain

substantially lower than the resources required to achieve global

targets, estimated at > US$ 5 billion for the years 20102015.

3. ,QWHUQDWLRQDO IXQGLQJLV H[SHFWHGWR SHDN LQ DW86 ELOOLRQ

)URPWRLWLVSURMHFWHGWRUHPDLQUHODWLYHO\

VWDEOHEXWWKHQGHFUHDVHWR86ELOOLRQLQ$UHGXFWLRQ

LQ FRPPLWPHQWV IURP WKH *OREDO )XQG LV SDUWO\ RIIVHW E\

LQFUHDVHGFRPPLWPHQWVIURPWKH8QLWHG.LQJGRPV'HSDUWPHQW

IRU,QWHUQDWLRQDO'HYHORSPHQW'),'RIXSWR86PLOOLRQ

by 2015. Information on domestic government funding formalaria control is less complete. Available information suggestsWKDWGRPHVWLFIXQGLQJLVJHQHUDOO\OHVVWKDQ86SHUSHUVRQ

DWULVNDQGUHSUHVHQWVDVPDOOSURSRUWLRQRIWKHWRWDOoQDQFLQJRImalaria control in the most highly endemic countries.

4. Cost savings within vector control programmes may be possibleEXWDUHOLNHO\WREHPRGHVWIRUVHYHUDOUHDVRQVLWKHSULFH

RI DQ ,71 ZKLFK UHSUHVHQWV WKH ODUJHVW FRPSRQHQW RI WKH

FRVW RI ,71 SURJUDPPHV KDV GHFUHDVHG E\ EHWZHHQ

DQG EXW WKHUHGXFWLRQV PD\QRW EH PDLQWDLQHG

LI PDQXIDFWXUHUV FXW WKHLU PDQXIDFWXULQJ FDSDFLW\ LL ODUJH

SXUFKDVHUVXVXDOO\REWDLQWKHORZHVWSULFHVOHDYLQJOLWWOHURRP

IRUHIoFLHQFLHVWKURXJKLPSURYHGSURFXUHPHQWLLLWKHFRVWVRI

WKHWZRPDLQVWUDWHJLHVIRUGHOLYHULQJ,71VYLDPDVVFDPSDLJQV

RUKHDOWKVHUYLFHVDUHVLPLODUDQGW\SLFDOO\FRPSULVHRQO\q

RIWKHWRWDOFRVWRIGHOLYHU\PRUHRYHUGHOLYHU\FRVWVPD\

increase when programmes need to deliver only to householdsUHTXLULQJUHSODFHPHQW QHWVUDWKHU WKDQ WR DOO KRXVHKROGV Y

there is scope for reducing the cost per person protected by,56 E\H[SDQGLQJ ,56 SURJUDPPHVEXW WKH FRVW SHU SHUVRQ

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SURWHFWHGSHU\HDULV86LQODUJHSURJUDPPHVFRPSDUHGWRDSSUR[LPDWHO\86IRU,71V

5. ([SHQGLWXUH RQ WUHDWPHQW LV H[SHFWHG WR GHFUHDVH DV

SDUDVLWRORJLFDO WHVWLQJ LV H[SDQGHG WR DOO VXVSHFWHG FDVHV RIPDODULD :LWK FXUUHQW SULFHV RI 5'7V DQG $&7V 86 IRU5'7DQG86IRU$/DQGSHUIHFWFRPSOLDQFHZLWKWHVW UHVXOWV VDYLQJV RQ FRPPRGLWLHV FRXOG DPRXQW WR 86

68 million in the public sector in the WHO African Region.

+RZHYHUH[SDQGLQJWKHXVHRI5'7VPD\QRWOHDGWRRYHUDOOFRVWsavings because of the possible added costs due to increasedVWDIIWLPHWRSHUIRUPWHVWVHVWDEOLVKLQJTXDOLW\FRQWUROV\VWHPVDOWHUQDWLYHWKHUDSLHVIRUSDWLHQWVZLWKQHJDWLYHWHVWUHVXOWVDQG

the start-up costs of changing malaria case management policy.Any additional costs would need to be balanced against theLPSURYHG TXDOLW\ RI FDUH SURYLGHG WR SDWLHQWV EHWWHU KHDOWKRXWFRPHVWKHSRWHQWLDOUHGXFWLRQLQWKHULVNRIHPHUJHQFHDQGVSUHDG RI DQWLPDODULDOGUXJ UHVLVWDQFH DQGLPSURYHGPDODULD

surveillance.

6. Improved malaria control should result in lower numbers ofmalaria cases and lead to reductions in the cost of treatingSDWLHQWVDWWDLQPHQWRI XQLYHUVDODFFHVVWR ,71VLQ WKH:+2African Region in 2015 could reduce the number malaria casesattending public health facilities by 31 million to 48 million.7KH VDYLQJV RQ FRPPRGLWLHV DORQH $&7V DQG 5'7V ZRXOGDPRXQWWRPRUHWKDQ86PLOOLRQSHU\HDULQWKH$IULFDQRegion. However the full potential of these savings will not beUHDOL]HGLIDOOIHYHUFDVHVDUHWUHDWHGSUHVXPSWLYHO\DVPDODULDZLWKRXWFRQoUPDWLRQE\DGLDJQRVWLFWHVW

7. Potentially large savings could be made through newtechnologies. The development and deployment of ITNs lasting5 years could reduce the total number of ITNs required between

2011 and 2020 from 1.25 billion to 750 million. If the unitFRVWRIGHOLYHULQJERWKW\SHVRI,71VZHUHVLPLODUDW86D WRWDO RI 86 ELOOLRQ FRXOG EH VDYHG IURP D oQDQFLQJ

UHTXLUHPHQWRI86ELOOLRQ7KHSULFHRI5'7VKDVIDOOHQby 11%15% annually from 2008 to 2010. The developmentRIVWLOOFKHDSHUWHVWVFRXOGOHDGWRFRQVLGHUDEOHFRVWUHGXFWLRQV

even if RDTs were used for only half the suspected malariacases attending public health facilities in the WHO African5HJLRQKDOYLQJWKHSULFHIURPWKHFXUUHQW86WR86ZRXOGVDYH86PLOOLRQSHU\HDU

8. 0DODULDSURJUDPPHVDFFRXQWHGIRUDSSUR[LPDWHO\RI2IoFLDO'HYHORSPHQW $VVLVWDQFH 2'$ IRU KHDOWK DQG SRSXODWLRQ LQLQFUHDVLQJIURPLQ2YHUDOOoQDQFLQJIRUKHDOWKDQGSRSXODWLRQUHPDLQHGVWDEOHEHWZHHQDQGDQG

LVOLNHO\WRGRVRWKHUHDIWHU*LYHQVWDEOHWRWDOIXQGLQJDQGWKDWPDODULDSURJUDPPHVDOUHDG\UHFHLYHDVLJQLoFDQWSURSRUWLRQRIKHDOWK DQG SRSXODWLRQ oQDQFLQJIXUWKHU LQFUHDVHVLQ PDODULDIXQGLQJZLWKLQKHDOWKVHFWRUoQDQFLQJPD\EHXQOLNHO\

9. There appears to be scope for domestic governments to investPRUHLQPDODULDFRQWURO,IMXVWRIWRWDOGRPHVWLFVSHQGLQJ

ZHUHPDGHDYDLODEOHIRUPDODULDFRQWURORIWKHFRXQWULHVwith ongoing malaria transmission could raise enough toSURYLGH HDFK SHUVRQ DW ULVN ZLWK DFFHVV WR DQ ,71 *OREDO

economic growth has allowed many malaria-endemic countriesWRLQFUHDVHWRWDOGRPHVWLFJRYHUQPHQWVSHQGLQJPRUHWKDQ

FRXQWULHVLQFUHDVHGSHUFDSLWDVSHQGLQJE\86EHWZHHQ2000 and 2010.

10. ,QQRYDWLYH oQDQFLQJ PHFKDQLVPV DUH LQ WKH HDUO\ VWDJHV RIGHYHORSPHQW7D[HVRQERQGVDQGGHULYDWLYHVWUDQVDFWLRQVPD\

offer the greatest potential for revenue generation estimatedLQ H[FHVV RI 86 ELOOLRQ q EXW WKHLU VXJJHVWHG XVHV JREH\RQG PDODULD FRQWURO 7D[HV RQ DLUOLQH MRXUQH\V FXUUHQWO\

UDLVHPRUHWKDQ86 PLOOLRQIRUKHDOWKGHYHORSPHQWDQGWKHLUH[WHQVLRQWRDGGLWLRQDOFRXQWULHVFRXOGJHQHUDWHVLJQLoFDQWDGGLWLRQDO IXQGV 2WKHU FRXQWU\VSHFLoF VFKHPHV VXFK DV

WRXULVWWD[HVPD\RIIHURSSRUWXQLWLHVWR UDLVHIXQGVIRUFRQWURO

programmes in malaria-endemic countries.

Progress in vector control

Coverage with ITNs and IRS has increased rapidly in some

countries of sub-Saharan Africa, with household ITN ownership

reaching 50% by mid-2011 and IRS protecting 11% of the

population at risk. Resistance to pyrethroids has been detected in

27 countries in sub-Saharan Africa.

Insecticide-treated mosquito nets

11. ,QFRXQWULHVLQWKH$IULFDQ5HJLRQDQGLQRWKHU

WHO Regions had adopted the WHO recommendation toprovide ITNs forallSHUVRQVDWULVNIRUPDODULDQRWRQO\SUHJQDQWZRPHQDQGFKLOGUHQWKLVUHSUHVHQWVDQLQFUHDVHRIFRXQWULHVVLQFH$WRWDORIFRXQWULHVRIZKLFKDUHLQWKH$IULFDQ5HJLRQGLVWULEXWH,71VIUHHRIFKDUJH

12. The number of ITNs delivered by manufacturers increaseddramatically from 5.6 million in 2004 to 145 million in 2010

in sub-Saharan Africa. The numbers procured between 2008DQG PLOOLRQZHUH VXIoFLHQW WRFRYHU RIWKH

PLOOLRQSHUVRQVDWULVNEXWWKLVGRHVQRWWDNHLQWRDFFRXQW

delays in delivering ITNs in countries or loss of ITNs afterdelivery to households.

13. The number of ITNs supplied by manufacturers in 2011DSSHDUVWRKDYHGHFUHDVHGWRDSSUR[LPDWHO\PLOOLRQ7KLVLV

partly because some countries have made substantial progresstowards achieving universal access to ITNs in 2010 and are not\HWVFKHGXOHGWRUHRUGHU,71VEXWDOVREHFDXVHVRPHFRXQWULHVDUHVWLOOQRWH[SDQGLQJSURJUDPPHVWRDVXIoFLHQWVFDOH

14. 8VLQJ D PRGHO WKDW WDNHV LQWR DFFRXQW WKH QXPEHU RI ,71VVXSSOLHG E\ PDQXIDFWXUHUVWKH QXPEHU RI ,71VGHOLYHUHG E\QDWLRQDOPDODULDFRQWUROSURJUDPPHV10&3VDQGKRXVHKROG

VXUYH\GDWDWKHSHUFHQWDJHRIKRXVHKROGVRZQLQJDWOHDVWRQHITN in sub-Saharan Africa is estimated to have risen from 3% inWRLQ&RQVLGHUDEO\PRUHZRUNLVUHTXLUHGWR

ensure that ITNs reach all households where they are needed.

15. $QDO\VLVRIUHFHQWKRXVHKROGVXUYH\VLQGLFDWHVWKDWDSSUR[LPDWHO\

96% of persons with access to an ITN within the householdDFWXDOO\XVHLWVXJJHVWLQJWKDWWKHPDLQFRQVWUDLQWWRHQDEOLQJ

SHUVRQVDWULVNRIPDODULDWRVOHHSXQGHUDQ,71UHPDLQVWKHLQVXIoFLHQWDYDLODELOLW\RIQHWV

16. The rapid scale-up of ITN distribution in Africa is an enormousSXEOLF KHDOWK DFKLHYHPHQW EXW DOVR SUHVHQWV D IRUPLGDEOH

7/30/2019 1. WHO 2011

10/259x WORLD MALARIA REPORT 2011

challenge for the future in ensuring that the levels of coverageDUHPDLQWDLQHG7KHUHLVXQFHUWDLQW\RYHUWKHH[WHQWWRZKLFK,71HIIHFWLYHQHVVGHFD\VRYHUWLPHEXWWKHOLIHVSDQRIDORQJODVWLQJ LQVHFWLFLGDO QHW //,1LV FXUUHQWO\ HVWLPDWHG WR EHyears. Nets delivered in 2007 and 2008 are therefore now dueIRUUHSODFHPHQWVRRQWREHIROORZHGE\WKRVHGHOLYHUHGLQand 2010.

