Preparing for

certification of
malaria elimination
Second edition

Malaria-free
certification

I
Preparing for
certification of
malaria elimination
Second edition

i
 Preparing for certification of malaria elimination, second edition

ISBN 978-92-4-006200-9 (electronic version)

ISBN 978-92-4-006201-6 (print version)

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Preparing for certification of malaria elimination

ii Second edition
Contents

Acknowledgements v

Abbreviations vi

Glossary vii

Introduction 1

1. Overview of the certification procedure 3

2. Criteria for certification of malaria elimination 4

3. Steps in certification of malaria elimination 6

4. National preparation for certification of malaria elimination 9

4.1 Oversight and management 9
4.2 Documentation of an effective elimination programme 10
4.3 National elimination report 12
4.4 Prevention of re-establishment of transmission 13
4.4.1 National plan 13
4.4.2 Key elements of a programme for preventing
re-establishment of transmission 14
4.5 Self-assessment of readiness for certification 15
4.6 Independent evaluation mission 17
4.6.1 Timing17
4.6.2 Support expected from the country17
4.6.3 Composition of an independent evaluation mission17
4.6.4 Activities of an independent evaluation mission18
4.7 Granting and maintaining certification 19

5. Verification of subnational malaria elimination 21

5.1 Oversight and management 21
5.2 Criteria for verification of subnational malaria elimination 22

iii
 5.3 Steps in verification of subnational elimination 22
5.3.1 Subnational elimination report, supporting
documents and records23
5.3.2 Subnational verification mission24
5.4 Announcement of verification of malaria-free status
in subnational areas 24

References 25

Annexes 26
Annex 1. Documentation required for certification of malaria
elimination  27
Annex 2. An example of an official letter to request certification of
malaria elimination 32
Annex 3. Plan of action and timeline for certification33
Annex 4. Outline of a national elimination report 34
Annex 5. Checklist of elements for prevention of re-establishment of
malaria transmission 36
Annex 6. Generic agenda for an independent evaluation mission 43
Annex 7. Methods to verify malaria-free status in a county
- example from China 45

Preparing for certification of malaria elimination

iv Second edition
Acknowledgements

The first edition of this document was published in 2020, prepared

by the Elimination Unit of the WHO Global Malaria Programme.
The work was led by Li Xiao Hong and Kim Lindblade, with substantial
input and comments from Pedro Alonso, Abdisalan Noor, Amanda
Tiffany, Andrea Bosman and Jan Kolaczinski. The following staff in
WHO regional and country offices also contributed to the document:
Ebenezer Baba, Anderson Chinorumba and Abderahmane Kharchi
(WHO Regional Office for Africa); Maria Paz Ade, Blanca Escribano
Ferrer and Roberto Montoya (WHO Regional Office for the Americas);
Neena Nee Kesar Valecha and Risintha Premaratne (WHO Regional
Office for South-East Asia); Elkhan Gasimov (WHO Regional Office
for Europe); Ghasem Zamani (WHO Regional Office for the Eastern
Mediterranean); Rabindra Abeyasinghe, James Kelley and Glenda
Gonzales (WHO Regional Office for the Western Pacific); and Deyer
Gopinath (WHO Country Office for Thailand).

The second edition of this document was prepared by Li Xiao Hong,

with significant input and comments from Kim Lindblade, Pedro Alonso,
Abdisalan Noor and Elkhan Gasimov.

Members of the Malaria Elimination Certification Panel (now the

Technical Advisory Group on Malaria Elimination and Certification)
provided valuable contributions throughout the development of the
document and its update: Fred Binka, Keith Carter, Brian Greenwood
(Chair), Cecilia T. Hugo, Payre L. Joshi, Anatoly Kondrashin (Co-chair),
Reza Majdzadeh, Rossitza Mintcheva, Jose Najera, Daouda Ndiaye,
Martha L. Quinones, Trenton Ruebush II and Allan Schapira.

v
 Abbreviations

GMP Global Malaria Programme

MPAG Malaria Policy Advisory Group

NMP national malaria programme

SOP standard operating procedure

TAG-MEC Technical Advisory Group on Malaria Elimination and

Certification

Preparing for certification of malaria elimination

vi Second edition
Glossary

This glossary comprises all the key terms used in the present publication.
The definitions are extracted from WHO malaria terminology, updated in
December 2021 (1). As the terminology is reviewed continuously, readers
should visit the WHO GMP website at https://www.who.int/teams/global-
malaria-programme for updates.

case investigation Collection of information to allow classification of

a malaria case by origin of infection, i.e. imported,
indigenous, induced, introduced, relapsing or
recrudescent

Note: Case investigation may include administration of

a standardized questionnaire to a person in whom a
malaria infection is diagnosed and screening and testing
of people living in the same household or surrounding
areas.

case, imported Malaria case or infection in which the infection was

acquired outside the area in which it is diagnosed
case, index A case of which the epidemiological characteristics
trigger additional active case or infection detection.
The term “index case” is also used to designate the
case identified as the origin of infection of one or a
number of introduced cases.
case, indigenous A case contracted locally with no evidence of
importation and no direct link to transmission from an
imported case
case, induced A case the origin of which can be traced to a blood
transfusion or other form of parenteral inoculation
of the parasite but not to transmission by a natural
mosquito-borne inoculation

Note: In controlled human malaria infections in malaria

research, the parasite infection (challenge) may
originate from inoculated sporozoites, blood or infected
mosquitoes.

case, introduced A case contracted locally, with strong epidemiological

evidence linking it directly to a known imported case
(first-generation local transmission)

vii
 case, locally A case acquired locally by mosquito-borne
acquired transmission

Note: Locally acquired cases can be indigenous,

introduced, relapsing or recrudescent; the term
“autochthonous” is not commonly used.

case, malaria Occurrence of malaria infection in a person in whom

the presence of malaria parasites in the blood has
been confirmed by a diagnostic test

Note: A suspected malaria case cannot be considered

a malaria case until parasitological confirmation. A
malaria case can be classified as indigenous, induced,
introduced, imported, relapsing or recrudescent
(depending on the origin of infection); and as
symptomatic or asymptomatic. In malaria control
settings, a “case” is the occurrence of confirmed malaria
infection with illness or disease. In settings where malaria
is actively being eliminated or has been eliminated,
a “case” is the occurrence of any confirmed malaria
infection with or without symptoms.

case, relapsing Malaria case attributed to activation of hypnozoites of

Plasmodium vivax or P. ovale acquired previously

Note: The latency of a relapsing case can be

> 6-12 months. The occurrence of relapsing cases
is not an indication of operational failure, but their
existence should lead to evaluation of the possibility
of ongoing transmission.

chemoprophylaxis Administration of a medicine, at predefined intervals,

to prevent either the development of an infection or
progression of an infection to manifest disease
focus, malaria A defined and circumscribed area situated in a
currently or formerly malarious area that contains the
epidemiological and ecological factors necessary for
malaria transmission

Note: Foci can be classified as active, residual non-active

or cleared.

importation, rate Rate (or risk) of influx of parasites via infected

(or risk) of individuals or infected Anopheles spp. mosquitoes

Note: “Infected individuals” include residents infected

while visiting endemic areas as well as infected
immigrants. This term replaces the term “vulnerability”.

Preparing for certification of malaria elimination

viii Second edition
infectivity Ability of sporozoites of a specific strain of
Plasmodium to be injected by Anopheles mosquitoes
into susceptible humans and develop through the liver
stage to infect red blood cells (“infectivity to humans”)
and the ability of competent Anopheles mosquitoes
to ingest human Plasmodium gametocytes which
undergo development until the mosquito has infective
sporozoites in its salivary glands (“infectivity to
mosquitoes”).
malaria Interruption of local transmission (reduction to zero
elimination incidence of indigenous cases) of a specified malaria
parasite species in a defined geographical area as
a result of deliberate activities. Continued measures
to prevent re-establishment of transmission are
required.
Note: Certification of malaria elimination in a country
requires that local transmission is interrupted for the four
main human malaria parasites.

malaria Permanent reduction to zero of the worldwide

eradication incidence of infection caused by all human malaria
parasite species as a result of deliberate activities.
Interventions are no longer required once eradication
has been achieved.
malaria Degree to which an ecosystem in a given area at a
receptivity given time allows for the transmission of Plasmodium
spp. from a human through a vector mosquito to
another human.

