Surveillance and Response
to Prevent Malaria
Alexandre Macedo de Oliveira, MD, MSc, PhD
Division of Parasitic Diseases and Malaria
Centers for Disease Control and Prevention
Discuss thoughts about malaria reemergence
(thoughts, due to limited information on the

Discuss interventions to prevent and/or
respond to such events
Keep recommendations focused on what
feasible, or advisable, in the context of the

Terms of Interest
Malaria importation
A person acquires malaria in an endemic area
and goes to a non-endemic area
Malaria introduction
First-generation transmission of malaria
originating from an imported case in a
malaria-free area

Indigenous malaria
Local malaria transmission without any direct
link to an imported case
Terms of Interest
Malaria outbreak
Increase in number of expected cases in a
given area during a period of time
Either increase from baseline transmission or
Malaria reemergence vs. reestablishment vs.
In most cases, referring to the same thing
(though not always)
Malaria Reemergence
Presence of vectors, and ecological/climatic
conditions favorable to malaria transmission
How capable area is to allow for transmission
Proximity to malarious areas or possibility of
influx of malaria patients or vectors
Possibility of malaria parasite introduction
Risk assessment and monitoring
Programmatic and systemic readiness
for response
Malaria surveillance
Detection of initial cases
Ability to respond
Risk Assessment and Monitoring
Malariogenic potential
Factors influencing vulnerability and
Migration patterns, climate, rainfall
Malaria early warning systems
Different ways to set up such a system
Systemic Readiness
Maintenance of malaria expertise for malaria
control and prevention
Difficult in countries that reached malaria
Tendency to lose expertise once malaria no
longer a concern
Expertise and commodities ready to
Systemic Readiness
Malaria preparedness plan
Information on roles and responsibilities
during an outbreak or reemergence episode
Guidance on leadership, involvement of other
public health programs, communication
chain, resources mobilization

Description of relationships and reliance
on external partners
Operating procedures for intervention
implementation of control interventions
Systemic Readiness
Response team
At minimum: an epidemiologist, a
laboratorian and an entomologist
Desirable: logistician, communication
specialist, etc
Supply chain
Availability of drugs and diagnostic
Malaria Surveillance
Detection and reporting of cases
(during outbreak and not!!)
Basis for appropriate treatment
Reliance on laboratory proficiency
Need to be maintained
Entomological Monitoring
Ground work done as part of preparedness
Areas with malaria receptivity and/or
Yearly monitoring of vector composition
and insecticide resistance even if no

Support decisions on control measures
Outbreak Definition
Increase in number of expected cases in
a region during a period of time
In malaria-free areas
One, just one!!, introduced or
indigenous malaria case is an outbreak
Response Mode
Dynamic, activities and their intensity
changing over the course of a response
Case detection
Timely laboratory confirmation by expert
microscopy or molecular methods of all

In-depth interviews to asses place of
infection and collect demographic info
(imported vs. introduction and indigenous)

First Steps in Response
Inventory of local, regional and national
capacity to respond
Mobilization of proficient staff for laboratory
diagnosis and case management
Availability of supplies
Definition on communication channels and
leadership roles
Laboratory Methods
Gold standard method
Dependence on microscopists
Rapid diagnostic tests (RDTs)
Less sensitive
No quantification
Molecular-based tests
Little role in outbreak detection
Complementary (later) important role
Laboratory Preparedness
Maintenance of microscopy expertise at
either local or regional/central level
Continuous training needed
Availability of reagents and equipment
Appropriate supply chain (Edgar’s
Plans for scaling up microscopy capacity
if needed
Timely result reporting systems
Laboratory Preparedness
RDTs as alternative for timely case management
(treatment decisions)
Quality assurance and control systems in place
and running
Mandatory collection of smear for confirmation
(all positive cases, all or a sample of negative

Consider collection of samples in filter paper for
future molecular testing
Treatment Preparedness
Availability of good quality drugs (Edgar’s
expertise again)
Appropriate regimens for implicated
species and strain
Issue of chloroquine-sensitive
If in doubt, cover chloroquine-resistant
Training of healthcare workers in
identifying, testing and treating cases
Initial Cases Follow-up
Close clinical and parasitological monitoring
to ensure treatment compliance and parasite

Difficult as transmission progresses
Adopt broader case definition (less specific)
of suspected malaria case, eg fever
Reinforce passive case detection and
reporting in neighboring areas
Case Finding
Active case detection
Public health officials identifying
and reporting cases
Time consuming on response team
Passive case detection
Healthcare workers or laboratorians
identifying and reporting cases
Risk of missing cases
Generally a combination of the above
Contact Investigation
Evaluation of home and work contacts of
confirmed cases
Determination of radius for contact
investigation (most cases, household
contacts and immediate neighbors)

Testing of all contacts or only symptomatic
Epidemiological decision
Most infected people symptomatic in non-
endemic areas
Contact Investigation
Evolving contact investigation strategy
during re-emergence episodes
1. Only symptomatic contacts
2. All contacts irrespective to symptoms
3. Population-based surveys
Epidemiological decisions
More is not always better
Plot cases in time and space
Geographic mapping by place of residence
or probable place of infection
Periodical analysis of data and decisions
on what follow up/control measures
Decisions based on data, not assumptions
if possible
Control Measures
Proper case management
Identification of cases
Accurate diagnosis
Proper treatment
Vector control
Indoor residual spraying
Insecticide-treated nets (ITNs)
Larviciding in special cases
Limited and localized breeding
Questionable Interventions
Limited value, temporary effect
Mass drug administration
Risk of drug overuse and side effects
Cost effective when malaria prevalence
Follow-up Studies
Case-control studies
Determine causes and mechanisms of
Often later in an outbreak response
Not a reason to delay implementation of
control interventions
Molecular analysis
Later in outbreak for evaluation of
dissemination patterns
Melissa Briggs
Jaime Chang
Kathrine Tan
John Barnwell
Audrey Lenhart
Bill Brogdon
Many others
Melissa Briggs
Jaime Chang
Kathrine Tan
John Barnwell
Audrey Lenhart
Bill Brogdon
Many others
Jaime Chang
John Barnwell
Audrey Lenhart
Melissa Briggs
Kathrine Tan
Bill Brogdon
Many others
Laboratory Network
Availability of quality microscopy, if
RDTs as ‘first-line’ diagnostic tool but
smears taken for confirmatory
Samples in filter paper for subsequent
Confirmatory assays
Genotyping and resistance testing

Source: http://proyectomalariacolombia.co/files/amiravreda/Martes%209/Alexandre%20Macedo.pdf

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