Indoor residual spraying

17. ,56ZLWK:+2DSSURYHGFKHPLFDOVLQFOXGLQJ''7UHPDLQVRQHof the main interventions for reducing and interrupting malariatransmission through vector control in all epidemiologicalVHWWLQJV ,Q FRXQWULHV LQFOXGLQJ LQ WKH $IULFDQ5HJLRQUHFRPPHQGHG,56IRUPDODULDFRQWURODQGFRXQWULHVreported using DDT for IRS.

18. $WRWDORIPLOOLRQSHRSOHZHUHSURWHFWHGE\,56LQUHSUHVHQWLQJRIWKHJOREDOSRSXODWLRQDWULVN7KHQXPEHURIpeople protected by IRS in the African Region increased from 10PLOOLRQLQWRPLOOLRQLQLQFOXGLQJDOOFRXQWULHVLQVXE6DKDUDQ$IULFDPLOOLRQSHRSOHZHUHSURWHFWHGZKLFKFRUUHVSRQGVWRSURWHFWLRQIRURIWKHSRSXODWLRQDWULVN,Qother WHO Regions the number of people protected by IRS isgenerally stable.

Insecticide resistance

19. Monitoring of insecticide resistance is a necessary element ofany medium-scale or large-scale deployment of an insecticidalLQWHUYHQWLRQ ,Q FRXQWULHV UHSRUWHG WKDW WKH\ ZHUH

carrying out insecticide resistance monitoring.

20. Current methods of malaria control are highly dependent on aVLQJOHFODVVRI LQVHFWLFLGHVWKHS\UHWKURLGVZKLFKLVWKHRQO\LQVHFWLFLGHFODVVXVHGIRU,71VDQGDFFRXQWVIRUDSSUR[LPDWHO\77% of IRS in terms of spray area covered. The widespread useRIDVLQJOHFODVVRILQVHFWLFLGHLQFUHDVHVWKHULVNWKDWPRVTXLWRHVZLOOGHYHORSUHVLVWDQFHWRLW7KLVULVNLVRISDUWLFXODUFRQFHUQLQVXE6DKDUDQ$IULFDZKHUHLQVHFWLFLGDOYHFWRUFRQWUROLVEHLQJdeployed with unprecedented levels of coverage. Resistance topyrethroids has been reported in 27 countries in sub-Saharan$IULFD WKH SRLQW DW ZKLFK WKLV UHGXFHV WKH HIIHFWLYHQHVV RI

YHFWRUFRQWUROLVVWLOOXQFHUWDLQDQGPD\GHSHQGRQWKHORFDOO\LGHQWLoHG UHVLVWDQFH PHFKDQLVP $V UHTXHVWHG E\ WKH :RUOG+HDOWK $VVHPEO\ :+2 LV FXUUHQWO\ ZRUNLQJ ZLWK D ZLGHYDULHW\RIVWDNHKROGHUVWRGHYHORSD*OREDO3ODQIRU,QVHFWLFLGH5HVLVWDQFH0DQDJHPHQWLQPDODULDYHFWRUVWREHUHOHDVHGLQearly 2012.

Progress on chemoprevention

The percentage of pregnant women who received two doses of

IPTp during pregnancy in ranged from 4% to 68%.

21. ,QWHUPLWWHQW SUHYHQWLYH WUHDWPHQW ,37 LV UHFRPPHQGHGfor population groups in areas of high transmission whoare particularly vulnerable to Plasmodium infection and itsFRQVHTXHQFHVSDUWLFXODUO\SUHJQDQWZRPHQDQGLQIDQWV$WRWDO

of 35 of 45 sub-Saharan African countries had adopted IPT forSUHJQDQWZRPHQ,37SDVQDWLRQDOSROLF\E\WKHHQGRI3DSXD1HZ*XLQHDLQWKH:HVWHUQ3DFLoF5HJLRQDOVRDGRSWHG

this policy in 2009.

22. In the 21 high-burden countries in the African Region whichKDYHDGRSWHG,37SDVQDWLRQDOSROLF\GDWDUHSRUWHGE\10&3Vindicate that the percentage of women attending antenatal

clinics who received the second dose of IPTp in 2010 was 55%LQWHUTXDUWLOHUDQJHq

23. In 13 countries in the African Region for which householdVXUYH\GDWDZHUHDYDLODEOHIRUqWKHSHUFHQWDJHRIwomen who received two doses of IPTp during pregnancy inUDQJHGIURPLQ1DPLELDWRLQ=DPELDWKHZHLJKWHGDYHUDJHUHPDLQHGORZDWSULPDULO\GXHWRORZFRYHUDJHLQNigeria and the Democratic Republic of Congo.

24. $OOLQIDQWVDWULVNRIP. falciparum infection in countries in sub-Saharan Africa with moderate to high malaria transmission

VKRXOGUHFHLYHGRVHVRIVXOIDGR[LQHS\UDPHWKDPLQH63WREHSURYLGHGWKURXJKLPPXQL]DWLRQVHUYLFHVDWGHoQHGLQWHUYDOVcorresponding to routine vaccination schedules. No country has\HWDGRSWHGDQDWLRQDOSROLF\RI,37IRULQIDQWV,37LVLQFHLWVrecommendation in 2009.

Progress in diagnostic testing and malariatreatment

The number of RDTs and ACTs procured is increasing, and the

percentage of reported suspected cases receiving a parasitological

test has also increased, from 67% globally in 2005 to 73%

in 2009. Many cases still are treated presumptively without a

parasitological diagnosis.

Diagnostic testing

25. 3URPSW SDUDVLWRORJLFDOFRQoUPDWLRQ E\ PLFURVFRS\ RU 5'7LVUHFRPPHQGHG IRU DOOSDWLHQWVZLWK VXVSHFWHGPDODULD EHIRUHWUHDWPHQW LV VWDUWHG ,Q RI PDODULDHQGHPLFcountries in the African Region and 53 of 63 endemic countries

in other WHO Regions reported having adopted a policy ofSURYLGLQJ SDUDVLWRORJLFDO GLDJQRVLV IRU DOO DJH JURXSV DQLQFUHDVHRIFRXQWULHVLQWKH$IULFDQ5HJLRQVLQFHDQG

8 elsewhere.

26. The number of RDTs supplied by manufacturers increasedfrom 45 million in 2008 to 88 million in 2010. ProductWHVWLQJ KDVVKRZQ DQLPSURYHPHQW LQ WHVWTXDOLW\RYHU WLPH

and proportionally more high quality tests are being procuredRYHUWLPHQHDUO\RI5'7VSURFXUHGLQKDGSDQHOGHWHFWLRQVFRUHVRIPRUHWKDQFRPSDUHGZLWKRQO\

of RDTs procured in 2007.

27. The percentage of reported suspected malaria cases receivingDSDUDVLWRORJLFDOWHVWKDVLQFUHDVHGEHWZHHQDQGSDUWLFXODUO\LQWKH$IULFDQ5HJLRQIURPWR(DVWHUQ0HGLWHUUDQHDQ 5HJLRQ WR DQG 6RXWK(DVW $VLD5HJLRQH[FOXGLQJ,QGLDIURPWR/RZUDWHVSHUVLVW

7/30/2019 1. WHO 2011

11/259xiWORLD MALARIA REPORT 2011

LQWKHPDMRULW\RI$IULFDQFRXQWULHVLQRXWRIFRXQWULHVZKLFKUHSRUWHGRQWHVWLQJWKHSHUFHQWDJHRIFDVHVWHVWHGZDV

less than 20%.

28. Data from a limited number of countries suggest that bothmicroscopy and RDTs are less widely available in the privatesector than in the public sector. A total of 48 countries reportdeployment of RDTs at the community level and 11 million

patients were tested through such programmes in 2010.

Treatment

29. &RQoUPHGFDVHVRIXQFRPSOLFDWHGP. falciparum malaria shouldbe treated with an ACT. ,QFRXQWULHVDQGWHUULWRULHVKDG DGRSWHG $&7 IRU oUVWOLQH WUHDWPHQW RI P. falciparumPDODULDUHSUHVHQWLQJDQLQFUHDVHIURP FRXQWULHVLQP. vivax malaria should be treated with chloroquine whereWKLVGUXJLVHIIHFWLYHRUDQDSSURSULDWH$&7LQDUHDVZKHUH P.vivax is resistant to chloroquine. Treatment of P. vivax shouldbe combined with a 14-day course of primaquine to preventrelapse.

30. The number of ACT treatment courses procured by the publicsector increased greatly from 11.2 million in 2005 to 76 millionLQDQGUHDFKHGPLOOLRQLQ$WRWDORIPLOOLRQ

treatments were estimated to have been procured by the privateVHFWRULQ7RWDO$&7GHPDQGLVSURMHFWHGWRUHDFKPLOOLRQ WUHDWPHQWFRXUVHVLQ DQ LQFUHDVH RI RYHUthat in 2010. The main driver of this increase is the almostIROGLQFUHDVHLQVXEVLGL]HGSULYDWHVDOHVWKURXJKWKH$0)P

31.$ OLPLWHG QXPEHU RI UHFHQW KRXVHKROG VXUYH\V XQGHUWDNHQbetween 2008 and 2010 suggest that febrile patients attendingSXEOLFKHDOWKIDFLOLWLHVDUHPRUHOLNHO\WRUHFHLYHDQ$&7WKDQWKRVHDWWHQGLQJSULYDWHIDFLOLWLHVEXWWKLVPD\FKDQJHLQIRUWKRVHFRXQWULHVSDUWLFLSDWLQJLQWKH$0)PSLORWSURJUDPPH

32. ,QWKH$IULFDQ5HJLRQLQWKHQXPEHURI$&7VGLVWULEXWHG

by NMCPs was more than twice the total number of testsPLFURVFRS\ 5'7V FDUULHG RXW LQ LQGLFDWLQJ WKDWPDQ\SDWLHQWVFRQWLQXHWRUHFHLYH$&7VZLWKRXWFRQoUPDWRU\

diagnostic testing.

Drug resistance

33. WHO recommends that oral artemisinin-based monotherapiesEH ZLWKGUDZQ IURP WKH PDUNHW DQG UHSODFHG ZLWK $&7V%\ 1RYHPEHU FRXQWULHV ZHUH VWLOO DOORZLQJ WKHPDUNHWLQJ RI WKHVH SURGXFWVQR FKDQJH IURP DQGSKDUPDFHXWLFDO FRPSDQLHVZHUH PDUNHWLQJWKHP GRZQIURPLQ0RVWRIWKHFRXQWULHVWKDWVWLOODOORZWKHPDUNHWLQJRIPRQRWKHUDSLHVDUHLQWKH$IULFDQ5HJLRQZKLOHPRVWRIWKHmanufacturers are in India.

34. 7KHUDSHXWLF HIoFDF\ VWXGLHV UHPDLQ WKH JROG VWDQGDUG IRUJXLGLQJGUXJSROLF\DQGVKRXOGEHXQGHUWDNHQDWOHDVWHYHU\\HDUV (IoFDF\ VWXGLHV RI oUVWOLQHRU VHFRQGOLQH DQWLPDODULDO

treatments were completed in 31 of 75 countries where P.falciparumHIoFDF\VWXGLHVDUHSRVVLEOHLQFRXQWULHVHIoFDF\VWXGLHVDUHLPSUDFWLFDOEHFDXVHRIORZPDODULDLQFLGHQFHDQG15 countries are endemic for P. vivaxRQO\$IXUWKHUKDG

SODQQHGWRFRQGXFWVWXGLHVLQRU(IoFDF\VWXGLHVwere last conducted more than three years ago in 32 countries.