Note: This concept reflects vectorial capacity,

susceptibility of the human population to malaria
infection, and the strength of the health system, including
malaria interventions. Receptivity depends on vector
susceptibility to particular species of Plasmodium, and is
influenced by ecological and climatic factors.

malaria Malaria reintroduction is the occurrence of introduced

reintroduction cases (cases of first-generation local transmission that
are epidemiologically linked to a confirmed imported
case) in a country or area where the disease had
previously been eliminated
Note: Malaria reintroduction is different from re-
establishment of malaria transmission (see definition).

malaria-free Describes an area in which there is no continuing

local mosquito-borne malaria transmission and the
risk for acquiring malaria is limited to infection from
introduced cases

 ix
 malariogenic Potential level of transmission in a given area
potential arising from the combination of malaria receptivity,
importation rate (or risk) of malaria parasites and
infectivity.
Note: The concept of malariogenic potential is most
relevant for elimination and prevention of
re-establishment when indigenous transmission is almost
or entirely eliminated.

population at risk Population living in a geographical area where locally

acquired malaria cases have occurred in the past
3 years
transmission, Renewed presence of a measurable incidence of
re-establishment locally acquired malaria infection due to repeated
of cycles of mosquito-borne infections in an area in
which transmission had been interrupted

Note: A minimum indication of possible re-establishment

of transmission would be the occurrence of three or more
indigenous malaria cases of the same species per year
in the same focus, for 3 consecutive years.

vigilance A function of public health services for preventing

reintroduction of malaria. Vigilance consists of close
monitoring for any occurrence of malaria in receptive
areas and application of the necessary measures to
prevent re-establishment of transmission

Preparing for certification of malaria elimination

x Second edition
Introduction

Certification of malaria elimination is granted by WHO to a country,

further to a request from its government, after it has been proven
beyond reasonable doubt that local malaria transmission by Anopheles
mosquitoes1 has been interrupted in the country, resulting in zero
indigenous malaria cases for at least the past 3 consecutive years, and
a programme for the prevention of re-establishment of transmission is in
place. WHO was given the mandate to certify countries malaria-free by
the World Health Assembly in resolution WHA13.55 in 1960, which “requests
the Director-General to establish an official register, listing areas where
malaria eradication has been achieved, after inspection and certification
by a WHO evaluation team.” 2

The Global technical strategy for malaria 2016–2030, endorsed by the

World Health Assembly in 2015 and updated in 2021, includes targets for
malaria elimination and prevention of re-establishment of transmission (2).
WHO provides guidance on the dynamic strategies and activities that
will help countries achieve elimination and prevent re-establishment of
transmission in the Framework for malaria elimination (3). The Framework
updated the criteria and process for WHO certification of malaria
elimination initially established during the Global Malaria Eradication
Programme between 1955 and 1969. In line with these updates, the Malaria
Elimination Certification Panel (MECP), a standing committee entrusted
with reviewing and evaluating countries’ reports of malaria elimination and
recommending certification to WHO, was established in 2017. In 2021, the
MECP was renamed as Technical Advisory Group on Malaria Elimination
and Certification (TAG-MEC) (4).

The purpose of this document is to extend guidance to countries that are

nearing malaria elimination on preparing for certification. It provides an
overview of the certification procedure and details of activities required in
national preparation for certification. It includes tools that countries can
use to organize the documentation required for certification, to prepare a
national elimination report and to assess their readiness for certification.

1
Certification of malaria elimination by WHO requires the elimination of the four main human parasite
species: Plasmodium falciparum, P. vivax, P. ovale and P. malariae. Certification might be granted
to countries where cases of other Plasmodium species are reported if the risk to humans is assessed
negligible.
2
In the 1960s, the term “eradication” was used to describe interruption of transmission within a defined
geographical boundary. More recently, WHO defined “eradication” as the permanent reduction to zero of
the worldwide incidence of malaria. “Elimination” is used to refer to interruption of malaria transmission in
a defined geographical area (1).

1
 For countries with subnational elimination goals, the manual provides
guidance on verification of subnational malaria elimination, which is
overseen by national authorities. The target readership of this manual is
officials in ministries of health and other relevant departments, national
malaria programme (NMP) managers and staff, national elimination
advisory committees and partners who support countries in eliminating
malaria and preventing re-establishment.

Preparing for certification of malaria elimination

2 Second edition
1. Overview of the
certification procedure

Certification of malaria elimination is voluntary and is initiated at

a country’s request. The process provides an expert, objective and
independent review and evaluation of a country’s declaration of malaria
elimination and its programme to prevent re-establishment of transmission.
Preparation for certification begins before countries interrupt malaria
transmission through development of national malaria elimination
strategic plans, effective implementation of planned activities, monitoring
of progress and evaluation of impact. Documenting the efforts for
malaria elimination should begin during this time to prepare evidence for
certification.

Countries may request certification from WHO after reporting zero

indigenous human malaria cases for 3 consecutive years (36 months).
Countries prepare a national elimination report characterizing the history
of malaria in the country, detailing the activities undertaken to achieve
elimination, presenting evidence that the elimination goal has been
achieved and describing the programme to prevent re-establishment.
The TAG-MEC reviews the report and conducts an independent evaluation
mission to verify the findings in the report by reviewing documents and
records and conducting field visits and interviews with the ministry of
health, the NMP and other relevant sectors. The TAG-MEC weighs the
findings of the independent evaluation mission and recommends to WHO,
through the Malaria Policy Advisory Group (MPAG), whether the country
should be certified as having achieved malaria elimination at that time
or certification should be postponed. The WHO Director-General makes
a final decision on certification. When granted, countries are listed in
the official WHO Register of areas where malaria elimination has been
achieved (5).

3
 2. Criteria for
certification of malaria
elimination

WHO certification of malaria elimination requires applicant countries to

provide evidence that:

• local malaria transmission has been fully interrupted, resulting in

zero indigenous human malaria cases for at least the past
3 consecutive years (36 months), and

• an adequate programme for preventing re-establishment of

indigenous transmission is fully functional throughout the country.

To examine a country’s claim of malaria elimination, the TAG-MEC reviews

the activities and impact of the malaria programme in the years before
elimination to determine whether the activities, as recorded, could have
interrupted transmission in that country; and evaluates the coverage
and quality of the surveillance system during the 3 years (36 months)
of reporting zero indigenous malaria cases to determine whether the
surveillance system could have detected any indigenous malaria cases
should they have occurred.

To evaluate the adequacy of a country’s programme to prevent

re-establishment of malaria transmission, the TAG-MEC examines
the strategies, the technical soundness and comprehensiveness of the
activities in the plan, the quality and coverage of malaria surveillance and
response, the quality and coverage of diagnosis and treatment, capacity
for entomological surveillance and vector control and the sustainability of
provision of financial and human resources.

The evidence that the TAG-MEC uses to evaluate a country’s claim

of malaria elimination and an adequate programme to prevent re-
establishment includes:

• a national elimination report;

Preparing for certification of malaria elimination

4 Second edition
 • documents including written policies, processes and procedures of
the programme that provide overall guidance or instructions for
implementation of activities;

• records or information captured during performance, reporting or

evaluation of a malaria activity;

• observations and findings from the independent evaluation mission;

and

• other documentation, such as WHO documents and peer-reviewed

journal articles.

The TAG-MEC carefully reviews and evaluates the evidence presented by

the country and the findings of the independent evaluation mission and
determines whether the evidence supports both criteria for certification.

5
 3. Steps in certification
of malaria elimination

WHO officially initiates a certification procedure once an official request

for certification is sent from the government (usually the minister of health)
to the WHO Director-General. National preparation for certification must,
however, begin well before elimination is achieved to ensure that the
essential documentation and records are available and organized
to substantiate the country’s claim of elimination.

The steps in certification of malaria elimination are shown in Fig. 1 and

listed below.

1. Documentation of an effective elimination programme: In an

effective elimination programme, records are generated routinely.
Once a country embarks on elimination, the programme manager
should ensure that all records of patients, samples and activities are
retained according to legal requirements and for the time period
requested by WHO (Annex 1).

2. Orientation of the elimination programme to prevent

re-establishment: Countries re-orient their elimination programmes
to prevent re-establishment after elimination has been achieved in
order to maintain their malaria-free status. The programme structure
and surveillance might have to be changed to sustain malaria
activities.

3. Official request: After a country has reported zero indigenous

malaria cases for at least the past 3 consecutive years (36 months)
through a sensitive, robust surveillance system, the authorities submit
an official request for certification to the WHO Director-General,
through the WHO representative or the regional director if there
is no WHO office in the country. WHO then officially initiates the
certification procedure.
An example of an official request for certification is provided in Annex 2.
Completion of a national elimination report is not a precondition for
submitting an official request for certification. The WHO Director-General
will officially acknowledge receipt of the request.

Preparing for certification of malaria elimination

6 Second edition
 4. Readiness assessment: Countries self-assess their readiness for
certification with WHO assistance.

5. Plan of action and timeline: In consultation with the WHO regional

office and the WHO GMP, countries formulate a plan of action and
timeline for certification.
Examples of a plan of action and a timeline are provided in Annex 3.

6. Submission of a national elimination report: Countries finalize a

national elimination report and submit it to the WHO GMP through
their country and regional WHO offices.
An outline of a national elimination report is found in Annex 4. The WHO
GMP will officially acknowledge receipt of the report.

7. Independent evaluation mission: A subset of the TAG-MEC validates

findings in the national elimination report by conducting an
independent evaluation mission to the country.
The requirement for an independent evaluation mission might be waived for
countries in which the last indigenous case was reported more than 15 years
before submission of an official request for certification.

8. Consideration of evidence and recommendation: The full TAG-

MEC reviews the national elimination report and the report of the
independent evaluation mission and reaches consensus on
whether certification should be recommended or postponed.

9. Endorsement of the recommendation: The WHO MPAG reviews the

TAG-MEC recommendation to the WHO Director-General.

10. Certification: The WHO Director-General makes a final decision

and officially informs the government of the country in a letter to the
minister of health.

After announcement of certification by WHO, a brief account of the

country’s achievement of elimination and certification is published in the
Weekly Epidemiological Record. The country is subsequently listed in
the official WHO Register of areas where malaria elimination has been
achieved (5). The country continues work to prevent re-establishment of
transmission and reports any malaria cases annually to WHO, until global
malaria eradication is achieved.

7
8

FIGURE 1: Steps in certification of malaria elimination

Second edition
Preparing for certification of malaria elimination

Submission Submission of
of an official national Certification
request elimination report
36 months
Last zero
indigenous indigenous
case cases

Malaria programme documentation

Orientation of programme to prevent re-establishment

Self-
assessment TAG-MEC TAG-MEC MPAG Final
independent review review decision
evaluation by WHO
Plan mission Director-
of action General
and timeline
Responsibility:
Country
WHO
TAG-MEC
MPAG
4. National preparation
for certification of
malaria elimination

4.1 OVERSIGHT AND MANAGEMENT

Usually, the NMP oversees and manages national preparation for
certification. If a country no longer has an NMP at the time it is eligible to
request certification, a task force or working group can be set up to serve in
its stead.

WHO recommends that countries establish an independent national

malaria elimination advisory committee when they launch their elimination
programme to provide an objective, external view of progress, address
programmatic gaps and assist the country in achieving elimination
and preparing for certification (3).3 If an independent national advisory
committee was not formed before elimination, a national certification
committee or its equivalent could be formed to assist in preparation.
Box 1 provides the example of the terms of reference of a national
certification committee in Uzbekistan.

BOX 1.
Terms of reference for a national certification committee

1. Support coordination of all national entities engaged in certification

of malaria elimination, and determine a plan of action with a specific
timeline for completing national preparation.
2. Assist the national programme in gathering the documents and records
required for certification and in preparing a national elimination report.
3. Support preparation for certification at subnational level.
4. Support assessment of the adequacy of the programme to prevent
re-establishment of transmission.
5. Support assessment of readiness to receive the independent evaluation
mission.

3
Generic terms of reference for an independent national malaria elimination advisory committee are
provided in the Framework for malaria elimination.

9
 The members of the national certification committee, like those of
the independent national malaria elimination advisory committee,
might include academics or retired government malaria experts,
including epidemiologists, entomologists, health system specialists and
representatives of other ministries and departments that contributed to
malaria elimination or participate in prevention of re-establishment.

4.2 DOCUMENTATION OF AN EFFECTIVE

ELIMINATION PROGRAMME

Documents and records are generated routinely in an effective national

malaria programme. They capture lessons learnt along the way towards
elimination and provide information to support a country's claims
of malaria elimination and a functioning programme to prevent re-
establishment of transmission. In the years prior to malaria elimination, and
during the malaria-free period leading up to certification, NMPs should
assess whether the activities and results are documented appropriately
and ensure that documents and records are retained and organized to
prepare evidence for certification.

The documents required consist of the essential guidelines for all the
operations and activities of a programme. They provide written information
on policies, processes and procedures and are updated when new
evidence becomes available or there are changes in the health system.
They help ensure accuracy and consistency in implementation of a
programme and should be accessible to all relevant staff. The documents
reflect a programme’s organization and the quality of its management. For
certification, the documents that countries should keep and present to the
TAG-MEC are:

• national strategic and operational plans;

• strategies or plans of action for preventing re-establishment of

malaria;

• legislation or regulations related to malaria and vector control;

• guidelines, manuals or standard operating procedures (SOPs) for

surveillance, including forms for case notification, case investigation
and focus investigation and response;

• manuals and SOPs for diagnostic quality assurance;

• malaria treatment guidelines, including guidelines on

chemoprophylaxis for travelers;

Preparing for certification of malaria elimination

10 Second edition
 • guidelines, manuals and SOPs for entomological surveillance and
vector control; and

• memoranda of understanding for cross-border collaboration,

if applicable.

The necessary records consist of information, written by hand or on a

computer, recorded during the performance, reporting or evaluation of a
malaria activity. They are used for many purposes, including continuous
monitoring of implementation, evaluation of problems and management.
Records should be complete, legible and carefully maintained. They should
not be revised or modified without appropriate procedures such as dating,
signing and explaining the reason for each change. The completeness
and quality of the data (especially surveillance data) in records is essential
to ensure the strength of the evidence to support the claim of elimination.
Therefore NMPs must regularly validate the data with appropriate
procedures (6).

The records that countries should retain and make available for review by
the independent evaluation mission of the TAG-MEC can be grouped into
three categories.

ROUTINE MALARIA TRAINING, OTHER RECORDS

CONTROL ACTIVITIES MONITORING
AND EVALUATION
• patient registers at • training for various • reports of outbreaks
health facilities cadres of health staff and responses
• sample logs in • supervision and • meeting reports of
laboratories monitoring, feedback the independent
to units receiving national malaria
• case notification forms
supervision elimination advisory
• case investigation committee, multi-
• annual malaria
forms sectoral collaboration
programme reports
• malaria case database committee and cross-
and/or surveillance
border meetings
• focus register including reports
maps • reports on health
• malaria programme
education and
• focus investigation reviews or programme
raising awareness of
forms audits
health professionals,
• reports on activities • self-assessment populations at risk of
and results of of readiness for malaria and travelers
vector control and certification to endemic areas
entomological • all results of • other records that
surveillance subnational the NMP considers
• reports on activities verification may be useful for
and results of quality certification
assurance for diagnosis

11
 The minimum requirements FIGURE. 2:
for documents and records for Organization of documents and
certification at different levels of records in folders in Uzbekistan
the system and the periods they
should cover are summarized
in Annex 1. Some countries
organize the documents and
records required at the national
level into folders to ensure
ready retrieval during the
independent evaluation mission
(Fig. 2). At subnational level,
documents and records might
not necessarily be organized in
folders but should be accessible
at subnational health offices,
health facilities and laboratories.

4.3 NATIONAL ELIMINATION REPORT

The national elimination report is a comprehensive summary of the

country’s work to eliminate malaria and is the main document used by
the TAG-MEC to consider whether certification of malaria elimination
should be granted to an applicant country. It is a narrative report that
provides data and information to demonstrate that the country has met
the two criteria for certification. The ministry of health is responsible for
the credibility of the data and the information presented and submits the
report to WHO on behalf of the government. Guidance on preparation of a
national elimination report is provided in a template developed by GMP.4
Annex 4 gives an outline of a national elimination report. While it is strongly
recommended that countries prepare their reports according to the format
and instructions provided in the template, some variation is expected, given
differences among countries. The national elimination report should be
provided to WHO preferably in English, although reports written in other
official languages of the United Nations are also accepted.5 WHO will
officially acknowledge receipt of the report.

4
A Word template with detailed instructions on preparing a national elimination report is available at the
following link: https://www.who.int/publications/m/item/national-malaria-elimination-report
5
The six official languages of the United Nations are Arabic, Chinese, English, French, Russian and Spanish.

Preparing for certification of malaria elimination

12 Second edition
4.4 PREVENTION OF RE-ESTABLISHMENT
OF TRANSMISSION

After malaria has been eliminated, countries should reorient their

programmes to sustain the minimum activities necessary to prevent re-
establishment. As malaria is no longer a primary public health problem
when elimination is achieved, countries may integrate some of the
functions of a previously dedicated or vertical malaria programme
into other parts of the public health system. Measures should be taken,
however, to ensure that malaria services, particularly curative, preventive
and epidemiological services, remain operational during and after
integration to prevent resurgence.

Certification requires a costed, government-approved plan for prevention

of re-establishment of transmission and demonstration that key elements
of the programme are functional.

4.4.1 National plan

A national plan for prevention of re-establishment of transmission should

include the objectives to be achieved, the activities to be conducted, the
timeline for implementation of activities and the roles and responsibilities
of each participating sector (including non-health sectors). The plan
should be endorsed by the government, and the resources necessary at
central and subnational levels should be included in budgets to ensure
implementation.

The risk that malaria transmission will be re-established in a country is

heterogeneous, as it depends on the degree of receptivity of the ecosystem
for malaria transmission and the risk of importation of malaria parasites.
Receptivity and the risk of importation together determine the malariogenic
potential of an area, which in turn should determine the intensity of
surveillance, response activities and vector control that are necessary
to prevent re-establishment. Countries should stratify their subnational
units by malariogenic potential and consider the appropriate mix of
interventions to be targeted to the different strata. In non-receptive areas,
the goal of surveillance and case management is to detect and treat cases
early to prevent serious clinical consequences of the disease, including
death; thus, high-quality passive surveillance coupled with good case
management is the appropriate mix of interventions. In receptive areas,
the right mix of interventions will depend on the malariogenic potential,
but, at a minimum, should include high-quality passive surveillance, good
case management and case investigations (6). Countries should describe
the strategies they will use, including vector control, to mitigate the risk of
transmission in areas with high malariogenic potential.

13
 As an imported case of malaria could be identified anywhere and at any
time, malaria case management and surveillance for the disease must be
functional throughout the country. Nevertheless, as malaria is eliminated
and cases become rare, health care providers will naturally become less
familiar with the disease. Thus, the plan for prevention of re-establishment
should include activities to maintain vigilance for malaria in general health
services to avoid delayed diagnosis and treatment.

4.4.2 Key elements of a programme for preventing

re-establishment of transmission

As malariogenic potential differs (e.g. risk of importation of malaria cases,

species of malaria vectors, the physical environment, levels of social and
economic development, the strength of the health system), the activities
necessary to prevent re-establishment of malaria transmission will also
differ, as will the cost of maintaining malaria-free status. Nevertheless,
appropriate financing and human resource must be sustained in every
country so that the system maintains the capacity to detect and respond to
malaria cases, should they occur, in a timely, effective manner to prevent
severe clinical consequence and onward transmission.

Countries that interrupted indigenous transmission should consider a

number of key elements to ensure the adequacy of a programme to
prevent re-establishment.

• National structure: A national structure (e.g. a unit or a focal

point) should be in place to oversee and coordinate effective
implementation of the activities defined in the plan to prevent
re-establishment, even if the NMP no longer exists.

• Surveillance and response: An effective surveillance and response

system should be in place to ensure that all suspected malaria cases
are tested, treated, notified, investigated and responded to promptly
and that malaria outbreaks are detected early and contained
effectively (6). The country must have a strategy to maintain the
quality and coverage of surveillance and response.

• Malaria diagnosis network: The network of laboratories (or testing

centres) in the country should be able to provide quality-assured
parasitological confirmation of malaria infections (7) and confirm
the clearance of infection. A programme for periodic assessment of
the competence of laboratory staff must be in place and functional.