35. 6XVSHFWHGUHVLVWDQFH WR DUWHPLVLQLQV KDVQRZ EHHQLGHQWLoHGLQIRXUFRXQWULHVLQWKH*UHDWHU0HNRQJVXEUHJLRQ&DPERGLD0\DQPDU 7KDLODQG DQG 9LHW 1DP &RQWDLQPHQW HIIRUWVKDYH VKRZQ WKDW D UHGXFWLRQ LQ PDODULD LQFLGHQFH D NH\

component of the overall containment plan to halt the spread

RIUHVLVWDQWSDUDVLWHVFDQEHDFKLHYHG'HVSLWHWKHREVHUYHGFKDQJHVLQSDUDVLWHVHQVLWLYLW\WRDUWHPLVLQLQVWKHFOLQLFDODQGSDUDVLWRORJLFDOHIoFDF\RI$&7VUHPDLQVKLJKLQPRVWVHWWLQJV+RZHYHU KLJK WUHDWPHQW IDLOXUH UDWHV WR VHYHUDO $&7V LQ

particular to dihydroartemisinin-piperaquine which is one ofWKHQHZHVW$&7VKDVDOUHDG\EHHQLGHQWLoHGLQ3DLOLQSURYLQFHin Cambodia. This highlights the need for vigilance not onlyWR SURWHFW WKH HIoFDF\ RI DUWHPLVLQLQV EXW DOVR WKH SDUWQHUmedicines in the drug combinations.

36. In 2011 WHO published the Global Plan for ArtemisininResistance Containment*3$5&ZKLFKUHFRPPHQGVoYHNH\

activities for successful management of artemisinin resistance:

VWRSWKHVSUHDGRIUHVLVWDQWSDUDVLWHVLQFUHDVHPRQLWRULQJDQGVXUYHLOODQFH WR HYDOXDWH WKH WKUHDW RI DUWHPLVLQLQ UHVLVWDQFHimprove access to diagnostics and rational treatment with$&7VLQYHVWLQUHVHDUFKUHODWHGWRDUWHPLVLQLQUHVLVWDQFHDQG

motivate action and mobilize resources.

Impact of malaria control

A growing number of countries have recorded decreases

LQ WKHQXPEHURIFRQoUPHG FDVHV RIPDODULD DQG RU UHSRUWHG

admissions and deaths since 2000. Global control efforts have

resulted in a reduction in the incidence of malaria and malaria-

VSHFLoFPRUWDOLW\UDWHV

37. A total of 8 countries and one area in the WHO African RegionVKRZHG ! UHGXFWLRQ LQHLWKHU FRQoUPHGPDODULDFDVHVRU PDODULD DGPLVVLRQV DQG GHDWKV LQ UHFHQW \HDUV $OJHULD%RWVZDQD &DSH 9HUGH 1DPLELD 5ZDQGD 6DR 7RPH DQG3ULQFLSH 6RXWK $IULFD 6ZD]LODQG DQG =DQ]LEDU 8QLWHG5HSXEOLFRI 7DQ]DQLD(ULWUHD(WKLRSLD 6HQHJDODQG =DPELDVKRZHGUHGXFWLRQVRIq,QDOOFRXQWULHVWKHGHFUHDVHV

are associated with intense malaria control interventions.

38. The increases in malaria cases observed in Rwanda and in SaoTome and Principe in 2009 (two countries that had previouslyUHSRUWHG UHGXFWLRQV ZHUH UHYHUVHG DIWHU LQWHQVLoFDWLRQ RIcontrol measures. This highlights the need to build systemsfor effective surveillance of malaria and to rigorously maintaincontrol programmes even when cases have been reducedVXEVWDQWLDOO\ $FFRUGLQJWR DYDLODEOHLQIRUPDWLRQLQFUHDVHV LQcases and deaths observed in Zambia in 2009 have not yetbeen reversed.

39. While substantial decreases in the numbers of malaria casesare observed in countries with well developed surveillanceV\VWHPVLW LVPXFKPRUHGLIoFXOW WRGHWHFW VXFK FKDQJHV LQFRXQWULHVZKHUH VXUYHLOODQFH V\VWHPV DUHZHDNHUSDUWLFXODUO\in the more populous countries of Central and West Africa. InFRXQWULHVZKLFKDUHH[SDQGLQJWKHXVHRIPLFURVFRS\DQG5'7VWKHQXPEHUVRIFRQoUPHGFDVHVKDYHULVHQUHpHFWLQJFKDQJHVin diagnostic practice and concealing the underlying trends

7/30/2019 1. WHO 2011

12/259xii WORLD MALARIA REPORT 2011

in malaria incidence. More detailed investigation of trends inmalaria cases and changes in diagnostic practice is needed toobtain a more accurate picture of the real changes in malariaincidence.

40. ,Q RWKHU :+2 5HJLRQV WKH QXPEHU RI UHSRUWHG FDVHV RI

FRQoUPHGPDODULDGHFUHDVHGE\PRUHWKDQLQRIWKH

53 countries with ongoing transmission between 2000 and

2010 and downward trends of 25%50% were seen in 4 otherFRXQWULHV ,QWKH (XURSHDQ5HJLRQ UHSRUWHGRQO\ indigenous cases. The number of cases continued to fall leastLQ FRXQWULHV ZLWKWKH KLJKHVW LQFLGHQFHUDWHV LQGLFDWLQJ WKDW

greater attention should be given to countries which harbourmost of the malaria burden outside Africa.

41. There were 8 countries in the pre-elimination stage of malariacontrol in 2011 and 9 countries are implementing eliminationprogrammes nationwide (8 having entered the elimination phaseLQ$IXUWKHUFRXQWULHV%DKDPDV(J\SW*HRUJLD,UDT

-DPDLFD2PDQ5XVVLDQ)HGHUDWLRQDQG6\ULDQ$UDE5HSXEOLF

have interrupted transmission and are in the prevention ofUHLQWURGXFWLRQSKDVH$UPHQLDZDVFHUWLoHGDVIUHHRIPDODULD

E\WKH:+2'LUHFWRU*HQHUDOLQ

42. $QHVWLPDWHGELOOLRQSHRSOHZHUHDWULVNRIPDODULDLQ

2IWKLVWRWDOELOOLRQZHUHDWORZULVNUHSRUWHGFDVH

SHUSRSXODWLRQRIZKRPZHUHOLYLQJLQJHRJUDSKLF

regions other than the WHO African Region. The 1.2 billion at

KLJKULVN!FDVHSHUSRSXODWLRQZHUHOLYLQJPRVWO\LQ

WKH:+2$IULFDQDQG6RXWK(DVW$VLD5HJLRQV

43. There were an estimated 216 million episodes of malaria inZLWKDZLGHXQFHUWDLQW\LQWHUYDOWKqWKFHQWLOHVIURP

PLOOLRQWRPLOOLRQFDVHV$SSUR[LPDWHO\RU

PLOOLRQqPLOOLRQFDVHVZHUHLQWKH$IULFDQ5HJLRQ

with the South-East Asian Region accounting for another 13%.

44. 7KHUHZHUHDQHVWLPDWHGqPDODULD

GHDWKVLQRIZKLFKUDQJHq

ZHUHLQWKH$IULFDQ5HJLRQ$SSUR[LPDWHO\RIPDODULD

deaths globally were of children under 5 years of age.

45. The estimated incidence of malaria has fallen by 17% globallybetween 2000 and 2010. Larger percentage reductions areVHHQLQWKH(XURSHDQ$PHULFDQDQG:HVWHUQ

3DFLoF UHJLRQV 0DODULD VSHFLoF PRUWDOLW\ UDWHV KDYH

fallen by 25% between 2000 and 2010 with the largestSHUFHQWDJHUHGXFWLRQVVHHQLQ WKH(XURSHDQ$PHULFDQ

:HVWHUQ3DFLoFDQG$IULFDQ5HJLRQV

46. (VWLPDWHV RI PDODULD LQFLGHQFH DUH EDVHG LQ SDUW RQ WKH

numbers of cases reported by NMCPs. These case reportsare far from complete in most countries. A total of 24 millionFRQoUPHGPDODULDFDVHVZDVUHSRUWHGE\10&3VLQRU

11% of the estimated global case incidence.

7/30/2019 1. WHO 2011

13/2591WORLD MALARIA REPORT 2011

Chapter 1

Introduction

This report summarizes the current status of malaria in theworld. It reviews progress towards internationally agreed targets andJRDOVGHVFULEHVWUHQGVLQIXQGLQJDQGGRFXPHQWVWKHLQFUHDVLQJcoverage of interventions and their impact. Data from 106 malaria-HQGHPLF FRXQWULHVDQG WHUULWRULHV DUHDQDO\VHGXS WR WKHyear established by the international community to attain universalcoverage of preventive and case management interventions for allSRSXODWLRQVDWULVNRIPDODULDDQGUHGXFHWKHJOREDOPDODULDEXUGHQE\IURPWKHOHYHOVLQ$GGLWLRQDOO\LWLQFOXGHVFRXQWU\VSHFLoFLQIRUPDWLRQLQWKHIRUPRIFRXQWU\SURoOHVIRUFRXQWULHVDQGWHUULWRULHVZLWKRQJRLQJPDODULDWUDQVPLVVLRQFRPSOHPHQWHGE\DQQH[HVZKLFKSURYLGHGHWDLOHGLQIRUPDWLRQDERXWSURJUHVVin global malaria control and elimination.

&DXVHGE\oYHVSHFLHVRISDUDVLWHVRIWKHJHQXVPlasmodiumthat affect humans (P. falciparum, P. vivax, P. ovale, P. malariaeand P. knowlesi), malaria due to P. falciparumLVWKHPRVWGHDGO\and it predominates in Africa. P. vivax is less dangerous butPRUH ZLGHVSUHDGDQG WKH RWKHU WKUHH VSHFLHV DUH IRXQGPXFKless frequently. Malaria is transmitted to humans by the bite ofinfected female mosquitoes of more than 30 anopheline species.$QHVWLPDWHGELOOLRQSHRSOHZHUHDWULVNRIPDODULDLQDOWKRXJK RI DOO JHRJUDSKLFDO UHJLRQV SRSXODWLRQV OLYLQJ LQ VXE6DKDUDQ$IULFDKDYHWKHKLJKHVWULVNRIDFTXLULQJPDODULDLQ81 % of cases and 91 % of deaths are estimated to have occurredLQWKH:+2$IULFDQ5HJLRQZLWKFKLOGUHQXQGHUoYH\HDUVRIDJHand pregnant women being most severely affected.