• Case management: Good-quality malaria diagnosis and treatment

services (8) should be available throughout the country and to
everyone, irrespective of nationality. General health services must
maintain vigilance for prompt detection and treatment of any
malaria cases that might occur.

Preparing for certification of malaria elimination

14 Second edition
 • Vector control and entomological surveillance: In areas with high
malariogenic potential, entomological surveillance and vector control
must be maintained in order to reduce the likelihood of onward
transmission from imported parasites (6). Capacity to conduct vector
control as part of a response to interrupt local transmission during
outbreaks must be maintained in all receptive areas. Countries should
have a strategy to sustain necessary entomological surveillance.

• Multisectoral collaboration: Coordination and collaboration with

non-health sectors are important to ensure optimal coverage and
use of interventions in high-risk populations and to ensure the impact
and efficiency of those interventions.

• Inter-country information sharing and border collaboration:

Effective coordination and communication between bordering
countries can help mitigate the risk of re-establishment, particularly
in areas bordering countries with ongoing transmission, where the
malariogenic potential is frequently high.

• Raising awareness and providing preventive strategies for travellers:

Early detection of malaria cases can be improved by raising the
awareness of health practitioners and travellers to and from malaria-
endemic countries. Countries should provide advice to travellers
to endemic countries on malaria risk, avoiding mosquito bites and
chemoprophylaxis (9). Chemoprophylaxis may significantly reduce
the risk of infection and severe disease and should therefore be made
available to travellers to endemic countries.

A checklist of elements for assessing the adequacy of national programmes

for preventing re-establishment of transmission of malaria is given in
Annex 5.

4.5 SELF-ASSESSMENT OF READINESS FOR

CERTIFICATION

The purpose of self-assessment is to ensure the availability of the evidence

that the two criteria for certification have been met. The assessment
of readiness for certification is organized by the ministry of health and
could be implemented by the NMP, the independent national malaria
elimination advisory committee or a certification committee. Coordination
and engagement with other departments and sectors that participate in
malaria elimination and prevention of re-establishment is necessary in self-
assessment. WHO conducts field visits jointly with the ministry of health to
provide technical support to prepare for certification and an external point
of view on the readiness for certification. The results of the joint mission of
WHO and the ministry of health will inform a plan of action and timeline for
certification.

 15
 Methods for self-assessment of readiness for certification include desk
reviews and field visits. As the coverage and quality of the surveillance
and response system and its probable sustainability after elimination are
essential for determining whether the country has met the two certification
criteria, the performance of the surveillance and response system should
be a priority in the self-assessment. Results of the self-assessment and
any other evaluations are important records and should be retained for
certification (6).

Three components should be assessed for readiness for certification.

• Documents and records. The completeness of documents and

records should be assessed according to the requirements for
certification (Annex 1). At national level, countries are expected
to compile the necessary documents and records systematically,
so that they can be retrieved readily. Countries should ensure that
documents such as guideline and SOPs are up to date, available
and accessible to staff who need them. For example, SOPs for
quality-assured diagnosis should be available in laboratories while
treatment guidelines should be available in health facilities. Original
records should be stored in the health facilities and laboratories
that generated the data, with copies available at higher levels. The
completeness and quality of data must be reviewed as part of the
self-assessment. For example, countries should determine whether
the data from the national malaria database is consistent with that
on the original records in health facilities and laboratories, whether
all case notification and investigation forms were filled in completely,
and whether the evidence in the case investigation form is adequate
to support the case classification.

• National elimination report. The report should be based on

the template provided in Annex 4. The ministry of health might
consider inviting senior malaria experts or the independent national
elimination advisory committee to review and verify the report to
ensure its quality.

• Programme to prevent re-establishment of transmission.

As part of self-assessment of the programme to prevent re-
establishment of transmission, countries should evaluate whether the
curative, preventive and epidemiological services are fully functional
throughout the country (3). "Fully functional" means not only that
policies, strategies, written guidelines and SOPs are in place to
provide guidance for the implementation of activities but also
that staff are well trained and competent to provide the required
services. The assessment of whether the national health system
will be able to prevent re-establishment of malaria transmission
should include a review of the sustainability of financial and

Preparing for certification of malaria elimination

16 Second edition
 human resources, the quality and coverage of malaria surveillance
and response, diagnostic capacity and its sustainability and the
capacity for entomological surveillance and vector control. Annex 5
provides a list of the elements required to assess the adequacy of a
programme to prevent re-establishment of transmission.

4.6 INDEPENDENT EVALUATION MISSION

WHO requests a group of malaria experts from the TAG-MEC to validate

the findings of the national elimination report during an independent
evaluation mission to the country.

4.6.1 Timing

The timing of the independent evaluation mission depends on the country’s

progress in preparing all the required documentation and records, its
preparedness to prevent re-establishment of transmission, the results of
the joint assessment mission by WHO and the ministry of health, the timing
of submission of the national elimination report, the availability of the
members of the TAG-MEC and the availability of the country to receive
the mission. WHO and the ministry of health will agree on the dates for the
mission.

4.6.2 Support expected from the country

The NMP is expected to provide support in drafting and finalizing the

itinerary and agenda of the TAG-MEC independent evaluation mission,
in coordination with the WHO secretariat. The support could include
information on the availability of transport, distances between areas and
clearances required for the mission. At least one national representative,
usually the national programme manager, should accompany the team on
the independent evaluation mission and coordinate with subnational health
authorities. The cost of the participation of nationals in the mission
is expected to be borne by the government.

4.6.3 Composition of an independent evaluation mission

The team members for an independent evaluation mission are a selected

subset of the TAG-MEC and may include ad hoc members. The members
determine the activities of the mission, including the locations for field visits,
in consultation with WHO, and are responsible for the conclusion of the
mission. In addition to national representatives of the ministry of health,
WHO staff may join the mission as observers and provide coordination and
support.

17
 4.6.4 Activities of an independent evaluation mission

The independent evaluation mission verifies the data provided in the

national elimination report by examining documents, records and
interviews. The team also assesses the quality of surveillance, the level of
vigilance and the quality of other malaria services during field visits.

Team members usually arrive in the capital, where they visit the ministry
of health and the office of the NMP to orient themselves to the health
system and the malaria programme. Visits are also made to financial
and other departments to assess the human and financial resources
invested in malaria and the likelihood of their sustainability. The team
reviews supporting documents and records made available at national
level, including the database of malaria cases and foci. Depending on
the number of cases and foci in the country in the previous few years, the
team might review all or a sample of case and focus investigation forms
to determine whether the investigations were properly conducted and
whether the case classifications were justified.

The sites for field visits are selected by the members of the mission.
Considerations for areas to be visited include: the locations where the
last indigenous cases occurred; areas with high malariogenic potential;
localities with recent or past outbreaks; areas with multiple potential
malaria vectors; and locations with high-risk populations, such as
temporary workers, border communities, undocumented migrants,
refugees and indigenous populations. The team may decide to visit areas
in which there has been no malaria transmission for a number of years, if
they consider it necessary.

The team will visit public and private health facilities, laboratories,
pharmacies and epidemiological services at different levels of the
system, international points of entry and other government departments
and sectors that contributed to malaria elimination or participate in
prevention of re-establishment. The purpose of visits to health facilities
and laboratories is to determine the coverage and the quality of malaria
services and to assess their sustainability. During these visits, the team will
review documents and records and cross-check the data from various
administrative levels against information presented in the national
elimination report. The team will meet health staff to understand better
how the malaria programme was implemented, factors that contributed
to the achievement of elimination and the strategies that will be used to
sustain malaria-free status. The team interviews public and private health
practitioners in peripheral areas to determine the level of vigilance for
malaria in the general health services and thus the likelihood that malaria
cases will be detected, confirmed cases will be promptly and appropriately
treated and interventions will be rapidly deployed to prevent or interrupt
transmission. The team may visit facilities that are likely to underreport

Preparing for certification of malaria elimination

18 Second edition
cases to the surveillance system, including private pharmacies, private
medical practitioners, drug vendors and military and other health services
to determine the completeness of case reporting.

When security concerns prohibit the independent evaluation mission from

visiting certain areas of a country that they have proposed for field visits,
their activities can be modified to include off-site interviews with local
staff, virtual meetings and desk reviews of data from the affected areas.
In exceptional circumstances, when security concerns or travel restrictions,
including the impact of the COVID-19 pandemic, prevent an independent
evaluation mission from taking place as described, its postponement will
be considered. If the exceptional situation is unlikely to be resolved in the
foreseeable future, however, additional modifications that will not impair
the integrity of the process may be adopted. In addition to virtual meetings,
such modifications could include deployment of national or international
experts to conduct the field assessments as external evaluators under the
guidance of the TAG-MEC. Only members of the TAG-MEC will decide
on and recommend certification, including under such exceptional
circumstances. Significant modifications to the independent evaluation
mission proposed by WHO secretariat will be reviewed and approved in
advance by the TAG-MEC and the MPAG.

The team will brief the ministry of health on their findings after the field
visits have been completed. The conclusions and recommendations
presented by the team represent the views of the team members who
conducted the independent evaluation mission and not those of the
full TAG-MEC or of WHO. Annex 6 provides a generic agenda for an
independent evaluation mission.

4.7 GRANTING AND MAINTAINING CERTIFICATION

The TAG-MEC will meet to discuss the national elimination report and the
findings of the independent evaluation mission and will reach consensus
on whether certification should be recommended or postponed. The
main activities of the TAG-MEC during the certification procedure will be
summarized in a short report and reviewed by the MPAG, the role of which
is to ensure that the procedure has been conducted according to the SOPs.
The WHO Director-General will review the recommendation of the TAG-
MEC and take a final decision on certification. The government will be
informed of the decision in a letter to the minister of health.

After certification, countries continue to implement the programme to

prevent re-establishment of malaria transmission and are expected to
report at least annually on confirmed malaria cases detected, by species,
case classification and origin of cases for the World Malaria Report.

19
 Countries should immediately report any indigenous cases or outbreaks
to WHO so that the Organization can advise on further action to prevent
re-establishment. A minimum indication of possible re-establishment of
transmission is the occurrence of three or more indigenous malaria cases
of the same species per year in the same focus for 3 consecutive years.
As certification represents recognition of a considerable operational
achievement by a country, a careful investigation and consultation with the
TAG-MEC will be conducted before a country’s malaria-free certification
status is revoked.

Preparing for certification of malaria elimination

20 Second edition
5. Verification of
subnational malaria
elimination

Verification of subnational malaria elimination may be an option in large

countries and those with subnational elimination goals. It can promote
ownership of malaria elimination in subnational areas and strengthen
the commitment of local government to prevent re-establishment.
Subnational verification can help strengthen surveillance and response
systems and prepare the country for national certification, although it is
not a prerequisite for national certification. WHO provides technical
assistance to countries for subnational verification by advising them
on the procedure to be used. WHO does not, however, provide external
validation of elimination at subnational level, which is overseen by the
country itself.

5.1 OVERSIGHT AND MANAGEMENT

A national authority, usually the ministry of health, is responsible for

deciding on the method and granting malaria-free status to areas of the
country that have met national criteria for subnational elimination. The
independent national malaria elimination advisory committee (if there
is one) or a national certification committee could be entrusted by the
ministry of health to oversee subnational verification. As an example, the
terms of reference of such a committee in subnational verification in China
are listed in Box 2.

Depending on the number of subnational areas (states, regions or

provinces) that request verification, countries might send experts who are
not members of the national certification committee to join the evaluation
team in field visits. These might be academic or retired government
malaria experts, health system specialists or entomologists. Personnel from
subnational health authorities and programmes in the areas requesting
verification should not participate in assessment of their own states, regions
or provinces but could be deployed to other subnational areas.

21
 BOX 2.
Terms of reference for a national certification committee overseeing
verification of subnational elimination

1. Establish the method and procedures for subnational verification, and

pilot-test them in at least one subnational area.
2. Review the subnational elimination report and supporting documents
and records submitted by the government of the subnational area.
3. Form an evaluation team to conduct field visits to verify the data and
information presented in the subnational elimination report and to
determine that there has been no indigenous cases in at least the past
3 consecutive years (36 months) and that activities are in place to
prevent re-establishment of transmission.
4. Recommend to the ministry of health that the subnational area can be
declared malaria-free.

5.2 CRITERIA FOR VERIFICATION OF

SUBNATIONAL MALARIA ELIMINATION

The criteria used in verifying subnational elimination should be similar to

those for national certification.

The evidence used to evaluate a claim of malaria elimination in a

subnational area and to verify that effective activities are under way to
prevent re-establishment is similar to that used for national certification.
It comprises:

• a subnational elimination report;

• documents and records;

• observations and findings from a subnational verification mission

and

• additional documentation, such as peer-reviewed journal articles.

5.3 STEPS IN VERIFICATION OF SUBNATIONAL

ELIMINATION

The steps in subnational verification are likely to vary from country

to country according to the structure of their health system and the

Preparing for certification of malaria elimination

22 Second edition
organization of malaria activities. Engagement with subnational
government authorities is recommended, not only because it indicates
recognition of their leadership and their contribution to malaria elimination
but also because it will strengthen and sustain political commitment
to prevent re-establishment in the area. National and local authorities
have different roles in subnational verification: national authorities verify
the malaria free-status of subnational areas, in effect validating the
achievements of local authorities.

The steps in subnational verification might include the following.

1. The national authority designs a method for subnational verification,

using the WHO national certification process as a reference.

2. The health department of the state, region or province submits a

request to the national authority for subnational verification on
behalf of the local government authority.

3. The subnational health department submits a subnational

elimination report and compiles the supporting documents and
records required.

4. Upon receiving the request, the national authority organizes a

subnational verification mission. An evaluation team formed by
malariologists and experts in other areas, such as public health
and entomology, reviews the subnational elimination report and
other documents and records and conducts field visits to verify the
information. Countries might invite international malaria experts to
participate in subnational verification.

5. The evaluation team reports their findings and recommendation

about whether the area should be declared malaria-free.

6. The national authority makes a final decision to grant malaria-free

status to the state, region or province.

5.3.1 Subnational elimination report, supporting documents and

records

The subnational elimination report describes the characteristics of

malaria transmission in the subnational area, summarizes activities
undertaken to achieve malaria elimination, presents evidence that
elimination has been achieved and describes the activities under way
to prevent re-establishment. It should follow the format of the national
elimination report so that the data and information can be readily
integrated into the final national elimination report when the country
applies for WHO certification.

23
 Countries should decide which documents and records are to be used for
subnational verification, with reference to the minimum documentation
required by WHO for national certification (Annex 1).

5.3.2 Subnational verification mission

The subnational verification mission is an important part of subnational

verification. Its objectives are to verify the data presented in the
subnational elimination report and the supporting documents and records
and to assess the adequacy of activities to prevent re-establishment of
transmission in the area. As surveillance is important to both objectives, the
mission should prioritize verification of core functions and the quality of
the surveillance system (6), the vigilance of the general health services and
whether the last foci were cleared of transmission (zero indigenous cases in
the past 3 consecutive years).

The principles for selecting locations for field visits are the same as for
national certification, as described above. Countries might refer to the list
of elements required for prevention of re-establishment (Annex 5) and
the generic agenda for an independent evaluation mission (Annex 6) to
determine the activities and agendas of field visits. Annex 7 provides an
example of subnational verification in China.

5.4 ANNOUNCEMENT OF VERIFICATION OF

MALARIA-FREE STATUS IN SUBNATIONAL
AREAS

On the basis of the recommendation of the entity overseeing subnational

verification, the ministry of health decides whether malaria elimination
has been achieved in the region, state or province. The ministry of health is
encouraged to publish and announce verification of malaria-free status in
subnational areas as a means of recognizing the significance of this public
health achievement and encouraging other subnational areas to pursue
subnational elimination.

Preparing for certification of malaria elimination

24 Second edition
References

1. WHO malaria terminology, 2021 update. Geneva: World Health

Organization; 2021 (https://apps.who.int/iris/handle/10665/349442,
accessed October 2022).

2. Global technical strategy for malaria 2016–2030, 2021 update.

Geneva: World Health Organization; 2021 (https://apps.who.int/iris/
handle/10665/342995, accessed October 2022).

3. Framework for malaria elimination. Geneva: World Health

Organization; 2017 (https://apps.who.int/iris/handle/10665/254761,
accessed October 2022).

4. WHO Malaria Elimination Certification Panel. Terms of reference.

Geneva: World Health Organization; 2017 (https://www.who.int/docs/
default-source/malaria/mecp-documentation/who-mecp-tor.pdf,
accessed October 2022).

5. WHO. Paraguay and Uzbekistan certified as malaria-free.

Wkly Epidemiol Rec. 2019; 94:117-120. (https://apps.who.int/iris/
handle/10665/311173; accessed on October 2022).

6. Malaria surveillance, monitoring and evaluation: a reference manual.

Geneva: World Health Organization; 2018 (https://apps.who.int/iris/
handle/10665/272284, accessed October 2022).

7. Malaria microscopy quality assurance manual – Version 2.

Geneva: World Health Organization; 2016 (https://apps.who.int/iris/
handle/10665/204266, accessed October 2022).

8. WHO guidelines for malaria, 3 June 2022. Geneva: World Health

Organization; 2022 (https://apps.who.int/iris/handle/10665/354781,
accessed October 2022).

9. Malaria. Chapter 7. In: International travel and health. Geneva: World

Health Organization; updated 2020 (https://www.who.int/docs/
default-source/travel-and-health/2017-ith-chapter7.pdf, accessed
October 2022).

25
 Annexes

Preparing for certification of malaria elimination

26 Second edition
ANNEX 1. DOCUMENTATION REQUIRED FOR
CERTIFICATION OF MALARIA
ELIMINATION

Countries are expected to compile the national-level documents and

records required systematically so that they can be retrieved readily. At
subnational level, documents such as SOPs and guidelines should be
accessible to staff who use them. Records should be kept in subnational
health offices, health facilities and laboratories where the original data
were generated.

The time chart below illustrates the period that each required document or record should
cover. “Elimination” is the month in which a country reports its last indigenous case. “–10”
(or “–1”) represents 10 years (or 1 year) before the last indigenous case, when transmission
was ongoing. “1” (or “2”) represents the first (or the second) year after the last indigenous
case. “Present” is the point in time when the country receives the independent evaluation
mission, which can occur only after a country has reported zero indigenous cases for at
least 3 years (36 months). “Present” represents any year after a country becomes eligible
for certification. The reference period to be covered by each required document or record
is highlighted in orange in each row of the table.