0DODULD LV DQ HQWLUHO\ SUHYHQWDEOH DQG WUHDWDEOH GLVHDVHprovided that currently recommended interventions are properlyLPSOHPHQWHG7KHVHLQFOXGHLYHFWRUFRQWUROWKURXJKWKHXVHRILQVHFWLFLGHWUHDWHGQHWV,71VLQGRRUUHVLGXDOVSUD\LQJ,56DQG

LQVRPHVSHFLoFVHWWLQJVODUYDOFRQWUROLLFKHPRSUHYHQWLRQIRUWKHPRVWYXOQHUDEOHSRSXODWLRQVSDUWLFXODUO\SUHJQDQWZRPHQDQGLQIDQWVLLLFRQoUPDWLRQRIPDODULDGLDJQRVLVWKURXJKPLFURVFRS\RU UDSLG GLDJQRVWLF WHVWV 5'7V IRU HYHU\ VXVSHFWHG FDVH DQGLY WLPHO\ WUHDWPHQW ZLWK DSSURSULDWH DQWLPDODULDO PHGLFLQHV(according to the parasite species and any documented drugUHVLVWDQFH

7KH:RUOG0DODULD 5HSRUW LV D NH\ SXEOLFDWLRQ RI WKH:+2*OREDO 0DODULD 3URJUDPPH *03 SURYLGLQJ RYHU WKH \HDUV Dhistorical record of the global malaria situation and the progress

made through national and international efforts to control the

GLVHDVH*03KDVIRXUHVVHQWLDOUROHVLWRVHWFRPPXQLFDWHDQGSURPRWHWKHDGRSWLRQRIHYLGHQFHEDVHGQRUPVVWDQGDUGVSROLFLHVDQGJXLGHOLQHVLLWR HQVXUHRQJRLQJLQGHSHQGHQWDVVHVVPHQWRIJOREDO SURJUHVV LLL WR GHYHORS VWUDWHJLHV IRU FDSDFLW\ EXLOGLQJV\VWHPVVWUHQJWKHQLQJDQGVXUYHLOODQFHDQGLYWRLGHQWLI\WKUHDWVWRPDODULDFRQWURODQGHOLPLQDWLRQDQGQHZRSSRUWXQLWLHVIRUDFWLRQ

The World Malaria Report sets out a critical analysis andinterpretation of data provided by national malaria controlSURJUDPPHV10&3V LQ HQGHPLF FRXQWULHV 6WDQGDUG UHSRUWLQJforms were sent in March 2011 to 99 countries and territories withRQJRLQJPDODULDWUDQVPLVVLRQFRXQWULHVLQWKHFRQWUROSKDVHDQGFRXQWULHVLQWKHSUHHOLPLQDWLRQDQGHOLPLQDWLRQSKDVHV,QIRUPDWLRQ ZDV UHTXHVWHG RQ L SRSXODWLRQV DW ULVN LL YHFWRUVSHFLHV LLL QXPEHU RI FDVHV DGPLVVLRQV DQG GHDWKV IRU HDFKSDUDVLWHVSHFLHVLYFRPSOHWHQHVVRIRXWSDWLHQWUHSRUWLQJYSROLF\LPSOHPHQWDWLRQ YL FRPPRGLWLHV GLVWULEXWHG DQG LQWHUYHQWLRQVXQGHUWDNHQ YLL UHVXOWV RI KRXVHKROGVXUYH\V DQG YLLLPDODULDoQDQFLQJ Table 1.1 summarizes the percentage of countriesresponding by month and by WHO Region.

TABLE 1.1

Percentage of reporting forms received by month and by WHO Region, 2011

WHO REGION July August September October November Total countries

African 84% 91% 91% 91% 43

Americas 48% 76% 81% 86% 90% 21

South-East Asia 33% 100% 100% 100% 100% 10

European 100% 100% 100% 100% 100% 6

Eastern Mediterranean 22% 89% 89% 89% 89% 9

Western Pacifc 80% 90% 100% 100% 100% 10

TOTAL 30% 86% 91% 92% 93% 99

Source: NMCP data.

7/30/2019 1. WHO 2011

14/2592 WORLD MALARIA REPORT 2011

Information from household surveys was used to complementGDWDVXEPLWWHGE\10&3VQRWDEO\WKH'HPRJUDSKLFDQG+HDOWK6XUYH\V '+6 0XOWLSOH ,QGLFDWRU &OXVWHU 6XUYH\V 0,&6 DQG0DODULD,QGLFDWRU6XUYH\V0,67KHVHVXUYH\VSURYLGHLQIRUPDWLRQon the percentage of the population that sleeps under a mosquitoQHWDQGRIFKLOGUHQZLWKIHYHUZKRDUHWUHDWHGDQGWKHPHGLFDWLRQthey receive. Information was also received from ACT Watch onthe proportion of treatment outlets that have diagnostic facilitiesDQG DQWLPDODULDO PHGLFLQHVLQ VWRFN DQG RQ DQWLPDODULDO SULFHV

DQGVDOHVYROXPHV,QIRUPDWLRQRQPDODULDoQDQFLQJZDVREWDLQHGIURPWKH2(&'GDWDEDVHRQIRUHLJQDLGpRZVDQGGLUHFWO\IURPWKH*OREDO)XQGDQGWKH863UHVLGHQWV0DODULD,QLWLDWLYH30,

Data were analysed and interpreted by WHO staff atKHDGTXDUWHUVDQG UHJLRQDORIoFHVLQ H[WHQVLYHFRQVXOWDWLRQZLWK:+2FRXQWU\RIoFHVDQG10&3VUHJDUGLQJWKHLQWHUSUHWDWLRQRIcountry information. Assistance in data analysis and interpretationZDV DOVR SURYLGHG E\ $&7 :DWFK WKH $IULFDQ /HDGHUV 0DODULD$OOLDQFH$/0$WKH&OLQWRQ+HDOWK$FFHVV,QLWLDWLYH&+$,WKH,QVWLWXWHRI+HDOWK0HWULFVDQG(YDOXDWLRQ,+0(-RKQV+RSNLQV8QLYHUVLW\86&HQWHUVIRU'LVHDVH&RQWURODQG3UHYHQWLRQ&'&WKH *OREDO)XQG 0($685( '+6 7XODQH 8QLYHUVLW\DQG WKH

8QLWHG1DWLRQV&KLOGUHQV)XQG81,&()

The following chapters consider the policies and interventionsUHFRPPHQGHGE\:+2WKHLPSOHPHQWDWLRQRILQWHUYHQWLRQVDQGthe impact on malaria cases and deaths from a global and regionalSHUVSHFWLYH7KH\DOVRLQFOXGHFRXQWU\H[DPSOHVWRLOOXVWUDWHPRUHgeneral assessments within each chapter.

Chapter 2 summarizes internationally agreed goals for globalmalaria control and the policies and strategies recommendedby WHO to achieve them. It then discusses the indicatorsUHFRPPHQGHG E\ :+2 DQG RWKHU DJHQFLHV IRU PRQLWRULQJprogress towards targets.

Chapter 3 reviews the resource requirements for meetingglobal malaria control targets and recent trends in internationalDQGGRPHVWLFoQDQFLQJ,WFRQVLGHUVWKHVFRSHIRUSRWHQWLDOFRVWsavings and the prospects of mobilizing increased funding formalaria control.

Chapter 4 considers the policies that national programmeshave adopted for vector control implementation and the progressmade towards universal access to ITNs and IRS. It also addresses

the increasingly important issue of insecticide resistance and theappropriate monitoring and management of resistance.

Chapter 5 reviews progress in implementation ofFKHPRSUHYHQWLRQSDUWLFXODUO\WKHLQWHUPLWWHQWSUHYHQWLYHWUHDWPHQWRI PDODULD LQSUHJQDQF\ DQG LQLQIDQWV DQG WKH LQWURGXFWLRQ RIseasonal chemoprevention in older children. It also reports on thecurrent status of malaria vaccine development.

Chapter 6 UHSRUWV WKH H[WHQW WR ZKLFK QDWLRQDO SURJUDPPHVhave adopted policies for universal diagnostic testing ofVXVSHFWHGPDODULDFDVHVDQGH[DPLQHVWUHQGVLQWKHDYDLODELOLW\of parasitological testing. It reviews the adoption of policies andimplementation of programmes for improving access to effectivetreatment for malaria. The latest trends in drug resistance and effortsto contain artemisinin resistance on the Cambodia-Thailand borderDUHDOVRFRQVLGHUHGDVZHOODVWKHSURJUHVVPDGHLQZLWKGUDZLQJRUDODUWHPLVLQLQEDVHGPRQRWKHUDSLHVIURPWKHPDUNHW

Chapter 7 summarizes the trends in numbers of malaria casesand assesses the evidence that malaria control activities have hadan impact on malaria disease burden in each WHO Region. It

also provides an update on malaria elimination and on importedPDODULDDQGFRQFOXGHVE\SUHVHQWLQJHVWLPDWHVRIWKHQXPEHURIcases and deaths by WHO Region and worldwide for the period20002010.

3URoOHV of 99 countries with ongoing malaria transmission areSURYLGHGIROORZHGE\$QQH[HV which give data by country for themalaria-related indicators.

During 2010 there were 99 countries and territories with

ongoing malaria transmission and 7 countries in the prevention

RI UHLQWURGXFWLRQ SKDVHPDNLQJ D WRWDO RI FRXQWULHV LQ

ZKLFK PDODULD LV FRQVLGHUHG HQGHPLF ,Q -XO\ 6RXWK

6XGDQ EHFDPH DQ LQGHSHQGHQW VWDWH LQFUHDVLQJ WKH QXPEHUof countries and territories with ongoing transmission to 100

and total endemic countries and territories to 107. In October

$UPHQLDZDVFHUWLoHGIUHHRIPDODULDE\:+2UHGXFLQJ

the number of malaria-endemic countries and territories to 106.

$VLVWKHODWHVW\HDUIRUZKLFKPRVWGDWDDUHDYDLODEOH

results for South Sudan and Sudan are reported as from a single

FRXQWU\ +RZHYHU LQ WKH FRXQWU\ SURoOHV DQG DQQH[HV GDWD

from high-transmission and low transmission areas are reported

separately.

7/30/2019 1. WHO 2011


Chapter 2

Goals, targets, policies and strategies

for malaria control and elimination

This chapter summarizes the internationally agreed

goals for malaria control and the policies and

strategies recommended by WHO to achieve them. It

has four sections: (i) goals and targets; (ii) policies and

strategies; (iii) malaria elimination; and (iv) indicators

to track progress.

2.1 Goals and targets for malaria controland elimination

The year 2010 was an important milestone on the way toachievement of internationally agreed goals and targets for malariacontrol. It was the date set by the World Health Assembly inWRHQVXUHWKDWDWOHDVWRIWKRVHDWULVNRIRUVXIIHULQJ

IURP PDODULD ZRXOG EHQHoW IURPPDMRU SUHYHQWLYHDQG FXUDWLYHLQWHUYHQWLRQVLQ RUGHUWR UHGXFH WKHPDODULDEXUGHQE\ DW OHDVW

50% compared to the levels in 2000 (1 ,Q WKH 816HFUHWDU\*HQHUDOVHWDPRUHDPELWLRXVREMHFWLYHWRKDOWPDODULD

deaths by ensuring universal coverage of malaria interventionsE\ 7KH DLP ZDV WRPDNHLQGRRU UHVLGXDOVSUD\LQJ ,56

DQGORQJODVWLQJLQVHFWLFLGDOQHWV//,1VDYDLODEOHWRDOOSHRSOHDW

ULVNRIPDODULDHVSHFLDOO\FKLOGUHQDQGSUHJQDQWZRPHQLQ$IULFD

and for all public health facilities to be able to provide reliablediagnosis and effective treatment for malaria (2$OVRLQDQG DOLJQHG ZLWK WKHVH WDUJHWV WKH *OREDO 0DODULD $FWLRQ 3ODQ

*0$3ZDVODXQFKHGE\WKH5ROO%DFN0DODULD3DUWQHUVKLS5%0

DVDEOXHSULQWIRUWKHFRQWUROHOLPLQDWLRQDQGHYHQWXDOHUDGLFDWLRQ

RIPDODULDVHWWLQJDVLWVREMHFWLYHWKHUHGXFWLRQRIWKHQXPEHURIpreventable malaria deaths worldwide to near zero by 2015 (3

,Q WKH OLJKW RI SURJUHVV PDGH E\ 5%0 XSGDWHG WKH

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malaria-free world (4WKHWDUJHWVDUHQRZWRLUHGXFHJOREDOmalaria deaths to near zero by end-20151 LL UHGXFH JOREDOPDODULDFDVHVE\IURPOHYHOVE\HQGDQGLLL

HOLPLQDWHPDODULDE\HQGLQQHZFRXQWULHVVLQFH

including in the WHO European Region (5 Table 2.1 7KHVHtargets will be met by: achieving and sustaining universal access toDQGXWLOL]DWLRQRISUHYHQWLYHPHDVXUHVDFKLHYLQJXQLYHUVDODFFHVV

to case management in the public and private sectors and in the

1 In areas where public health facilities are able to provide a parasitologicalWHVWIRUDOOVXVSHFWHGPDODULDFDVHVQHDU]HURPDODULDGHDWKVLVGHoQHGDVQRPRUHWKDQFRQoUPHGPDODULDGHDWKSHUSRSXODWLRQDWULVN

FRPPXQLW\LQFOXGLQJ DSSURSULDWH UHIHUUDODQG DFFHOHUDWLQJ WKHdevelopment of surveillance systems.