Ongoing transmission Elimination Eligible for certification

-10 -9 -8 -7 -6 -5 -4 -3 -2 -1 1 2 3 4 5 6

AVAILABILITY OF DOCUMENTS AND RECORDS

REQUIRED DOCUMENTS AND RATIONALE
Health facility
National level Subnational level
and laboratory

Plans, reports and legislation

1. National malaria elimination strategic

plan and operational or implementation
plans
To understand how the country got to ✓
zero indigenous cases and provide an
overview of the elimination strategy

-10 -9 -8 -7 -6 -5 -4 -3 -2 -1 1 2 3 4 5 6
Reference time period: -5 to elimination

2. Plan of action for the prevention of

re-establishment of malaria
transmission
✓
To assess the likelihood that malaria-free
status can be maintained in the country

Reference time period: present

27
 AVAILABILITY OF DOCUMENTS AND RECORDS
REQUIRED DOCUMENTS AND RATIONALE
Health facility
National level Subnational level
and laboratory

3. Annual malaria programme reportsa

To provide an overview of malaria
activities undertaken and evidence that
an annual review system is in place ✓
to monitor programme progress and
optimize response

-10 -9 -8 -7 -6 -5 -4 -3 -2 -1 1 2 3 4 5 6
Reference time period: -5 years to present

4. Recent published and unpublished

reports of studies on malaria
epidemiology and malaria vectorsb ✓
To provide evidence for current strategies
to prevent re-establishment
Reference time period: Any reports that the programme believes may support the current strategies to prevent
re-establishment

5. Legislation or regulations related to

malaria and vector control
To demonstrate that malaria is a ✓
mandatory notifiable disease
Reference time period: All current legislation

Surveillance

6. Guidelines and SOPs for malaria

surveillance
To assess that the design of the ✓ ✓
surveillance system is appropriate
for prevention of re-establishment
Reference time period: Current guidelinesc

7. Annual malaria surveillance reportsd

To show changes in malaria transmission ✓ ✓
over time
-10 -9 -8 -7 -6 -5 -4 -3 -2 -1 1 2 3 4 5 6
Reference time period: –5 years to present

8. Malaria case database

To provide information on cases for
assessment of the surveillance system ✓ ✓ ✓
and to understand the epidemiology of
malaria over time.e
-10 -9 -8 -7 -6 -5 -4 -3 -2 -1 1 2 3 4 5 6
Reference time period: –10 years to present

Preparing for certification of malaria elimination

28 Second edition
 AVAILABILITY OF DOCUMENTS AND RECORDS
REQUIRED DOCUMENTS AND RATIONALE
Health facility
National level Subnational level
and laboratory

9. Malaria case investigation and

notification forms
The original case investigation and
notification forms must be provided to ✓ ✓ ✓
permit evaluation of the completeness
of data collection and accuracy of case
classification
-10 -9 -8 -7 -6 -5 -4 -3 -2 -1 1 2 3 4 5 6
Reference time period: –5 years to presentf

10. Focus register, including focus

investigation forms and maps
Including reports on focus management
and response to demonstrate ✓ ✓
effectiveness of activities to interrupt
transmission in the last focig
-10 -9 -8 -7 -6 -5 -4 -3 -2 -1 1 2 3 4 5 6
Reference time period: –5 years to 3

Diagnosis

11. SOPs and bench aids for malaria

diagnosis
To demonstrate that laboratories have ✓ ✓ ✓
correct guidance, aligned with that of
WHO
Reference time period: Current document

12. Reports (or records) of quality

control and assurance activities for
diagnosis
To demonstrate that the quality of ✓ ✓ ✓
malaria diagnosis is assured in the
country and the capacity is likely to be
sustained
-10 -9 -8 -7 -6 -5 -4 -3 -2 -1 1 2 3 4 5 6
Reference time period: 0 to present

13. Sample (laboratory) register

To validate case notifications against
source material and to assess the quality ✓
of surveillance data
-10 -9 -8 -7 -6 -5 -4 -3 -2 -1 1 2 3 4 5 6
Reference time period: –5 years to present

29
 AVAILABILITY OF DOCUMENTS AND RECORDS
REQUIRED DOCUMENTS AND RATIONALE
Health facility
National level Subnational level
and laboratory

Case management

14. National malaria treatment

guidelinesh
To determine whether guidelines ✓ ✓ ✓
are aligned with current WHO
recommendations
Reference time period: Current guidelines (any past guidelines can be included)

15. Patient log or register

To determine the completeness and
quality of malaria treatment and to ✓
assess the consistency of surveillance
data
-10 -9 -8 -7 -6 -5 -4 -3 -2 -1 1 2 3 4 5 6
Reference time period: –5 years to present

Vector control

16. Guidelines or SOPs for entomological

surveillance and vector control
To determine whether guidelines are ✓ ✓
appropriate and aligned with WHO
recommendations
Reference time period: Current guidelines (any past guidelines can be included)

17. Annual reports of entomological and

vector control activities
To understand how the country arrived
at zero indigenous cases and whether ✓ ✓
activities are appropriate to prevent re-
establishment
-10 -9 -8 -7 -6 -5 -4 -3 -2 -1 1 2 3 4 5 6
Reference time period: –5 years to present

Enabling environment to support elimination and prevention of

re-establishment of transmission

18. Reports of multi-sectoral

collaboration
To demonstrate that multi-sectoral
collaboration was in place during the ✓ ✓
elimination phase and will support
the country’s plan to prevent
re-establishment
-10 -9 -8 -7 -6 -5 -4 -3 -2 -1 1 2 3 4 5 6
Reference time period: –5 years to present i

Preparing for certification of malaria elimination

30 Second edition
 AVAILABILITY OF DOCUMENTS AND RECORDS
REQUIRED DOCUMENTS AND RATIONALE
Health facility
National level Subnational level
and laboratory

19. Reports of cross-border coordination

activitiesj
To document cross-border collaboration ✓ ✓
to support elimination and prevention of
re-establishment
-10 -9 -8 -7 -6 -5 -4 -3 -2 -1 1 2 3 4 5 6
Reference time period: –5 years to present

20. Documentation of health education

and community awareness-raisingk
To demonstrate that health education
and community engagement were used ✓ ✓
to achieve elimination and will support
the country's plan to prevent
re-establishment
-10 -9 -8 -7 -6 -5 -4 -3 -2 -1 1 2 3 4 5 6
Reference time period: –5 years to present

a
The annual programme report can be combined with the annual surveillance report. Training activities
may be included in the annual programme report or presented separately.

b
Results of operational research should be included.

c
If guidelines and SOPs for malaria surveillance have changed after countries report zero indigenous
cases, the previous guidelines and SOPs of the surveillance system during the elimination phase should be
included.

d
This may be combined with the annual malaria programme report. Records of surveillance assessments
should be included, if available.

e
The malaria case database should be electronic, and access should be provided to WHO pre-certification
and independent evaluation mission teams. Subnational authorities should have access to or copies of the
database that include the cases diagnosed or infected in their jurisdiction.

f
The investigation forms for all cases identified during the previous 3 years (36 months) of zero indigenous
cases, at least, must be made available.

g
The focus register is a database of all focus investigations and the activities for management and
response. Countries that did not use a focus approach should provide equivalent reports on how
transmission was interrupted during the 5 years before the country reached zero indigenous cases.

h
If the national treatment guidelines are not aligned with WHO recommendations, countries should provide
justification for any differences.

i
Reports on multi-sectoral collaboration before reaching zero indigenous cases should be included to
demonstrate the established collaboration mechanism, if available. Meeting reports, agreements such as
memoranda of understanding, action plans and implementation reports should be included, if available.

j
Includes meeting reports, signed agreements, action plans and implementation reports. Reports on
cross-border collaboration before reaching zero indigenous cases should be included, if available.

k
Reports on relevant health education programmes or other relevant activities.

31
 ANNEX 2. AN EXAMPLE OF AN OFFICIAL LETTER
TO REQUEST CERTIFICATION OF
MALARIA ELIMINATION*

To: [Name of Director-General] The letter

should be sent
Director-General
to the current
World Health Organization WHO Director-
Geneva, Switzerland General

Dear [name of Director-General]

To describe the
I am writing to inform you that the Ministry of Health of [country name] has
purpose of the
registered a satisfactory result in eliminating malaria. The last indigenous
letter. Provide the
case of malaria occurred more than 36 months ago, on [date]. Our country is
date of the last
implementing a plan to prevent re-establishment of malaria transmission to
indigenous case
maintain our malaria-free status.
of malaria.

This success has been the result of many decades of effort and great sacrifice
on the part of our health care workers. Our country is pleased to contribute to
Briefly describe
the global vision of a world free of malaria.
how malaria
elimination is
achieved
I would like to request WHO to initiate the process of certification of malaria
elimination in [country name]. We will be pleased to provide all the necessary Request WHO
support for completing the process of certification of malaria elimination. to initiate the
certification
process

[Signature]
Minister of
Health should
sign off the
Minister of Health
letter, on
behalf of the
Government

* The letter should be sent to the WHO Director-General through the WHO representative or the regional
director if there is no WHO office in the country.

32
ANNEX 3. PLAN OF ACTION AND TIMELINE FOR
CERTIFICATION

The duration of the certification procedure after submission of an official

request varies significantly by country for several reasons, including the
time necessary for countries to finalize, translate and submit their national
elimination reports, their readiness to receive an independent evaluation
mission, the availability of TAG-MEC members and the time required to
prepare for an independent evaluation mission. Once WHO receives a final
version of the national elimination report, certification may take a minimum
of 4 months.

RESPONSIBLE
ACTIVITY REMARKS
PARTY

1 Submit an official Ministry of health Countries should approach WHO as early

request as possible when at least 3 consecutive
years (36 months) have passed without
an indigenous case and a decision has
been taken to apply for certification.

2 Submit the national Ministry of health The national elimination report should be
elimination report provided to WHO preferably in English.
to WHO Reports written in other official languages
of the United Nations are also accepted.

3 Review of the TAG-MEC The TAG-MEC requires a minimum of

national elimination 4 weeks to complete its review.
report

4 Independent Subset of TAG-MEC In general, missions last 2 weeks, but

evaluation mission the duration may depend on the size of
the country and the complexity of the
malaria situation.

5 Mission evaluation Subset of TAG-MEC The TAG-MEC requires a minimum of

report 4 weeks to complete its evaluation
report after conclusion of the
independent evaluation mission.

6 Review and TAG-MEC, GMP Meetings of the TAG-MEC are generally

discussion of the scheduled once a year.
mission evaluation
report and
recommendation
on certification

7 MPAG reviews and MPAG, GMP Within 2 weeks of TAG-MEC

concurs with the recommendation
recommendation
of the TAG-MEC

8 Decision made by WHO Director- Within 3 weeks of concurrence by the

the WHO Director- General MPAG
General

33
 ANNEX 4. OUTLINE OF A NATIONAL ELIMINATION
REPORT

A Word template with detailed instructions on preparing a national

elimination report is available at the following link: https://www.who.int/
publications/m/item/national-malaria-elimination-report.

Executive summary

1. General information

1.1 Geography
1.2 Ecological regions
1.3 Climate
1.4 Population and its movements
1.5 Economy
1.6 Health profile
1.7 Description of health system and organization of health
services

2. Malaria in the country

2.1 History
2.2 Epidemiology
2.3 High-risk populations and hard-to-reach areas
2.4 Last indigenous malaria cases and foci in the country
2.5 Entomological aspects of malaria transmission

3. Organizational structure of national malaria programme

3.1 Programme
3.2 National malaria elimination advisory committee
3.3 Malaria partner organizations

4. Strategies and activities undertaken to eliminate malaria

4.1 Legislation and regulations relevant to malaria elimination

4.2 Stratification and targeted strategies
4.3 Surveillance and response systems
4.4 Monitoring and evaluation of the surveillance system
4.5 Malaria diagnosis
4.6 Case management
4.7 Vector control and entomological surveillance
4.8 High-risk populations and hard-to-reach areas
4.9 Operational research

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34 Second edition
 4.10 Public health education and community engagement
4.11 Inter- or multi-sectoral collaboration
4.12 Cross-border coordination and collaboration

5. Prevention of re-establishment of malaria transmission

5.1 Overview
5.2 Stratification by receptivity and risk of importation
5.3 Surveillance and response system
5.4 Malaria diagnosis
5.5 Case management
5.6 Vector control and entomological surveillance
5.7 Travellers’ health
5.8 Public health education
5.9 Inter- and multi-sectoral collaboration
5.10 Cross-border coordination and collaboration
5.11 Monitoring and evaluation of the plan to prevent re-establishment
of transmission

6. Budget for malaria

7. Annexes

Annex 1. Results of surveillance assessment by administrative divisions

35
 ANNEX 5. CHECKLIST OF ELEMENTS FOR
PREVENTION OF RE-ESTABLISHMENT
OF MALARIA TRANSMISSION

CRITICAL ELEMENT MILESTONES

1. 1.1
National plan for The plan is appropriate, costed and endorsed by the
prevention of government.
re-establishment
of transmission 1.2

The plan should define The plan defines the roles and responsibilities of different
the objectives to be sectors (including non-health sectors) involved.
achieved, the activities to
be conducted, the entities 1.3
responsible for conducting An updated map of the country stratified by receptivity and
the activities, the resources risk of importation, at a minimum, is included in the plan
necessary at central and to prevent re-establishment. Key interventions at different
subnational levels and the strata are described.
timeline for implementation.
The plan should be 1.4
reviewed regularly to adapt
A sufficient budget is allocated for implementation of
to changes in malariogenic
activities, and finances have been mobilized to support the
potential.
plan.

2. 2.1
National programme A central unit is responsible for preventing re-establishment
structure of malaria transmission.a If the functions of the central
structure are shared among several entities or institutions,
All programmes require
their roles and responsibilities are clearly defined and
a central structure for
coordination among different entities is effective.
oversight of implementation
of national strategies, 2.2
to provide technical
leadership, set policies The national structure is effective in overseeing
and guidelines, coordinate implementation of activities, coordinating national training,
national training, and monitoring disease trends, reporting malaria cases and
evaluate overall progress. coordinating outbreak response.

3. 3.1
Diagnosis A national focal point or coordinator has been appointed to
oversee the quality assurance programme.
The network of laboratories
(or testing centres) is 3.2
functional and can
provide quality-assured An official national reference laboratory has been
parasitological confirmation designated.b
of malaria infection to all
populations. 3.3
A microscopy quality The roles and responsibilities of institutions engaged in
assurance system is in place quality assurance at national and subnational levels are
and functional. defined.

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 CRITICAL ELEMENT MILESTONES

3. 3.4
Diagnosis (cont.) A group of highly competent microscopists has been
identified as the core group for the national quality
assurance programme. It is preferable that all are certified
through an external competence assessment.c

3.5
All microscopists receive regular training, re-training and
competence assessments.d

3.6
An internal quality assurance system, particularly for
Giemsa staining and cross-checking of blood slides, is in
place.

3.7
At least one of the following approaches is used for external
quality assessment: regular on-site supportive supervision,
proficiency testing (or direct evaluation) or blinded cross-
checking of slides by laboratories at different levels.e

3.8
Laboratories or diagnostic (testing) centres are well staffed
and equipped with adequate diagnostic capacity and
good record-keeping.f

3.9
Written SOPs and bench aids are available in all
laboratories.

3.10
Microscopists and laboratory technicians follow SOPs,
as evidenced by good-quality stained blood slides and
accurate readings.

3.11
Laboratory consumables and reagents are supplied
continuously, with no stock-outs.

3.12
Rapid diagnostic tests, if used in the country, are WHO-
prequalified and appropriately target the malaria species
most common in the country or likely to be imported.

3.13
Written SOPs and bench aids for use of rapid diagnostic
tests for malaria are available and used according to the
manufacturer’s guidance.

3.14
Rapid diagnostic tests are available at health facilities.g

37
 CRITICAL ELEMENT MILESTONES

3. 3.15
Diagnosis (cont.) When applicable, health facility staff are trained and
proficient in using and interpreting rapid diagnostic tests.h

3.16
Outreach training and supportive supervision are provided
to support use of rapid diagnostic tests in peripheral health
facilities.
4. 4.1
Case management Written national treatment guidelines are available in all
health facilities that provide malaria treatment and are
A system that provides
aligned with WHO guidance, including for severe malaria.
good-quality curative
services is functional 4.2
throughout the country.
A programme to raise awareness among general health
care providers is in place to maintain vigilance. General
health care providers are vigilant in suspecting malaria
in patients with fever and a history of travel to or from
a malaria-endemic area, and they are aware of the
availability of diagnosis and treatment in the country.
4.3
Training in malaria diagnosis and case management,
including updated malaria information, is provided to health
practitioners who provide malaria diagnosis and treatment.
4.4
A functional referral system is in place to refer patients with
severe malaria to hospitals.
4.5
Sufficient treatment courses are available when and where
needed; stock-outs of antimalarial drugs are prevented.
5. 5.1
Surveillance and response Written surveillance guidelines (SOPs, manuals, guidelines)
system for passive, proactive and reactive case detection, case
reporting and case investigations are available, aligned with
A system of early detection,
WHO recommendations and implemented.
treatment, mandatory
notification, case and focus 5.2
investigation is in place
Regular task-based training in surveillance is provided to
throughout the country. The
provincial, district or health facility staff responsible for case
capacity and the quality of
notification, investigation and classification.i
case investigation, malaria
outbreak investigation and 5.3
response are maintained;
Private clinics and providers that see patients with fever are
all malaria cases are
trained in appropriate surveillance procedures.
investigated, and the
collected information is 5.4
kept in the national case
By law, malaria is a notifiable disease, and a protocol for
database.
case notification exists, including for the private sector.

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 CRITICAL ELEMENT MILESTONES

5. 5.5
Surveillance and response A suspected case is clearly defined in guidelines and SOPs.
system (cont.)
5.6
All suspected cases are tested for malaria by microscopy or
with rapid diagnostic tests and results are reported.j

5.7
The minimum data for each case are recorded
electronically.k

5.8
Case-based data are reported to provincial, district and
national levels according to protocol.

5.9
Private, military, police, faith-based and nongovernmental
organization clinics also report case-based data to the
ministry of health.

5.10
The strategy and guidelines for the proactive case
detection strategy (objectives, high-risk populations,
geographical units, timing) are available, appropriate and
implemented.

5.11
Case investigation forms elicit minimal essential data
(patient demographics, residence, illness history, diagnostic
test results, treatment, travel history) for case classification,
are available and are fully completed for each case.

5.12
All cases are classified correctly according to WHO
guidelines and are reviewed by technical bodies.l

5.13
Protocols to investigate and respond to malaria outbreaks
are included in the country’s outbreak response system.

5.14
Contingency plans for rapid deployment of supplies
(diagnostic tests, antimalarial treatments and vector
control) are in place in case of outbreaks.

5.15
Country reports all malaria cases annually to WHO.

39
 CRITICAL ELEMENT MILESTONES

6. 6.1
Entomological surveillance Written SOPs for entomological surveillance are available,
and vector control aligned with WHO guidance for preventing
re-establishment and implemented.
Entomological surveillance
and vector control should 6.2
be continued, with
emphasis on areas of high Sentinel sites for entomological surveillance have been
malariogenic potential (i.e. established according to national guidelines.
receptive areas with a risk
6.3
of importation).
Basic behavioural characteristics (indoor vs outdoor biting
Capacity to respond to
preferences, indoor vs outdoor resting preferences, blood
possible resurgences with
meal preferences) are known for primary and secondary
appropriate vector control
vectors.
should be maintained.
6.4
Written vector control guidelines and SOPs are available,
aligned with WHO recommendations and implemented.