$FKLHYHPHQWRI WKHVHREMHFWLYHV DQG WDUJHWV DUH EDVHG RQDnumber of critical assumptions:

v 6XIoFLHQW DQG WLPHO\ GRPHVWLF DQG LQWHUQDWLRQDO IXQGLQJ LVavailable to accomplish and sustain scale-up of the interventionsQHHGHGWRPHHWWKHREMHFWLYHVWDUJHWVDQGPLOHVWRQHV

v Scale-up of preventive measures and greater access to diagnostictesting and treatment through the public and private sectorsDQG FRPPXQLW\ FDVH PDQDJHPHQW DORQJ ZLWK UHIHUUDO ZKHQQHHGHGDUHVXIoFLHQWWR DOORZHIIHFWLYHWUHDWPHQWRIDOO FDVHVRIFRQoUPHGPDODULD

v Political commitment to sustain malaria control interventionsand high-quality surveillance including the elimination ofPDODULDZKHUHWKDWLVWHFKQLFDOO\RSHUDWLRQDOO\DQGoQDQFLDOO\feasible continues even as malaria cases and deaths declineVLJQLoFDQWO\

v Access to vulnerable populations and the safety and security ofKHDOWKZRUNHUVDUHPDLQWDLQHGWRHQVXUHVXUYHLOODQFHRXWEUHDNUHVSRQVHDQGGHOLYHU\RIGLDJQRVWLFWUHDWPHQWDQGSUHYHQWLYHLQWHUYHQWLRQV WR SRSXODWLRQV LQ IUDJLOH DQG FRQpLFWDIIHFWHGstates.

$FNQRZOHGJLQJ WKDW CEXVLQHVV DV XVXDO ZLOO QRW EH HQRXJKIRU DFKLHYLQJ WKH DJUHHG JRDOV WKH :RUOG +HDOWK $VVHPEO\ LQ0D\XUJHG0HPEHU6WDWHV:+2DQGLQWHUQDWLRQDOSDUWQHUVWR XQGHUWDNH D VHULHV RI DFWLRQV WR VXVWDLQ WKH JDLQVWKDW KDYHbeen made in decreasing the burden of malaria and reducingWUDQVPLVVLRQqDPRQJRWKHUVWRWDNHLPPHGLDWHDFWLRQWRFRPEDW

resistance to artemisinin-based medicines and resistance toinsecticides (6

7KHGHDGOLQHIRUDFKLHYLQJWKH5%0REMHFWLYHFRLQFLGHVZLWKWKDWRIWKH0LOOHQQLXP'HYHORSPHQW*RDOV0'*V0DODULDFRQWUROIRUPVSDUWRI0'*qWRKDYHKDOWHGDQGEHJXQWRUHYHUVHWKHLQFLGHQFHRIPDODULDDQGRWKHUPDMRUGLVHDVHVE\*LYHQWKDWPDODULDaccounted for 8% of deaths in children under 5 years of age globally

in 2008 and 16% of deaths in children under 5 in Africa (7LWLVDOVRFHQWUDOWR0'*qDFKLHYLQJDWZRWKLUGVUHGXFWLRQLQWKHPRUWDOLW\rate among children under 5 years of age between 1990 and 2015.

0DODULDFRQWUROLVDGGLWLRQDOO\H[SHFWHGWRFRQWULEXWHWRDFKLHYHPHQWRI0'*HUDGLFDWHH[WUHPHSRYHUW\DQGKXQJHU0'*DFKLHYHXQLYHUVDOSULPDU\HGXFDWLRQ0'*SURPRWHJHQGHUHTXDOLW\DQGHPSRZHUZRPHQ0'*LPSURYHPDWHUQDOKHDOWKDQG0'*GHYHORSDJOREDOSDUWQHUVKLSIRUGHYHORSPHQW8

7/30/2019 1. WHO 2011


2.2 Malaria control policies and strategies

The strategic approaches to malaria control come within twoPDMRUGRPDLQVLSUHYHQWLRQDQGLLFDVHPDQDJHPHQW7RJHWKHU

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severe disease.

2.2.1 Malaria prevention through malaria vector control

The goals of malaria vector control are two-fold:

v to protect individual people against infective malaria mosquitoELWHVDQG

v to reduce the intensity of local malaria transmission atFRPPXQLW\OHYHOE\UHGXFLQJWKHORQJHYLW\GHQVLW\DQGKXPDQ

vector contact of the local vector mosquito population.

The two most powerful and most broadly applied

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reducing human-vector contact and by reducing the lifespan of

female mosquitoes (so that they do not survive long enough to

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both by protecting the person sleeping under the net (individualOHYHO DQGE\ H[WHQGLQJWKH HIIHFW WR DQHQWLUH DUHDFRPPXQLW\

OHYHO3HUVRQDOSURWHFWLRQRSHUDWHVE\SUHYHQWLQJFRQWDFWEHWZHHQthe mosquito and the person under the net. The wider effect occursZKHQWKHLQVHFWLFLGHLQWKHQHWDFWXDOO\NLOOVWKHPRVTXLWRHVWKDWWRXFKLWWKHUHIRUHDIIHFWLQJWKHYHFWRUSRSXODWLRQDQGORZHULQJWKHRYHUDOO LQWHQVLW\ RI WUDQVPLVVLRQ LQ WKH WDUJHWHG DUHD +RZHYHU

the protective effect of ITNs for people sleeping outside the netwithin the same household is less than for those sleeping underthe net (11 7KHUHIRUH VLQFH :+2 KDV UHFRPPHQGHGXQLYHUVDOFRYHUDJHZLWK,71VSUHIHUDEO\//,1VUDWKHUWKDQDSUH

determined number per household.

IRS involves the application of residual insecticides to the innerVXUIDFHVRI GZHOOLQJV ZKHUH PDQ\YHFWRU VSHFLHV RI DQRSKHOLQHPRVTXLWRWHQGWRUHVWDIWHUWDNLQJDEORRGPHDO12,56LVHIIHFWLYH

LQUDSLGO\FRQWUROOLQJPDODULDWUDQVPLVVLRQKHQFHLQUHGXFLQJWKHORFDOEXUGHQRIPDODULDPRUELGLW\DQGPRUWDOLW\SURYLGHGWKDWPRVW

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are treated (13

Achieving universal coverage with effective vector controlrequires a sustained programme of vector control deliveryoperations which are carried out correctly and on time. This in turnUHTXLUHVVSHFLDOL]HGSHUVRQQHODW QDWLRQDO SURYLQFLDODQGGLVWULFW

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TABLE 2.1

Goals and targets for malaria control

Targets for 2005 Targets for 2010 Targets for 2015Reduce global malaria deaths from 2000 levels by 50% (3)

Reduce global malaria cases from 2000 levels by 50% (3)

Reduce global malaria deaths to near zero (5)

Reduce global malaria deaths from 2000 levels by 75% (1)

Reduce global malaria cases from 2000 levels by 75% (1,5)

MDG 6: Have halted and begun to reverse the incidence of malaria and other majordiseases (8)

At least 60% of those at risk of malariaparticularly pregnant women and childrenXQGHUoYH\HDUVRIDJHEHQHoWIURPWKH

most suitable combination of personal andcommunity protective measures (9)

At least 60% of all pregnant women whoDUHDWULVNRIPDODULDHVSHFLDOO\WKRVH

LQWKHLUoUVWSUHJQDQFLHVKDYHDFFHVVWR

chemoprophylaxis or presumptive intermittenttreatment (9)

Achieve universal coverage for all populations at riskof malaria using locally appropriate interventions forprevention and case management (3)

RISHRSOHDWULVNIURPPDODULDDUHSURWHFWHGWKDQNV

to locally appropriate vector control methods such asLQVHFWLFLGHWUHDWHGQHWV,71VDQGZKHUHDSSURSULDWH

LQGRRUUHVLGXDOVSUD\LQJ,56DQGLQVRPHVHWWLQJVRWKHU

environmental and biological measures (1, 10)

At least 80% of pregnant women receive intermittentpreventive treatment in areas where malaria transmissionis stable (1, 10)

$FKLHYHXQLYHUVDODFFHVVWRDQGXWLOL]DWLRQRISUHYHQWLRQPHDVXUHV%\HQGLQ

FRXQWULHVZKHUHXQLYHUVDODFFHVVDQGXWLOL]DWLRQKDYHQRW\HWEHHQDFKLHYHGDFKLHYH

100% access to and utilization of prevention measures for all populations at risk withlocally appropriate interventions (5)

Sustain universal access to and utilization of prevention measures: By 2015 andEH\RQGDOOFRXQWULHVVXVWDLQXQLYHUVDODFFHVVWRDQGXWLOL]DWLRQRIDQDSSURSULDWH

package of preventive interventions (5)

At least 60% of those suffering from malariahave prompt access to and are able to use

FRUUHFWDIIRUGDEOHDQGDSSURSULDWHWUHDWPHQWwithin 24 hours of the onset of symptoms (9)

80% of malaria patients are diagnosed and treated withHIIHFWLYHDQWLPDODULDOPHGLFLQHVHJDUWHPLVLQLQEDVHG

combination therapy (ACT) within one day of the onset ofillness (1, 10)

$FKLHYHXQLYHUVDODFFHVVWRFDVHPDQDJHPHQWLQWKHSXEOLFVHFWRU%\HQG

RIVXVSHFWHGFDVHVUHFHLYHDPDODULDGLDJQRVWLFWHVWDQGRIFRQoUPHG

cases receive treatment with appropriate and effective antimalarial drugs (5)$FKLHYHXQLYHUVDODFFHVVWRFDVHPDQDJHPHQWRUDSSURSULDWHUHIHUUDOLQWKHSULYDWH

VHFWRU%\HQGRIVXVSHFWHGFDVHVUHFHLYHDPDODULDGLDJQRVWLFWHVW

DQGRIFRQoUPHGFDVHVUHFHLYHWUHDWPHQWZLWKDSSURSULDWHDQGHIIHFWLYH

antimalarial drugs (5)

Achieve universal access to community case management (CCM) of malaria: ByHQGLQFRXQWULHVZKHUH&&0RIPDODULDLVDQDSSURSULDWHVWUDWHJ\RI

IHYHUVXVSHFWHGFDVHVUHFHLYHDPDODULDGLDJQRVWLFWHVWDQGRIFRQoUPHG

uncomplicated cases receive treatment with appropriate and effective antimalarialGUXJVDQGRIVXVSHFWHGDQGFRQoUPHGVHYHUHFDVHVUHFHLYHDSSURSULDWH

referral (5)

$FFHOHUDWHGHYHORSPHQWRIVXUYHLOODQFHV\VWHPV%\HQGDOOGLVWULFWVDUH

FDSDEOHRIUHSRUWLQJPRQWKO\QXPEHUVRIVXVSHFWHGPDODULDFDVHVQXPEHURIFDVHV

IURPDOOSXEOLFKHDOWKIDFLOLWLHVRUDFRQVLVWHQWVDPSOHRIWKHP (5)

7/30/2019 1. WHO 2011


FRQWUROLQWHUYHQWLRQVWKHVHWHDPVPXVWDOVRKDYHWKHFDSDFLW\WR

monitor and investigate vector-related and operational factors thatPD\FRPSURPLVHLQWHUYHQWLRQHIIHFWLYHQHVVIRUZKLFKVSHFLDOL]HG

HQWRPRORJLFDONQRZOHGJHDQGVNLOOVDUHHVVHQWLDO

WHO recommendations for vector control are the following:

Insecticide-treated nets

1. As high coverage rates are needed to realize the full potentialRIYHFWRUFRQWURO:+2UHFRPPHQGVWKDWLQDUHDVWDUJHWHGIRUPDODULDSUHYHQWLRQ,71VVKRXOGEHPDGHDYDLODEOHWRDOOSHRSOHDWULVNLHkXQLYHUVDODFFHVVy14%HFDXVHRIWKHRSHUDWLRQDO

DGYDQWDJHV RI //,1V RYHU ,71V DQG WKH IDFW WKDW WKH YDVWPDMRULW\RIQHWVEHLQJSURFXUHGDQGGLVWULEXWHGWRGD\DUHLQGHHG//,1VWKHUHPDLQGHURIWKLVVHFWLRQZLOOUHIHUWR//,1VUDWKHU

WKDQ,71V,QRUGHUWRPHHWWKHWDUJHWRIXQLYHUVDODFFHVVLWis currently proposed that one LLIN should be distributed forHYHU\WZRSHUVRQV$WWKHKRXVHKROGOHYHOWKHGLVWULEXWLRQRI

one LLIN for every two members of the household will entailrounding up in households with an odd number of membersHJ //,1VIRUD KRXVHKROGZLWK PHPEHUVHWF%HFDXVH

RIWKLVURXQGLQJ XS WKH DFKLHYHPHQWRI kRQH //,1 IRU HYHU\

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target population (13

2. LLINs should be provided either free of charge or be highlyVXEVLGL]HG &RVW VKRXOG QRW EH D EDUULHU WR PDNLQJ WKHP

DYDLODEOH WRDOO SHRSOH DWULVNRI PDODULDHVSHFLDOO\WKRVHDW

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3. 8QLYHUVDO DFFHVV WR //,1V LV EHVW DFKLHYHG DQG PDLQWDLQHG

by a combination of delivery systems. The basic concept is aFRPELQDWLRQRICFDWFKXSDQGCNHHSXS&DWFKXSPHDQVPDVV

GLVWULEXWLRQ FDPSDLJQV ZKLFK FDQ UDSLGO\ DFKLHYH XQLYHUVDO

coverage of LLINs. However it is essential to complementVXFKFDPSDLJQV ZLWKFRQWLQXRXV CNHHS XS GHOLYHU\ V\VWHPV

particularly routine delivery to pregnant women throughantenatal services and to infants at immunization clinics. InPDODULDULVN DUHDV HQVXULQJ WKDW WKHVH URXWLQH V\VWHPV KDYH

WKHVXVWDLQHG //,1V VWRFNV QHHGHG WR SURYLGH DQ//,1 WR DOO

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priority as repeated campaigns (14

BOX 2.1

New or updated plans, policies and guidelines in 2011

Global plan for artemisinin resistance containment*HQHYD:RUOG+HDOWK2UJDQL]DWLRQhttp://www.who.int/malaria/publications/atoz/artemisinin_resistance_containment_2011.pdf

Consideration of mass drug administration for thecontainment of artemisinin-resistant malaria in the GreaterMekong subregion: report of a consensus meeting, 2728September 2010, Geneva, Switzerland. *HQHYD:RUOG+HDOWK2UJDQL]DWLRQhttp://whqlibdoc.who.int/publications/2011/9789241501644_eng.pdf

Good practices for selecting and procuring rapid diagnostictests for malaria*HQHYD:RUOG+HDOWK2UJDQL]DWLRQhttp://whqlibdoc.who.int/publications/2011/9789241501125_eng.pdf

The technical basis for coordinated action against insecticideresistance: preserving the effectiveness of modern malariavector control: meeting report. *HQHYD:RUOG+HDOWK2UJDQL]DWLRQhttp://whqlibdoc.who.int/publications/2011/9789241501095_eng.pdf

The use of DDT in malaria vector control. WHO PositionStatement*HQHYD:RUOG+HDOWK2UJDQL]DWLRQZKTOLEGRFZKRLQWKT:+2B+70B*03BBHQJSGI

Universal access to malaria diagnostic testing: an operationalmanual*HQHYD:RUOG+HDOWK2UJDQL]DWLRQhttp://whqlibdoc.who.int/publications/2011/9789241502092_eng.pdf

Guidelines for monitoring the durability of long-lastinginsecticidal mosquito nets under operational conditions.

*HQHYD:RUOG+HDOWK2UJDQL]DWLRQhttp://whqlibdoc.who.int/publications/2011/9789241501705_eng.pdf

WHO recommended long-lasting insecticidal mosquito nets.*HQHYD:+23HVWLFLGHV(YDOXDWLRQ6FKHPH:+23(6:RUOG+HDOWK2UJDQL]DWLRQhttp://www.who.int/whopes/Long_ODVWLQJBLQVHFWLFLGDOBQHWVB-XOBSGI

Report of the fourteenth WHOPES working group meeting.*HQHYD:RUOG+HDOWK2UJDQL]DWLRQhttp://whqlibdoc.who.int/publications/2011/9789241502160_eng.pdf

Global Fund proposal development: WHO Policy brief. *HQHYD:RUOG+HDOWK2UJDQL]DWLRQwww.who.int/malaria/publications/atoz/malaria_gf_proposal_dev_who_policy_brief_201106.pdf

Intermittent preventive treatment for infants usingsulfadoxine-pyrimethamine (SP-IPTi) for malaria control inAfrica: Implementation Field Guide. :+2*OREDO0DODULD3URJUDPPH*03DQG'HSDUWPHQWRI,PPXQL]DWLRQ9DFFLQHV

DQG%LRORJLFDOV,9%DQG81,&()*HQHYD:RUOG+HDOWK2UJDQL]DWLRQhttp://whqlibdoc.who.int/hq/2011/WHO_IVB_11.07_eng.pdf

Methods and techniques for assessing exposure to antimalarialdrugs in clinical field studies.*HQHYD:RUOG+HDOWKOrganization. In press

A system to improve Value for Money in LLIN procurementthrough market competition based on cost per year of effectivecoverage. Concept Note. *HQHYD:RUOG+HDOWK2UJDQL]DWLRQ2011. http://www.who.int/malaria/publications/atoz/gmpllin_effective_coverage_concept_note.pdf

The role of larval source management for malaria control,with particular reference to Africa.*HQHYD:RUOG+HDOWKOrganization. In press

7/30/2019 1. WHO 2011


4. ,QRUGHUWREHSURWHFWHGKRXVHKROGVPXVWQRWRQO\RZQ//,1V

but also use them. Behaviour change interventions includingLQIRUPDWLRQ HGXFDWLRQ FRPPXQLFDWLRQ ,(& FDPSDLJQV

and post-distribution hang-up campaigns are stronglyrecommended (14

5. Only LLINs recommended by the WHO Pesticide Evaluation6FKHPH :+23(6 VKRXOG EH SURFXUHG E\ QDWLRQDO PDODULD

control programmes and partners for malaria control. At present

there are 12 recommended products (15 16 17 'HWDLOHGJXLGDQFHRQJRRGSUDFWLFHLQWKHKDQGOLQJDQGXVHRISHVWLFLGHVDQG RQTXDOLW\ FRQWURO LQSURFXUHPHQW FDQ EHIRXQG RQWKH

WHOPES website (18,QGHSHQGHQWTXDOLW\FRQWURORISURGXFWVLQFOXGLQJLQVHFWLFLGHVVKRXOGEHXQGHUWDNHQEHIRUHVKLSPHQW

to ensure that sub-standard products are not delivered tocountries. The supplier of pesticide should bear the cost ofDQDO\VLVLQFOXGLQJIRUVDPSOHVWREHVHQWWRDQDFFUHGLWHGRU

recognized laboratory for analysis for countries that do not havenational quality control laboratories (19

6. ,WLVQRZUHFRJQL]HGWKDWWKHOLIHVSDQRI//,1VLVYDULDEOHDPRQJVHWWLQJV DQG DPRQJ SURGXFWV 7KHUHIRUH DOO ODUJHVFDOH //,1

programmes (including those implemented by non-governmental

RUJDQL]DWLRQVVKRXOGPDNHHIIRUWVWRPRQLWRU//,1GXUDELOLW\LQWKH ORFDO VHWWLQJ XVLQJ VWDQGDUGPHWKRGV SXEOLVKHG LQ

(207KHFROOHFWLRQRIORFDOGDWDRQWKHFRPSDUDWLYHGXUDELOLW\RIDOWHUQDWLYH//,1SURGXFWVXVLQJULJRURXVDQGDXGLWDEOHPHWKRGV

LVH[SHFWHGWRHQDEOHSURFXUHPHQWGHFLVLRQVWREHPDGHRQWKHEDVLVRIkSULFHSHU\HDURISURWHFWLRQyUDWKHUWKDQXQLWSULFHSHUQHW

WKLVLQWXUQLVH[SHFWHGWREULQJUDSLGDQGSRWHQWLDOO\VXEVWDQWLDO

cost savings. This is important because LLINs represent a large

proportion of the global malaria control budget (21

Indoor residual spraying

7. ,56 LV DSSOLFDEOH LQ PDQ\ HSLGHPLRORJLFDO VHWWLQJV SURYLGHG

the operational and resource feasibility are considered in policyand programming decisions. IRS requires specialized sprayHTXLSPHQWDQG WHFKQLTXHV DQGERWK WKHHTXLSPHQW DQGWKH

quality of application must be scrupulously maintained.

8. Currently 12 insecticides belonging to 4 chemical classes arerecommended by WHOPES for IRS (22$QLQVHFWLFLGHIRU,56LVVHOHFWHGLQDJLYHQDUHDRQWKHEDVLVRIGDWDRQUHVLVWDQFHWKH

UHVLGXDOHIoFDF\RIWKHLQVHFWLFLGHFRVWVVDIHW\DQGWKHW\SHRI

surface to be sprayed.

9. ''7KDVDFRPSDUDWLYHO\ORQJUHVLGXDOHIoFDF\PRQWKVDV

an insecticide for IRS. The use of DDT in agriculture is bannedXQGHUWKH6WRFNKROP&RQYHQWLRQEXWFRXQWULHVFDQXVH''7IRU,56IRUDVORQJDVQHFHVVDU\DQGLQWKHTXDQWLWLHVQHHGHG

provided that the WHO guidelines and recommendations areIROORZHGDQGXQWLOORFDOO\DSSURSULDWHFRVWHIIHFWLYHDOWHUQDWLYHV

are available for a sustainable transition from DDT (23

Larval control

10. ,Q D IHZ VSHFLoF VHWWLQJV DQG FLUFXPVWDQFHV WKH FRUH

interventions of IRS and LLINs may be complemented by otherPHWKRGVVXFKDVODUYDOVRXUFHFRQWUROLQFOXGLQJHQYLURQPHQWDO

PDQDJHPHQW +RZHYHU ODUYDO FRQWURO LV DSSURSULDWH DQGDGYLVDEOH RQO\ LQ D PLQRULW\ RI VHWWLQJV ZKHUH PRVTXLWR

EUHHGLQJVLWHVDUHIHZo[HGDQGHDV\WRLGHQWLI\PDSDQGWUHDW,QRWKHUFLUFXPVWDQFHVLWLVYHU\GLIoFXOWWRoQGDVXIoFLHQWO\

KLJK SURSRUWLRQ RI WKH EUHHGLQJ VLWHV ZLWKLQ WKH pLJKW UDQJH

of the vector (13 &XUUHQWO\ FRPSRXQGV DQG IRUPXODWLRQVfor mosquito larval control are recommended by WHOPESIRU /DUYDO 6RXUFH 0DQDJHPHQW /60 ,Q $IULFD ODUYLFLGLQJ

LQWHUYHQWLRQVDUHPRVWOLNHO\WREHDSSURSULDWHLQXUEDQVHWWLQJV

DQGDUHXQOLNHO\WREHFRVWHIIHFWLYHLQPRVWUXUDOVHWWLQJV24

2.2.2 Insecticide resistance

11. 7KH VSUHDG RI LQVHFWLFLGH UHVLVWDQFH HVSHFLDOO\ S\UHWKURLG

UHVLVWDQFH LQ $IULFD LV D PDMRU WKUHDW IRU YHFWRU FRQWURO

programmes. Insecticide resistance management has to beconsidered as important as epidemiological cost-effectivenessLQ DOO SURJUDPPDWLF GHFLVLRQVDERXW YHFWRU FRQWURO LQFOXGLQJ

the selection of insecticides for IRS (25,QSDUWLFXODU

v Resistance management measures should be part of every vector

FRQWUROSURJUDPPHDQGGHSOR\HGSUHHPSWLYHO\ZLWKRXWZDLWLQJ

for signs of the presence of resistance or of control failure.

v $VXEVWDQWLDOLQWHQVLoFDWLRQRIUHVLVWDQFHPRQLWRULQJLVQHHGHGXVLQJERWKELRDVVVD\VXVFHSWLELOLW\WHVWVDQGJHQHWLFPHWKRGV

Resistance monitoring should be seen as a necessary elementof any medium- or large-scale deployment of an insecticidalLQWHUYHQWLRQ LQFOXGLQJ //,1 GLVWULEXWLRQ E\ 1*2V LW LV WKH

UHVSRQVLELOLW\RIWKHLPSOHPHQWLQJDJHQF\WRPDNHVXUHWKDWWKLV

testing is done properly. All data on vector resistance should beVXEPLWWHG LQFRQoGHQFHLI QHFHVVDU\WRWKH QDWLRQDOPDODULD

FRQWUROSURJUDPPHZLWKLQWKUHHPRQWKVRIWKHWHVWSHUIRUPDQFH

HYHQLIWKHVWXG\LVQRW\HWFRPSOHWH'RQRUVoQDQFLQJLQVHFWLFLGH

procurement should ensure that the decision regarding thechoice of insecticide is supported by adequate and up-to-dateinformation on resistance among local anopheline vectors.

v 8VLQJWKHVDPHLQVHFWLFLGHIRUPXOWLSOHVXFFHVVLYH,56F\FOHVLV

QRWUHFRPPHQGHGLWLVSUHIHUDEOHWRXVHDV\VWHPRIURWDWLRQ

with a different insecticide class being used each year. In areasZKHUH,56LVWKHPDLQYHFWRUFRQWUROLQWHUYHQWLRQWKLVURWDWLRQ

system may include the use of a pyrethroid.

v ,QDUHDV ZLWK KLJK //,1 FRYHUDJHS\UHWKURLGV VKRXOG QRW EH

used for IRS.