6.5
Vector control is used at optimal coverage in areas with
significant malariogenic potential.

6.6
The coverage, quality and effectiveness of vector
control are routinely monitored in areas with significant
malariogenic potential.

6.7
Vector control staff who conduct indoor residual spraying,
distribute long-lasting insecticide treated nets or conduct
larviciding have received training within the past 3 years.

6.8
Equipment and insecticide are available, and their quality
is assured.

7. 7.1
Multi-sectoral A mechanism for coordination or information-sharing
collaboration among sectors is established and functional.
Coordination and 7.2
collaboration with non-
health sectors ensures For large countries, a mechanism for coordination among
optimal coverage and sectors is established and functional at subnational level.
use of interventions by
high-risk populations,
and the implementation
of interventions achieve
impact and efficiency.m

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40 Second edition
 CRITICAL ELEMENT MILESTONES

8. 8.1
Inter-country information- A mechanism for sharing information on malaria outbreaks
sharing and border or cases has been established with neighbouring malaria-
collaboration endemic countries and is being used to exchange
information.
Effective coordination and
communication among 8.2
neighbouring countries
can mitigate the risk of For malaria foci that traverse the border with a
re-establishment. neighbouring country, measures are in place to ensure that
transmission is eliminated throughout the focus and the risk
of re-establishment of transmission is mitigated.

9. 9.1
Raising awareness and At points of entry, travellers are provided with information
provision of prevention on malaria, including guidance on where and when to seek
strategies care.
Early detection can 9.2
be improved, and
re-establishment of malaria A programme to raise awareness among people travelling
transmission can be to malaria-endemic countries on preventing malaria
avoided if the population (chemoprophylaxis and prevention of mosquito bites) is in
at risk of malaria is aware place.
of the risk and is provided
9.3
with information, measures
and strategies to prevent Drugs for chemoprophylaxis are available in the country.
infection and obtain
diagnosis and treatment.

Source: This checklist of elements for prevention of re-establishment is taken from the Malaria Elimination
Audit Tool currently under development. This tool can be requested from malaria-elimination@who.int.

a
The term “national malaria programme” is not used in this section because, after malaria is eliminated,
the responsibility for prevention of re-establishment of malaria transmission may fall to several units, and
a national programme may no longer exist as such.

b
A copy of the document authorizing the national reference laboratory to oversee quality assurance in
the country should be made available.

c
The roster of microscopists who make up the core group should be available. Preferably, they will have
valid certificates from an external quality assurance scheme.

d
All records of external competence assessments for malaria microscopy, training curricula and material
should be available and reviewed.

e
Records of supervisory visits should be available in laboratories at all levels. Microscopists should receive
written feedback from their proficiency panels and reports of slide cross-checking.

f
The sample register (log) is up to date and accurate; written feedback received from superior-level
laboratories is available.

g
The availability of rapid diagnostic tests at different levels of the health system and the appropriate use
of rapid diagnostic tests should be in accordance with the national strategic plan.

h
Health facility staff should be observed while performing a rapid diagnostic test to ensure accurate
knowledge of procedures and interpretation.

41
 I
To prevent re-establishment, many countries integrate their response to malaria cases into their out-
break response systems.

j
Countries should endeavour to report all suspected cases as well as the results of testing. Some
countries may report these data in aggregate (i.e. number of suspected malaria cases tested and
number found positive). Preferably, minimal data on demographics and risk factors should be reported
for all suspected cases of malaria. Optimally, minimum data on risk factors should be recorded for all
patients (e.g. travel history, symptom history) to permit analysis of the proportion of suspected cases
identified and tested.

k
Information on the minimum data to be recorded for each case is provided in Malaria surveillance,
monitoring and evaluation: a reference manual. Geneva: World Health Organization; 2018.

l
Technical bodies could consist of an independent national elimination advisory committee, a national
certification committee or other technical committee that has expertise in epidemiological investigation.
Technical bodies can provide objective, unbiased views of the data that support case classification and
thus improve accuracy.

m
Non-health sectors and departments, such as for agriculture and water management, labour, tourism,
immigration, education, security and the army, are involved in preventing malaria transmission and
should be coordinated to increase impact.

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42 Second edition
ANNEX 6. GENERIC AGENDA FOR AN
INDEPENDENT EVALUATION MISSION

The agenda is based on the assumption that the team is divided into two
groups, although this will depend on the mission.

DATE GROUP 1 GROUP 2

WEEK 1
Monday Morning:
• Briefing in the WHO country office
• Meeting with the minister of health and other national health officialsa
• Meeting with a representative of finance ministry or equivalent
• Meeting with the national malaria team and national certification
committeeb
Afternoon:
• Visit to the national reference laboratory and meeting with staff
• Review of supporting documents and records, including the national
malaria case database
Tuesday • Visits to other institutions involved in the programme for elimination and
prevention of re-establishment (e.g. entomological institute, tropical
disease treatment hospital)
• Continue meeting with NMP
• Continue reviewing supporting documents and records, especially
surveillance data
Wednesday • Travel to region A • Travel to region B
• Visit health office in region A • Visit health office in region B
Thursday • Visit malaria sector, entomological • Visit malaria sector,
service and vector control unit and entomological service and
meet with staff vector control unit and meet
with staff
• Travel to district A of region A
• Travel to district A of region B
• Visits to public and private health
facilities (or community health • Visits to public and private
centres) in district A of region A health facilities (or community
health centres) in district A of
region B
Friday • Travel to district B of region A • Travel to district B of region B
• Visits to public and private health • Visits to public and private
facilities (or community health health facilities (or community
centres) in district B of region A health centres) in district B of
region B
Saturday Visits to other sectors: border health posts, travel clinics, immigration offices
Sunday Break

43
 DATE GROUP 1 GROUP 2
WEEK 2
Monday Travel back to capital city Travel back to capital city
Visit other sectors involved in malaria elimination and prevention of
re-establishment (e.g. military hospitals, labour department, tourism
office, water management department)
Tuesday • Continue visits to other sectors involved in malaria elimination and
prevention of re-establishment
• Team meeting to discuss findings from field visits
Wednesday • Consolidate findings from field visits, and prepare a presentation
Thursday • Call additional meetings with staff from NMP if necessary
Friday Briefing to the ministry of health
Briefing to the national malaria team
Saturday Departure

a
Countries could consider preparing a presentation on their health system to facilitate the discussion.

b
The NMP could consider preparing a presentation on its history.

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44 Second edition
 ANNEX 7. METHODS FOR VERIFICATION OF MALARIA-FREE STATUS IN A COUNTY -
EXAMPLE OF CHINA

In China, the methods used for subnational verification differ slightly in counties, prefectures and provinces. While the methods
used for subnational verification in a province are similar to those for national certification, the methods used to verify
malaria-free status in a county or a prefecture are simplified, illustrated in the table below.

COMPONENT ELEMENTS STANDARD METHODS SITE

1. Subnational elimination report is complete. Desk review
Self-assessment
report
2. Testing of blood Sample logs are available in laboratories. Visit laboratories in health facilities, and review Laboratories
samples from sample logs.
Implementation patients with Sample logs are complete and up to date.
of elimination fever
strategy and Number of blood samples tested for malaria is
quality of appropriate and comparable to that defined in
implementation the work plans.a
Quality-assured Slides are cross-checked monthly, and the Review the record and feedback received on cross- Laboratories
diagnosis results of cross-checking of slides are available. checking of slides.
Diagnosis is quality assured. Randomly select 30 negative slides, examine the
quality of the blood smears and staining, and verify
the results.
Case notification All detected cases are reported. Review sample logs and patient logs. Cross- Public health office in
check the number of positive cases detected in health facilitiesb
the laboratory and the number of complete case
notifications, and match the data with those in the
national malaria database.
45
46
Case treatment All cases were treated with a complete Review patient logs and treatment records. Health facilities
course; P. vivax cases completed anti-relapse
treatment.
Case investigation Case investigation forms are filled in Review all case investigation forms, and verify case County Centre of
completely. classification. Disease Control and
Second edition
Preparing for certification of malaria elimination

Preventionc
Adequate evidence is provided and supports
the case classification.
Focus Every focus has a report on focus investigation Review focus investigation reports. County Centre of
investigation and and response. Disease Control and
response Prevention
Response and management of focus are in line
with national guidelines.
3. Vigilance for malaria in general health services Clinicians and health practitioners are selected to County Centre of
is maintained. answer the questionnaire. Disease Control and
Vigilance in Prevention
general health
services and Laboratory technicians are competent in Laboratory technicians are selected from different County Centre of
capacity identifying Plasmodium parasites. health facilities to assess competence. Disease Control and
to provide Prevention
quality-assured
diagnosis
4. Support Annual work plans and annual reports on Check the availability of the plans. County Centre of
Programme implementation implementation are available. Disease Control and
management of elimination Prevention
Local government provides budget for Review the financing records.
strategies
elimination.

Malaria A unit responsible for malaria (or parasitic Visit the county Centre of Disease Control and
programme diseases) exists, and malaria service positions Prevention, and check its organogram.
structure and are occupied.
human resources
Training Training is provided to various cadres of staff. Review training records.

a
According to national guidelines, all suspected cases should be tested for malaria. In addition, in areas where the risk of re-establishment of transmission is considered high, the NMP
sets a standard on the number of blood samples expected to be tested for malaria. This standard is used for monitoring and supervision.
b
In China, each hospital has a public health officer who is responsible for case notification of all infectious diseases through the health information system.

c
County Centre of Diseases Control and Prevention is responsible for case and focus investigations and response.
47
 For further information please contact:
Global Malaria Programme
World Health Organization
20, avenue Appia
CH-1211 Geneva 27
Switzerland
Email: GMPinfo@who.int

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48 Second edition