12. &XUUHQWO\ WKHUH LV KHDY\ UHOLDQFH RQ S\UHWKURLGV IRU PDODULD

vector control especially in the form of LLINs. The preservationof pyrethroid susceptibility in target vector populations istherefore an overwhelming priority in the choice of vectorcontrol methods. The combination of non-pyrethroid IRS with//,1V LQYROYHV VLJQLoFDQWO\ LQFUHDVHG FRVWV EXW LW KDV WZR

H[SHFWHGDGYDQWDJHV)LUVWWKHUHLVHYLGHQFHWKDWWKHSUHVHQFH

of a non-pyrethroid on the wall reduces the strength of selectionfor pyrethroid resistance that might occur as a result of an LLINLQWKHVDPHURRPWKLVFRPELQDWLRQLVWKHUHIRUHUHFRPPHQGHG

as a means of insecticide resistance management (256HFRQGthere is observational evidence suggesting that the combinationRI,56DQG//,1VLVPRUHHIIHFWLYHWKDQHLWKHULQWHUYHQWLRQDORQH

especially if the combination helps to increase overall coveragewith vector control (266XFKHYLGHQFHLVOLPLWHGDQGFROOHFWLRQ

of data from a wide variety of settings is needed. It should benoted that in areas with high levels of LLIN coverage in whichS\UHWKURLGUHVLVWDQFHLV LGHQWLoHG IRFDO ,56LV UHFRPPHQGHG

%URDG GHSOR\PHQW RI ,56 DQG //,1V LQ FRPELQDWLRQ ZKLOH

SRWHQWLDOO\YHU\HIIHFWLYHLVFXUUHQWO\oQDQFLDOO\XQVXVWDLQDEOH

7/30/2019 1. WHO 2011


WHO is currently developing a Global Plan for InsecticideResistance Management in malaria vectors *3,50 WKURXJK

H[WHQVLYHFRQVXOWDWLRQZLWKD ZLGHYDULHW\RIVWDNHKROGHUVLWZLOO

be released in early 2012.

2.2.3 Diagnosis and treatment of malaria

7KHPDLQREMHFWLYHVRIDQDQWLPDODULDOWUHDWPHQWSROLF\DUH

v WRUHGXFHPRUELGLW\DQGPRUWDOLW\E\HQVXULQJUDSLGFRPSOHWH

cure of Plasmodium LQIHFWLRQWKXVSUHYHQWLQJWKHSURJUHVVLRQRIXQFRPSOLFDWHGPDODULDWRVHYHUHDQGSRWHQWLDOO\IDWDOGLVHDVH

as well as preventing chronic infection that leads to malaria-UHODWHGDQDHPLD

v to reduce the frequency and duration of malaria infection duringSUHJQDQF\DQGLWVQHJDWLYHLPSDFWRQWKHIHWXVDQG

v to curtail the transmission of malaria by reducing the humanparasite reservoir.

The 2nd edition of the WHO Guidelines for the treatment ofmalaria was published in March 2010 (277KH FXUUHQW :+2recommendations for diagnosis and treatment are as follows:

1. 3URPSW SDUDVLWRORJLFDO FRQoUPDWLRQ E\ PLFURVFRS\ RU

DOWHUQDWLYHO\E\UDSLGGLDJQRVWLFWHVWV5'7VLVUHFRPPHQGHG

in all patients with suspected malaria before treatment is started.Antimalarial treatment solely on the basis of clinical suspicionshould only be considered when a parasitological diagnosisis not accessible.1 Treatment based on diagnostic testing is

good clinical practice and has the following advantages overpresumptive treatment of all fever episodes:

v improved care of parasite-positive patients because ofFRQoUPDWLRQRILQIHFWLRQ

v LGHQWLoFDWLRQ RI SDUDVLWHQHJDWLYH SDWLHQWV LQ ZKRP DQRWKHU

GLDJQRVLVPXVWEHVRXJKWDQGWUHDWHGDFFRUGLQJO\

v avoidance of antimalarial medicine use in parasite-negativeSDWLHQWVWKHUHE\ UHGXFLQJ VLGHHIIHFWVGUXJ LQWHUDFWLRQV DQG

VHOHFWLRQSUHVVXUHIRUGUXJUHVLVWDQFHDQGSRWHQWLDOO\UHVXOWLQJ

LQoQDQFLDOVDYLQJV

v EHWWHU SXEOLF WUXVW LQ WKH HIoFDF\ RI DUWHPLVLQLQEDVHG

FRPELQDWLRQ WKHUDS\ $&7 ZKHQ LW LV XVHG RQO\ WR WUHDW

FRQoUPHGPDODULDFDVHVDQG

v better public trust in diagnosis and treatment of non-malariacauses of febrile illness.

2. 8QFRPSOLFDWHGP. falciparum malaria should be treated withDQ$&7 ,QDGGLWLRQ WRDQ $&7 D VLQJOH GRVH RISULPDTXLQH

is recommended for treatment of P. falciparum malaria asan anti-gametocyte medicine (particularly as a component ofD SUHHOLPLQDWLRQ RU DQ HOLPLQDWLRQ SURJUDPPH VXEMHFW WR

FRQVLGHUDWLRQRIWKHULVNVRIKDHPRO\VLVLQSDWLHQWVZLWKJOXFRVH

GHK\GURJHQDVH*3'GHoFLHQF\

1 :LWKLQDVKRUWWLPHOHVVWKDQKRXUVRIWKHSDWLHQWVSUHVHQWDWLRQDWthe point of care.

3. P. vivax malaria should be treated with chloroquine in areasZKHUHWKLVGUXJLVHIIHFWLYHDQDSSURSULDWH$&7QRWDUWHVXQDWHSOXVVXOIDGR[LQHS\ULPHWKDPLQHVKRXOGEHXVHGLQDUHDVZKHUHP. vivax resistance to chloroquine has been documented. Bothchloroquine and ACTs should be combined with a 14-daycourse of primaquine for the treatment of P.vivax malaria inRUGHUWRSUHYHQWUHODSVHVVXEMHFWWRFRQVLGHUDWLRQRIWKHULVNRIKDHPRO\VLVLQSDWLHQWVZLWK*3'GHoFLHQF\

4. The 5 ACTs currently recommended for use are artemetherSOXV OXPHIDQWULQH DUWHVXQDWH SOXV DPRGLDTXLQH DUWHVXQDWHSOXV PHpRTXLQH DUWHVXQDWH SOXV VXOIDGR[LQHS\ULPHWKDPLQH

and dihydroartemisinin plus piperaquine. The choice of the$&7VKRXOGEHEDVHGRQWKHHIoFDF\RIWKHFRPELQDWLRQLQWKH

country or area of intended use.

5. Artemisinin and its derivatives should not be used as oralmonotherapies for the treatment of uncomplicated malaria aspoor adherence to the required 7 days of treatment resultsin partial clearance of malaria parasites which will promoteresistance to this critically important class of antimalarials.

6. Severe malaria should be treated with a parenteral artesunate and

followed by a complete course of an effective ACT as soon as theSDWLHQW FDQ WDNH RUDO PHGLFDWLRQV :KHUH FRPSOHWH SDUHQWHUDOWUHDWPHQW RI VHYHUH PDODULD LV QRW SRVVLEOH HJ LQ SHULSKHUDO

KHDOWKSRVWVSDWLHQWVVKRXOGEHJLYHQSUHUHIHUUDOWUHDWPHQWDQGreferred immediately to an appropriate facility for further treatment.

2SWLRQVDYDLODEOHIRUSUHUHIHUUDOWUHDWPHQWDUHDUWHVXQDWHUHFWDO

TXLQLQH,0DUWHVXQDWH,0RUDUWHPHWKHU,0

7. ,Q VHWWLQJV ZLWK OLPLWHG KHDOWK IDFLOLW\ DFFHVV GLDJQRVLV DQGtreatment should be provided at community level through aSURJUDPPHRI FRPPXQLW\FDVHPDQDJHPHQWIRUPHUO\ NQRZQ

DV KRPHEDVHG PDQDJHPHQW RI PDODULD7KH LQWURGXFWLRQ RISDUDVLWRORJLFDO WHVWLQJ RI PDODULD DOORZV WKH LGHQWLoFDWLRQ RIQRQPDODULDIHEULOHLOOQHVVHVZKLFKDOVRQHHGDSSURSULDWHFDUH

notably pneumonia and other causes of childhood mortality.The successful implementation of community case managementtherefore requires diagnosis and treatment for other frequentcauses of febrile disease. This new strategy is termed integratedFRPPXQLW\FDVHPDQDJHPHQWL&&0RIFKLOGKRRGLOOQHVV

2.2.4 Intermittent preventive treatment

Intermittent preventive treatment is the administration of a fullFRXUVHRIDQHIIHFWLYHDQWLPDODULDOWUHDWPHQWDWVSHFLoHGWLPHSRLQWV

WRDGHoQHGSRSXODWLRQDWULVNRIPDODULDUHJDUGOHVVRIZKHWKHUWKHUHFLSLHQWVDUHSDUDVLWDHPLFZLWKWKHREMHFWLYHRIUHGXFLQJWKHmalaria burden in the target population.

1. Intermittent preventive treatment in pregnancy (IPTp): AllSUHJQDQWZRPHQDWULVNRI P. falciparum infection in countriesLQVXE6DKDUDQ$IULFDZLWKVWDEOHPDODULDWUDQVPLVVLRQVKRXOGUHFHLYH DW OHDVW GRVHV RI VXOIDGR[LQHS\ULPHWKDPLQH 63JLYHQDW WKH oUVWDQG VHFRQG VFKHGXOHGDQWHQDWDO FDUHYLVLWVDWOHDVW RQHPRQWK DSDUW DIWHU kTXLFNHQLQJy WKHoUVW QRWHG

PRYHPHQWRIWKHIHWXV7KHGRVHVRI63VKRXOGEHWDNHQXQGHUdirect observation during the antenatal visits (28

2. Intermittent preventive treatment in infants (IPTi): All infants atULVNRIP. falciparum infection in countries in sub-Saharan Africawith moderate to high malaria transmission should receive 3 doses

RI63DORQJZLWK WKH'73 '73DQGPHDVOHV LPPXQL]DWLRQthrough the routine immunization programme (2930

7/30/2019 1. WHO 2011


2.2.5 Resistance to antimalarial drugs

$QWLPDODULDOGUXJUHVLVWDQFHLV DPDMRUSXEOLFKHDOWKSUREOHPwhich hinders the control of malaria. Continuous monitoring ofWKHHIoFDF\RI DQGUHVLVWDQFH WR DQWLPDODULDO GUXJV LV LPSRUWDQW

to inform treatment policy and ensure early detection of changingpatterns of resistance.

7KHUDSHXWLF GUXJ HIoFDF\ VWXGLHV DOORZ PHDVXUHPHQW RI WKHFOLQLFDODQGSDUDVLWRORJLFDOHIoFDF\RIPHGLFLQHVDQGWKHGHWHFWLRQRI

subtle changes in treatment outcome when monitored consistentlyRYHU WLPH 7KHUDSHXWLF GUXJ HIoFDF\ VWXGLHV DUH FRQVLGHUHG WKH

JROG VWDQGDUG IRU GHWHUPLQLQJ DQWLPDODULDO GUXJ HIoFDF\ DQG

their results are the primary data used by national malaria controlprogrammes to revise the national malaria treatment policies foroUVWDQGVHFRQGOLQHGUXJVDQGHQVXUHDSSURSULDWHPDQDJHPHQW

RIFOLQLFDO FDVHV7KHUDSHXWLFGUXJHIoFDF\VWXGLHVDUH DOVRXVHG

WRGHWHFWVXVSHFWHGDUWHPLVLQLQUHVLVWDQFHGHoQHGDVDQLQFUHDVH

LQSDUDVLWHFOHDUDQFHWLPHDVHYLGHQFHGE\

10% of cases withparasites detectable on day 3 after treatment with an ACT.

BOX 2.2

The Global Plan for Artemisinin Resistance Containment(GPARC)

The Global Plan for Artemisinin Resistance Containment*3$5&ZDVUHOHDVHGLQ-DQXDU\LQUHVSRQVHWRWKH

HPHUJHQFHRI DUWHPLVLQLQ UHVLVWDQFH LQ WKH *UHDWHU 0HNRQJ

VXEUHJLRQ7KHJRDORIWKH*3$5&LVWRSURWHFW$&7VDVDQeffective treatment for P. falciparum PDODULD E\ GHoQLQJpriorities for the containment and prevention of artemisininUHVLVWDQFH )LYH DFWLYLWLHV DUH UHFRPPHQGHG E\ WKH *3$5&

as important for successful management of artemisininresistance:

1. 6WRSWKHVSUHDGRIUHVLVWDQWSDUDVLWHV. In areas for whichWKHUHLV HYLGHQFHRIDUWHPLVLQLQUHVLVWDQFHDQLPPHGLDWH

comprehensive response using a combination of malariacontrol and elimination measures is needed to stop thesurvival and spread of resistant parasites.

2. ,QFUHDVH PRQLWRULQJ DQG VXUYHLOODQFH WR HYDOXDWH WKHWKUHDW RI DUWHPLVLQLQ UHVLVWDQFH Regular monitoringand surveillance are essential to rapidly identify newfoci of resistant parasites and to provide information forcontainment and prevention activities. Countries endemicIRU PDODULD VKRXOG XQGHUWDNH URXWLQH PRQLWRULQJ RI

antimalarial drugs at sentinel sites every 24 months inRUGHUWRGHWHFWFKDQJHVLQWKHLUWKHUDSHXWLFHIoFDF\31

3. ,PSURYH DFFHVV WR GLDJQRVWLFV DQG UDWLRQDO WUHDWPHQW

ZLWK $&7V 3URJUDPPHV VKRXOG HQVXUH FRQVLVWHQW

DFFXUDWH GLDJQRVWLF WHVWLQJ RI VXVSHFWHG PDODULD FDVHV

EHWWHU DFFHVV WR $&7V IRU FRQoUPHG FDVHV FRPSOLDQFH

ZLWK$&7WUHDWPHQWDQGUHPRYDOIURPWKHPDUNHWRIRUDOartemisinin-based monotherapies as well as substandardand counterfeit antimalarial medicines.

4. ,QYHVWLQDUWHPLVLQLQUHVLVWDQFHUHODWHGUHVHDUFKResearchis important to improve understanding of resistance andthe ability to manage it. Priority should be given to researchLQoYHGLVFLSOLQHVVKRXOGEHDSULRULW\ODERUDWRU\UHVHDUFK

UHVHDUFK DQG GHYHORSPHQW DSSOLHG DQG oHOG UHVHDUFK

RSHUDWLRQDOUHVHDUFKDQGPDWKHPDWLFDOPRGHOLQJ

5. 0RWLYDWH DFWLRQ DQG PRELOL]H UHVRXUFHV SuccessfulLPSOHPHQWDWLRQRIWKH*3$5&ZLOOGHSHQGRQPRWLYDWLQJ

PDQ\VWDNHKROGHUVDWJOREDOUHJLRQDODQGQDWLRQDOOHYHOVWR

support or conduct the recommended activities.

7KH*3$5&GHoQHVWKUHHWLHUVEDVHGRQWKHHYLGHQFHRI

artemisinin resistance. Each endemic country should evaluate

LWV OHYHO RI ULVN DQG DSSO\ WKH *3$5& UHFRPPHQGDWLRQV

accordingly.

Tier 1: Areas with credible evidence of artemisininresistance. The recommended response for tier 1 areas isD FRPELQDWLRQ RI LQWHQVLoHG PDODULD FRQWURO DQG WRROV IRU

elimination including: parasitological diagnosis for all patients

ZLWK VXVSHFWHG PDODULD D IXOO FRXUVH RI TXDOLW\DVVXUHG$&7V SOXV SULPDTXLQH IRU FRQoUPHG FDVHV YHFWRU FRQWURO

to lower transmission and minimize the spread of resistantSDUDVLWHV DQG ODXQFK RI VSHFLoF DFWLYLWLHV WR FRQWDLQ RUHOLPLQDWH UHVLVWDQW SDUDVLWHV VXFK DV LQWHQVLoHG PRQLWRULQJRIWKHUDSHXWLFHIoFDF\QHDUFXUUHQWIRFLWRWUDFNWKHVSUHDGRI DUWHPLVLQLQ UHVLVWDQFH HQIRUFHPHQW WR HOLPLQDWH XVH RI

oral artemisinin-based monotherapies and substandard andFRXQWHUIHLW DQWLPDODULDO PHGLFLQHV SURJUDPPHV WR UHDFKPRELOH DQG PLJUDQW SRSXODWLRQV ZLWK DGHTXDWH SUHYHQWLRQ

GLDJQRVLVDQGWUHDWPHQWDQGHSLGHPLRORJLFDORUWUDQVPLVVLRQreduction tools.

7LHU$UHDVZLWKVLJQLoFDQWLQpRZRIPRELOHDQGPLJUDQWpopulations from tier 1 areas or shared borders with tier 1DUHDV$VLQWLHUDUHDVWKHUHFRPPHQGDWLRQVODUJHO\PLUURUWKRVHIRUPDODULDFRQWURO7KHVSHFLoFUHFRPPHQGDWLRQVIRUWLHUDUHDVDUHLQWHQVLI\DQGDFFHOHUDWHPDODULDFRQWURODFWLYLWLHVLPSOHPHQWVSHFLoFPHDVXUHVWRPDQDJHWKHSRWHQWLDOVSUHDG

RIUHVLVWDQWSDUDVLWHVIURPWLHUDUHDVLQFOXGLQJSURJUDPPHVWRUHDFKPRELOHDQGPLJUDQWSRSXODWLRQVODXQFKRIDFWLYLWLHVVSHFLoFIRUWKHSUHYHQWLRQRIUHVLVWDQFHLQSDUWLFXODULQWHQVLoHGPRQLWRULQJ RI WKHUDSHXWLF HIoFDF\ WR WUDFN WKH VSUHDG RIDUWHPLVLQLQ UHVLVWDQFH DQG HGXFDWLRQ DQG HQIRUFHPHQW WR

eliminate the use of oral artemisinin-based monotherapiesand substandard and counterfeit antimalarial medicines.

Tier 3: P. falciparum endemic areas which have noevidence of artemisinin resistance and have limited contactZLWKWLHUDUHDV,QWLHUWKHPDLQREMHFWLYHLVWRSUHYHQWWKHemergence of artemisinin resistance in implementation andVFDOHXSRI HIIHFWLYHFRQWUROPHDVXUHV LQFOXGLQJ LQFUHDVLQJDFFHVV WR SDUDVLWRORJLFDO GLDJQRVLV LPSURYLQJ DFFHVV WRTXDOLW\DVVXUHG$&7VIRUFRQoUPHGFDVHVLQFUHDVLQJFRYHUDJHZLWKYHFWRUFRQWUROWROLPLWPDODULDWUDQVPLVVLRQPRQLWRULQJ

WKHWKHUDSHXWLF HIoFDF\ RI oUVW DQGVHFRQGOLQH WUHDWPHQWVHYHU\PRQWKVLQWURGXFLQJRUHQIRUFLQJDFWLRQVWRHOLPLQDWHthe use of oral artemisinin-based monotherapies or poor-quality drugs.

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To interpret and compare results within and between regionsDQGWRIROORZWUHQGVRYHUWLPHWKHUDSHXWLFHIoFDF\PRQLWRULQJPXVWbe conducted with similar standardized procedures. WHO updatedWKH SURWRFRO IRU DVVHVVLQJ DQWLPDODULDO GUXJ HIoFDF\ LQ (31:+2KDVDOVRGHYHORSHGDJXLGHOLQHRQJHQRW\SLQJPDODULDSDUDVLWHV WR GLVWLQJXLVK EHWZHHQ UHLQIHFWLRQ DQG UHFUXGHVFHQFHZKLFKLVQHFHVVDU\DVSDUWRIWKHWKHUDSHXWLFHIoFDF\WHVWLQJ32The following recommendations are drawn from the 2009 editionof 0HWKRGVIRUVXUYHLOODQFHRIDQWLPDODULDOGUXJHIoFDF\(31

1. National malaria control programmes should establishVHQWLQHOVLWHVVHOHFWHGKHDOWKIDFLOLWLHVIRU WKHVXUYHLOODQFH RIDQWLPDODULDOGUXJHIoFDF\([SHULHQFHVXJJHVWVWKDWq VLWHVper country will achieve a balance between representativenessand practicality. The sentinel sites should represent all theepidemiological strata in the country but it is essential to selectDCPDQDJHDEOHQXPEHURIVLWHVWRHQVXUHSURSHUPRQLWRULQJDQGsupervision.

2. (IoFDF\ RI oUVW DQG VHFRQGOLQH PHGLFLQHVVKRXOG EH WHVWHGDWOHDVWRQFHHYHU\PRQWKVDWDOOVLWHV)RUWKHSXUSRVHVRIFRPSDUDELOLW\DVVHVVPHQWVVKRXOGDOZD\VEHFRQGXFWHGDWWKHsame time of year.

3. A follow-up of 28 days is recommended as the minimumduration for medicines with elimination half-lives of less than GD\V DPRGLDTXLQH DUWHPLVLQLQ GHULYDWLYHV DWRYDTXRQHqSURJXDQLOFKORURTXLQHOXPHIDQWULQHTXLQLQHDQGVXOIDGR[LQHS\ULPHWKDPLQH )RU PHGLFLQHV ZLWK ORQJHU HOLPLQDWLRQ KDOIOLYHV PHpRTXLQH SLSHUDTXLQH D ORQJHU IROORZXS SHULRG RI42 days is necessary.

4. 7KHVWDQGDUGSURWRFROWRWHVWWKHHIoFDF\RIPHGLFLQHVDJDLQVWP. falciparum QHHGV DGMXVWPHQW IRU P. vivax. Since P. vivaxinfection has a dormant liver stage and therefore the potentialWR UHODSVH PDQ\ FRXQWULHV UHFRPPHQG SULPDTXLQH WKHUDS\

for radical cure. Administration of primaquine concurrently orsoon after administration of chloroquine may conceal resistanceWR FKORURTXLQH DORQH UHVXOWLQJLQ XQGHUHVWLPDWLRQ RI WKHULVNRI WKHUDSHXWLF IDLOXUH RU UHVLVWDQFH WR FKORURTXLQH 7KHUHIRUHin certain cases primaquine therapy should be postponedXQWLO DIWHU WKH GD\ IROORZXS1RQHWKHOHVV LI ORFDO KHDOWKpolicy includes mandatory administration of primaquine withFKORURTXLQHWKHIDLOXUHUDWHVKRXOGEHFRQVLGHUHGWREHWKDWRIthe combinatio

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1. WHO 2011